Doctor of Philosophy in Women's Studies

Reproductive Health of Women in Indian Slums:A Study of Slums in District Aligarh

Thesis

Submitted For the Award of the Degree of

Doctor of Philosophy In Women’s Studies

Sameera Khanam Under The Supervision of

Prof. Abdul Waheed

Centre for Women’s Studies Aligarh Muslim University ALIGARH (INDIA) 2013

ACKNOWLEDGEMENTS

I wish to thank many people who made this study an enthralling experience for me. First, I wish to thank Professor Abdul Waheed, my supervisor and mentor. The insight gained during the ‘discourses’ with him is beyond linguistic expressions.

I would like to express my deep and sincere thanks to Prof. Shireen Moosvi for her constant encouragement and motivation.

I also extend my sincere thanks to Dr. Azra Moosvi, Director, Advance Center for Women’s Studies, AMU, Aligarh for her help and invaluable support to this work. I am also extremely thankful to Prof. Nighat Ahmad for her support. I am also grateful to all my respected teachers at the centre for their constant encouragement, particularly Dr. Shadab Bano and Dr. Aziz Faisal for their thoughtful discussions and suggestions.

My special thanks go to Prof. Mohd. Shahid, Dean Faculty of Social Sciences, MANUU Hyderabad who introduced me and drew my interest to the area of reproductive health. I am thankful to him also for his many insightful suggestions, advices and interesting discussions.

I would also like to express my heartfelt thanks to Dr. Naseem Ahmed Khan, Chairman Dept. of Social Work, senior colleagues and students of Dept. of Social Work, AMU, Aligarh.

My sincere thanks are due to Prof. S. Imtiaz Hasnain, Department of Linguistics and Prof. Shagufta Imtiaz, Women’s College for their genuine concern for my Ph.D.

I am also grateful to the staff of Maulana Azad Library, A.M.U; Seminar, Advance Center for Women’s Studies; Seminar of Sociology and Social Work, A.M.U.

I would like to pay my sincere thanks to the staff of Aligarh Municipal Corporation and District Urban Development Authority, Aligarh for providing me the details of the slums in the city. I acknowledge Mr. Shamim, for his warm receptions that I was accorded with on each of my several visits to the Aligarh Municipal Corporation office.

My sincere thanks are due to Dr. Kulshreshtra Chief Medical Officer, Aligarh and Dr. S.A Khan, Immunization incharge, Mr. Faiz Medical Social Worker at Malkhan Singh District hospital in reaching out the sites of data collection and Dr. Gyanendra Mishra for helping me at various stages of this research study.

My thanks are also due to Mr. Shariq, Mr. Awez, Ms. Nighat, Ms. Samina Mr. Rizwan for their help and concern. I shall always be grateful to my friends Afzal, Idrees, Rifat, Tariq, Shuez and Fatima Apa for helping me at various stages of this study.

My heartfelt thanks to all the participants who took part in this study, without them this study would not have been possible.

I am indebted to my brother, father and mother-in-law for their compassion and dua.

At this point of time I cannot stop thinking about two most important persons in my life my late grandfather and my late mother. They are no more but their encouragement and warmth has always inspired me.

Finally, to my husband Syed Ghufran Hashmi, I will always remain grateful for all of his contributions in my studies and for the confidence he kept instilling in me. I am thankful to my wonderful and loving son Ali. This thesis would not have been possible without their support.

International Conference on Population and Development (ICPD) at Cairo, Egypt (1994) is the paradigm shift that put an end to the demographically driven programs and policies. It has heralded a new dawn of individual and reproductive rights – client-centred, demand driven and target free approach. Later on World Conference on Women at Beijing, China (1995) explicitly recognized and asserted the rights of all women to control all aspects of their health, particularly reproductive health. The unabated growth of urban population in India has caused a huge increase in slum population and forced its inhabitants to live in absence of basic health and civic amenities. As a result people in slums are vulnerable to disease and poor health. Even the government policies and programs tend to neglect the problems of the slum population in India. NFHS 3 (2005-06) in its study of eight cities in India highlighted the differential status of people in slums on almost all the indicators of reproductive health, the situation is particularly disquieting in smaller cities and towns. This implies an urgent need to understand the reproductive health status of women in slums. It is in this background this study aims to analyze the reproductive health status of women in slums. The study has the following objectives.

 To examine fertility trend of women in slums.  To investigate the nature and extent of ante natal care utilisation among women in slums  To explore the extent of institutional and home delivery among women in slums.  To understand the contraceptive practices among slum dwellers  To analyze and assess the influence of socio-economic correlates namely caste, education of women and occupation of the husband on fertility, ante natal care utilisation, child delivery and contraceptive practices of women in slums.

Though the study is intended to study slums of Aligarh district but due to unavailability of data on slums of other urban agglomeration in Aligarh district, the study focused on slums of Aligarh city. The study is limited to a sample of 180 households collected from six slums of Aligarh city. In the collection of primary data, both survey method and qualitative techniques like FGDs and case studies are used. The intention was to extend the quantitative data with rich qualitative data. Secondary data is utilized to analyze facts and figures collected from Census and Aligarh Municipal Corporation. The data thus collected are analyzed and inferences are drawn accordingly with the help of percentages and mean averages, and to bring more clarity regarding subtleties and nuances it was complemented with the FGDs and case studies. The thesis is divided into seven chapters. The first chapter provides introduction to the research area and brings conceptual clarity to reproductive health. It discusses the debates centered around reproductive health, its various dimensions an objectives of the study. The second chapter is on reproductive health in policies and realities which discusses reproductive health in various policies and programs of government of India. The chapter also deliberates upon the major indicators of reproductive health and to put them in perspective these indicators were compared with national data on indicators of reproductive health. Chapter three is on reproductive health of women in Indian slums which discusses the concept of slums and proliferation of slums across India and also focuses on the review of the existing literature on reproductive health of women in Indian slums. Chapter four is on research methods, adopted in the present study. Chapter five provides descriptive profile of the selected slums, households and the participants. Chapter six contains data analysis of the present research and the discussions and inferences are drawn accordingly. The thesis ends with Chapter seven providing conclusion and the ways forward. The findings of the present study are summed up according to the objectives of the study. The study endeavored to examine fertility trend and how socio-economic correlates affect it. Upon the analysis of data fertility was seen to be affected by the socio-economic correlates. The data was collected on women’s education, their caste category and their husband’s occupation. Fertility was reported higher among women who were uneducated than those who were educated.

It is seen in this study that those women who have their husbands in self employment, had exorbitantly higher share in more than three children than any other occupational group. The women whose husbands were casual labourers also had higher fertility than women whose husbands were regular salaried employees either in private or in government sector. Women whose husbands were employed in the government sector are found to have the lowest fertility level.

It was observed in this study that ANC utilization is quite high and majority of the women sought ANC services from the government sources – anganwadi centers, urban primary health centers and health camps organized by the district hospitals and the university medical college. However, it was also observed that three quarters of sampled women did not have 100 days consumption of IFA tablets. From the qualitative data it became clear that lack of proper counselling and information dissemination regarding anaemia and under supply of IFA tablets were the primary reasons for underutilization of the tablets. ANC utilization is found to be positively associated with women’s education and husband’s occupation. Women whose husbands were salaried class employed either in government sector or in private sector ANC utilization was substantially high among them. In the caste category ANC utilization was the highest among SC category and the lowest among OBCs. Majority of the women in the sampled population preferred home delivery over institutional one. Among women who had institutional deliveries, majority of them occurred in public health facilities. The study suggests a positive relationship between institutional delivery, women’s education and husband’s occupation. Among the caste category home delivery was the highest in SCs and the lowest in OBCs. Dais and her services in child delivery are considered valuable in the community. The study also found that majority of the women use contraception and among the contraceptive users majority of them use condoms followed by sterilization. The qualitative data provides description of the contraceptive adoption and also raises certain

methodological issues related to quantitative data where participants respond what they perceive they should which glosses over the data as in this case the high percentage of condom use. The study observed positive relationship between contraception, caste category, women’s education and husband’s occupation. The study has observed higher contraceptive use in general caste category than that of OBCs and SCs, however, sterilization was the highest among SCs. It was also seen in this study that women whose husbands were casual labourers were less likely to use contraception than the those who were salaried especially in government job, though this distinction diminished in salaried in private sector and in self employed category. From the intensive data analysis and insight gained from FGDs and case studies it is abundantly clear that reproductive health involves dynamism, the study challenges the established wisdom related to women’s reproductive behavior and posits them in their unique socio-cultural and socio-economic milieu.

CONTENTS

Certificate from the Supervisor I Declaration by the Candidate II Course Work/Pre-Submission Viva Certificate III Copyright Transfer Certificate IV Acknowledgements V-VI Contents VII-X List of Tables XI

CHAPTER ONE: INTRODUCTION 01-18 1.0 Overview 1.1 Reproductive Health: The Concept 1.2 Dimensions of Reproductive Health 1.2.1 Socio-Cultural Dimension 1.2.2 Rights Dimension 1.2.3 Legal Dimension 1.2.4 Clinical Dimension 1.3 The Debate 1.4 Indicators of Reproductive Health 1.5 Objective of the Study 1.6 Conclusion

CHAPTER TWO: REPRODUCTIVE HEALTH IN POLICIES 19 - 47 AND REALITIES 2.0 Overview 2.1 Policies and Programs in India 2.1.1Family Planning Program 2.1.2 Reproductive and Child Health (RCH) Program 2.1.3Population Policy 2.2 The Realities 2.2.1 Total Fertility Rate (TFR) 2.2.2 Contraceptive Prevalence Rate (CPR) 2.2.3 Maternal Mortality Ratio (MMR) 2.2.4 Antenatal Care (ANC) Coverage 2.2.5 Births Attended by Skilled Health Personnel

VII

2.2.6 The Availability of Basic Emergency Obstetric Care Services 2.2.7 Peri-natal Mortality Rate 2.2.8 Low Birth Weight 2.2.9 Prevalence of Anaemia in Women 2.2.10 Percentage of Obstetric and Gynecological Admissions Owing to Abortion 2.2.11 Prevalence of Infertility in Women 2.2.12 Prevalence of HIV Infection in Pregnant Women 2.2.13 Knowledge of HIV-related Preventive Practices 2.3 Conclusion

CHAPTER THREE: REPRODUCTIVE HEALTH OF WOMEN IN INDIAN SLUMS 48 - 70 3.0 Overview 3.1 Defining Slum 3.2 Growth of Slums in India 3.3 Living Conditions in Slums 3.4 Reproductive Health of Women in Indian Slums 3.4.1 Fertility and Contraception 3.4.1.1Factors Affecting Fertility and Contraception 3.4.1.1.1Socio-Demographic 3.4.1.1.2 Access to Reproductive Services 3.4.1.1.3 Socio-Cultural 3.4.2 ANC and Delivery 3.4.2.1 Factors Affecting ANC and Child Delivery 3.4.2.1.1 Socio-Demographic 3.4.2.1.2 Accessibility 3.4.2.1.3 Affordability 3.4.2.1.4 Socio-Cultural 3.5 Conclusion

CHAPTER FOUR: THE SETTING AND DESIGN OF THE STUDY 71 - 84 4.0 Overview 4.1 Aligarh District 4.2 Aligarh City 4.2.1 Population and Health Status of Aligarh City 4.2.2 Health Infrastructure in the City 4.3 Slums of the City 4.4 The Design of the Study

VIII

4.5 Objectives of the Study 4.6 Sampling Design 4.7 Method of Investigation 4.8 Research Instrument 4.8.1 Interview Schedule 4.8.2 Focused Group Discussion (FGD) 4.8.3 Case Study 4.9 Pilot Study 4.10 Data Processing and Analysis 4.11 Limitations of the Study 4.12 Challenges Faced During Data Collection 4.13 Conclusion

CHAPTER FIVE: SLUMS, HOUSEHOLDS AND 85 - 101 PARTICIPANTS: A PROFILE 5.0 Overview 5.1 Profile of the Selected Slums 5.1.1 Jangalgarhi 5.1.2 Shastri Nagar 5.1.3 Chuharpur 5.1.4 Rambagh Colony 5.1.5 Zakir Nagar 5.1.6 Maulanaazad Nagar 5.2 Household and its Basic Amenities 5.3 Socio-Economic and Demographic Profile of the Participants 5.4 Utilization of Health Care Facilities 5.5 Conclusion

CHAPTER SIX: REPRODUCTIVE HEALTH OF WOMEN IN ALIGARH SLUMS 102 - 149 6.0 Overview 6.1 Fertility 6.2 Anti Natal Care (ANC) 6.2.1 ANC Utilization 6.2.2 Constraints in ANC Utilization 6.3 Child Delivery: Institutional or Home 6.3.1 Reasons for Institutional Delivery 6.3.2 Reasons for Home Delivery 6.4 Contraception

6.4.1 Constraints in Contraception Use 6.4.2 Problems with Contraceptive Use 6.5 Conclusion

CHAPTER SEVEN: FINDINGS AND CONCLUSION 150 - 165 7.0 Overview 7.1 Findings and Interpretation 7.1.1 Fertility 7.1.2 ANC 7.1.3 Child Delivery: Institutional or Home 7.1.4 Contraception 7.2 Suggestions 7.2.1 For Policy Makers 7.2.2 For Health Professionals and Community Workers

REFERENCES 166 - 182 APPENDICES i. Appendix: Interview Schedule ii. Appendix: FGDs Inventory iii. Appendix: Case Study Summary iv. Appendix: Details of Slums in Aligarh v. Appendix: Location of Slums on City Map vi. Appendix: City Map of Aligarh showing specific areas of study vii. Appendix: Glossary

LIST OF TABLES

Table 3.1 Decennial Growth of Urban Population Table 3.2 Slum Population in India Table 3.3 Slum Populations in States Table 4.1 Tehsil wise Distribution of Blocks Table 4.2 Indicators of Health and Demography of Aligarh District Table 5.1 Household: Type, Ownership and Habitation Table 5.2 Availability of Kitchen, LPG Connection and Toilet Table 5.3 Drinking Water, Electricity Connection and Ration Card Table 5.4 Religion and Caste Category Table 5.5 Women’s Education Table 5.6 Working Status of Women Table 5.7 Occupation of the Husband Table 5.8 Age of Women Table 5.9 Utilization of Health Care Facilities Table 6.1 Number of Children Table 6.2 Caste Category and Number of Children Table 6.3 Education of Women and Number of Children Table 6.4 Husband’s Occupation and Number of Children Table 6.5 ANC Utilization Table 6.6 Source of ANC Utilization Table 6.7 TT Injection and IFA Tablet Utilization Table 6.8 Caste Category and ANC Utilization Table 6.9 Husband’s Occupation and ANC Utilization Table 6.10 Women’s Education and ANC Utilization Table 6.11 Prevalence of Institutional Delivery Table 6.12 Women’s Education and Place of Child Delivery Table 6.13 Husband’s Occupation and Place of Child Delivery Table 6.14 Caste Category and Place of Child Delivery Table 6.15 Contraception Utilization and its Methods Table 6.16 Caste Category and Contraception Utilization Table 6.17 Caste Category and Method of Contraception Table 6.18 Women’s Education and Contraception Utilization Table: 6.19 Husband’s Occupation and Contraception Utilization Table 6.20 Types of Contraception and its Related Complications Table 6.21 Medical Help for Contraception related Complications

CHAPTER ONE

INTRODUCTION

1.0 Overview This chapter provides introduction to the present study entitled “Reproductive Health of Women in Indian Slums: A Study of slums in District Aligarh”. It begins with the discussion on the concept and definitions of reproductive health (1.1). Then, in the next section dimensions of reproductive health (1.2), namely, socio-cultural dimension (1.2.1), rights dimension (1.2.2), legal dimension (1.2.3) and clinical dimension (1.2.4) are elaborated; followed by the section (1.3) which deals with scholarly debates on reproductive health. The chapter further moves on to the discussion of indicators of reproductive health (1.4), selected for the present study. Then the following section throws light on the objectives (1.5) of the study, which also includes discussion on the socio-economic correlates selected for this study.

1.1 Reproductive Health: The Concept Reproductive health is a buzz word; it is a comprehensive and complex concept which presents a synoptic view of individual’s reproductive life and behavior. The concept of reproductive health is not static and does not portray a monolithic idea. It is a dynamic concept which recognizes the various socio-cultural aspects affecting individual’s reproductive life. It is important to note that issues of mortality, morbidity, and fertility were at the centre stage right from the 19th century but were in currency as fertility behavior, birth control, family planning, etc. However, the concept of reproductive health is a recent phenomenon which emerged in the 1980s. (Qadeer, 1998) and later brought to the public sphere by International Conference on Population and Development (ICPD) in 1994. The ICPD is in fact designated as a paradigm shift in the field of women’s health and population.

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However, it would be interesting to note that how the concept of reproductive health was defined prior to ICPD. Mahmood Fathalla, in 1988 defined reproductive health as “a state in which people have the ability to reproduce and regulate their fertility; women are able to go through pregnancy and childbirth safely; the outcome of pregnancy is successful in terms of maternal and infant survival and well-being; and couples are able to have sexual relations free from fear of pregnancy and contracting disease”. This definition places more importance on the aspect of child bearing, and ignores the notion of freedom to decide in matters related to reproduction. Though it recognized the need and importance of fertility regulation in reproductive health but missed to incorporate the idea of bodily autonomy in matters of fertility regulation. Another important dimension of this definition is that it gives prominence to the idea of disease in sexual relations without acknowledging and recognizing the social dimension attached to it making it a hegemonic biomedical concept. Correa and Petchesky (1994) stressed that the body exists in a socially mediated universe and should never be overlooked. Similarly, Dixon-Muller (1993) who accommodated the feminist concerns of bodily integrity or control over one’s body in his definition of reproductive health, argued that reproductive health means women’s capability to.

• Understand and enjoy her sexuality by gaining full knowledge of it. • Regulate her fertility through access to services and information • Remain free of reproductive morbidity (and death) • Bear and raise healthy children

This definition includes sexuality as an important aspect of reproductive health, and is remarkable in its conception of reproductive health as women’s ability to understand and enjoy her sexuality. It was an elaborative attempt; still it failed to recognize the situation and conditions in which women can make decisions about their fertility. It also failed to take into account the multidimensionality of reproductive health which received importance in ICPD later. The new paradigm of reproductive health moved birth control out of the umbrella of family planning and planned parenthood into the realm of

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individual rights (Dixon-Mueller, 1993). The definitions and constituent element of reproductive health also underwent significant changes in the 1990s and it received huge prominence. There are remarkable similarities between Malthusian times and the 1990s when the concept was brought to the public fore. Both the periods were characterized by a relentless drive to create free markets, not by chance nor as a result of spontaneous development, but as an artifact of power and statecraft. This new global market was to be created by a second wave of globalization with the imposition of structural adjustment program. Hartman (1995) notes that population control discourses obtained a new lease of life and its resurgence in the 1990s as Cold war obsessions gave way to new definitions of security establishment in the US. Population growth threatened international stability in the post-Cold War period. While it is acknowledged that economic growth and empowerment of women are necessary to reduce birth rates, vigorous family planning measures cost least and were most pragmatic means for defusing the threat to international peace. The American interest is clear: it needed to commit the leadership and resources to a multilateral effort to drastically expand ‘family planning services’ (Carnegie Endowment cited in Hartman, 1993).

At the same time the World Bank underwent a shift of opinion from viewing poverty alleviation as the key to fertility decline to the view that population problems cannot wait for their solution on socio-economic development. Population growth presented an obstacle to economic recovery and thus it is a ‘necessity to succeed with the structural adjustment effort’ (ibid.). 1990s was also a period where the feminist demand of reproductive rights was at its pinnacle. It was the time of the third wave feminism which highlighted the issues of women of color and interrogated the universal assumption of women’s concerns grounded on the post structural paradigm and deconstruction line of thought. The 1990s was also characterized by the conviction that the global environmental problem requires international solutions through immediate intervention. It was during this period the understanding and significance of sustainable development grew as an answer to growing environmental problems. Culturally also the 1990s was the period which witnessed the rise of multiculturalism and technology driven alternative 3

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media and age of internet where there is scope for all the voices to be heard. In such situation whether it is the creation of free markets through globalization, or the call for sustainable development to deal with the issue of environmental degradation or the women’s growing demand for reproductive health all of them have significant bearing on women’s lives and health. It was during this period that ICPD was held and brought reproductive health to the public fore.

The International Conference on Population and Development (ICPD) was held in Cairo, Egypt, in 1994. It was the third population conference organized by the United Nations Fund for Population Activities (UNFPA) and was attended by 179 countries. The ICPD is attributed with many epithets like paradigm shift, landmark, watershed, etc. The reason for such glorification of ICPD is that it put an end to the discussion that had dictated population studies since the first World Population Conference. The World Population Conference in Bucharest in 1974 debated that development is the best contraceptive and, therefore development should be the necessary prerequisite for sustained fertility decline. This view stood against those who asserted that family planning services must be implemented to meet the high demand for fertility control which they believed existed. Bucharest Conference witnessed a wide gulf between these two academic positions resulting into ambivalence and ambiguity in many countries about which approach to take. Ten years later, at the 1984 International Conference on Population, held at Mexico City it was argued that population growth was in fact a “neutral phenomenon” which was essentially a critique of their own stand taken about population in Bucharest consequently bringing more ambiguity and perplexity to the population issue. In this regard the ICPD was a giant leap towards resolving the population issues and its related ambiguity by placing the population problem squarely in the development context and focusing attention on individual needs instead of demographic targets. The ICPD is also credited with providing a comprehensive definition of reproductive health. ICPD Program of Action defined reproductive health as:

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“a state of complete physical, mental and social wellbeing and not merely absence of disease or infirmity in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore 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.” (ICPD, 1995:31)

The ICPD definition of reproductive health acknowledged manifold and multilayered aspect of reproductive health. It viewed the concept as a holistic one encompassing physical, mental and social well-being and not just the physical aspect of reproduction. With the inclusion of dimensions other than that of physicality, it has broadened the scope of reproductive health and resulted into the inclusion of issues like domestic violence and sexuality which were hitherto absent. It also recognizes and addresses the psychological dimensions borne out of the way in which gender relations are played out at the individual level (Wood, Maforah, and Jewkes, 1998). It clearly pays attention to the needs of individuals and on the empowerment of women, and the emergence of an evolving discourse about human reproduction and health. It is a remarkable shift from the previous approach that treated women instrumentally, as tools to implement population program and policies. The reproductive health approach adopted at ICPD is premised on a view that values women intrinsically and is genuinely concerned about their health and well-being. Women’s reproductive capacity was transformed from an object of population control to a matter of women’s empowerment to exercise personal autonomy in relation to their sexual and reproductive health within their social, economic and political contexts. Women’s health in general and their sexual and reproductive health in particular, are determined not only by their access to health services but also by their status in society and pervasive gender discrimination (Shalev, 2000).

Later on after ICPD various scholars defined reproductive health by making the ICPD definition as their base. Shireen J. Jejeebhoy (1997) defined reproductive health as an orientation which mean that people have the ability to reproduce as well as to regulate

CHAPTER ONE: INTRODUCTION

their fertility; that women are able to undergo pregnancy and childbirth safely; that obstetric and gynaecological disorders are addressed; that the outcome of pregnancy is successful in terms of maternal and child health and well-being; and that couples are able to enjoy sexual relations free from the fear of disease. She further elaborates that reproductive health is affected by a variety of socio-cultural and biological factors on the one hand and the quality of the delivery system and its responsiveness to women's needs on the other. So there is a need to have women based reproductive health at policy and program level which should responds to the needs of women in a culturally sensitive manner. From this definition reproductive health could be understood in terms of. • Fertility regulation • Safe pregnancy and child birth • Maternal and child well-being • Sexual relations free from the fear of disease

She further elaborates on the need to see these aspects of reproductive health in the particular socio-cultural setting and the need to have not only quality of services but also the need to have quality of the delivery system which could make the services available to the people.

Saroj Pachauri defined reproductive health as, “prevention and management of unwanted pregnancies, services to promote safe motherhood and child survival, nutrition services for vulnerable groups, prevention and treatment of reproductive tract infections (RTIs) and sexually transmitted infections (STIs), reproductive health services for adolescents, health, sexuality and gender information, education and counseling, establishment of an effective referral system” (Pachauri, 1995). This definition thinks of reproductive health from service delivery point of view and these services required professional help, this way this definition provides ample space for technology and has overlooked the socio- cultural factors which affect women’s lives tremendously. Such definition typifies the technology fixation in reproductive health. With such definitions scholars transform 6

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reproductive health into a gamut of services, all based on technology. Hence the actual operationalization further limits its scope to contraception, maternal and child health services, RTIs and STDs, abortions and sterility (Qadeer, 2011). This technology fixation further got asserted by World Bank which views family planning services as necessary inputs to improve women’s health. Hence fertility control per se becomes the central aspect of public health package (World Bank, 1993).

1.2 Dimensions of Reproductive Health The ICPD definition of reproductive health stretched the scope of reproductive health before and beyond the years of reproduction, and is closely associated with socio-cultural factors, gender roles and the respect and protection of human rights, in regard to sexuality and personal relationships (Mathur, 2008). With such a comprehensive definition of reproductive health, ICPD not only acknowledged but also asserted that reproductive health is not merely about reproduction rather it is a dynamic concept incorporating socio-economic, cultural and political dimension affecting women’s reproductive lives. It is important to note that reproductive health cannot be understood without examining the various dimensions attached to it. For example, anaemia at any time in childhood, adolescence would impact on women’s reproductive health, lack of information of reproductive health services and domestic violence all will have significant bearing on women’s reproductive health. Understanding of spatial interrelatedness, diversified culture, biological growth and its interplay with natural environments enhance a new perspective for examination of reproductive health across the globe. No society, no religion, no culture, and no system of national law have been neutral about issue of reproduction. The subject of reproductive health is a broad concept and very complex in nature as it can encompass many aspects relating to women’s health and its associated environments. Because of its complexity it can be studied under various dimensions ranging from pure medical perspective focusing on biological morbidity and epidemiological analysis to pure socio-cultural. There is enough literature available which reiterate and assert the multidimensionality of the concept. On the basis of the

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existing literature we can categorize the dimensions of reproductive health into the following broad, major categories.

1.2.1 Socio-Cultural Dimension Reproductive health as defined by ICPD is all inclusive encompassing not merely the physical but also the mental and social wellbeing. It should not be seen in terms of clinical, pathological condition associated with reproductive system, its functions and processes. It was asserted by ICPD that reproductive health means 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. It is important to understand that the idea of having contended and safe sex life and the freedom and choice to decide about number and spacing of children all are culture specific and contingent on specific socio- cultural settings. In this light it becomes abundantly clear how reproductive health status is affected by socio-cultural factors. Societal and cultural factors have significant ramifications on all major indicators of reproductive health like total fertility rate, contraceptive prevalence, maternal mortality, etc. In a country like India, where women’s status is significantly related to her fertility career, where child birth is not merely a biological event, rather a social event in such situation the choice to have or not to have children, to have contraception or not is not entirely a women’s prerogative rather they are decided by various familial and kinship relationships like husband, mother, parents- in-laws, neighbors and friends. At the same time various reproductive health indicators like total fertility rate and contraceptive prevalence are affected by many socio-cultural factors like women’s education, age at marriage, perception of ideal number of children, etc. The socio-cultural aspect of reproductive health has a cumulative effect over a lifetime. There exists a strong correlation between the social inequity and reproductive health. Reproductive behavior is shaped by social relations and institutions; it is embedded within specific social relations and political and cultural contexts. Reproductive behavior is shaped by social relations and institutions at the local level, such as kinship groups, informal social networks, local political institutions, and religious and spiritual advisors and healers, which are influenced by and are the product of the 8

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wider social, political, economic and historical processes (Price and Hawkins, 2007). It is important to take into account that women are assigned subordinate status in society, and thus the concept asserts certain enabling conditions as prerequisite for women’s reproductive well being and argues that reproductive health involves one’s relationship with children, sexual partners, caregivers, community and society at large (Correa and Petchesky, 1994). Socio-cultural dimensions have significant bearing on various components of reproductive health like maternal health, family planning, STDs, etc. It is abundantly clear that the reproductive health is not only a matter of access to services but is contingent on status of women in society which is shaped by gender relations in the society (Shalev, 2000). In area of health particularly reproductive health it is well accepted that gender plays a crucial role in women’s vulnerability, the exposure to disease and in their health seeking behavior, their ability to access health services, their experience of health services and social and economic consequence of a health problem. Women’s health seeking behavior is very gender specific and particularly when it comes to health seeking behavior towards a reproductive illness or morbidity it is often associated with shame, guilt and doubt. Even the health care providers also have gender biases. Their lack of understanding of the ways in which gender roles affect women’s health seeking behavior can often lead to victim blaming.

The United Nations conferences in Cairo and Beijing also established the importance of gender as a critical dimension of reproductive health (Mathur, 2008). Though gender is crucially related to socio-cultural dimension but because of its magnitude it has received prominence in reproductive health literature, hence needs to be discussed separately. The ability to make free and informed choices in reproductive life, including those involving childbearing, underpins self-determination in all other areas of women's lives. In that respect also gender receives attention, because these issues affect women so profoundly, reproductive health cannot be separated from the wider goal of gender equality (UNFPA, 2005). The effect of gender on sexuality and reproductive health of women and men are reflected in the control of women’s bodies, their sexuality, and their reproductive health rights. Another important aspect of gender dimension is women empowerment. Cairo 9

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Program of Action marked a new understanding among world bodies that population and development are inextricably linked, and that women's empowerment is the key to both. In fact the concept of reproductive health is applauded for incorporating these dimensions. Expanding the scope of population policy to include the context in which reproductive decisions are made permits us to assess more realistically the forces that affect reproductive motivations and behavior. In this way, gender and “women's empowerment” issues become key elements of reproductive health. Women's empowerment includes extending them all civil, cultural, economic, political and social rights. It involves processes by which women are empowered to express and defend their rights and to gain greater self esteem and control over their own lives and relationships (Farah, 2005). The reproductive health agenda with a gender perspective also includes the unequal power dynamics between two sexes and demonstrate that its implementation is beneficial for both men and women in the long run, and to develop a vision of gender equality that can liberate both sexes from the constraints of traditional unequal arrangements (Obermeyer, 1999).

1.2.2 Rights Dimension Reproductive health is significantly influenced by rights discourse to the extent that it got its place in IPCD document where reproductive right is defined as basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have information and means to do so and the right to make decision concerning reproduction free of discrimination, coercion and violence as expressed in human rights documents (IPCD, 1995). The rights dimension of reproductive health has two important philosophical bases human rights dimension and feminist orientation. With such orientation reproductive health is not only a matter of effective health interventions, but also a matter of social justice and human rights particularly when women have subordinate status in society. Hence the improvement of reproductive health is not only a matter of effective health interventions, but also a matter of social justice and human rights. Reproductive rights is an essential component of reproductive health which centers around idea of freedom to decide how many children 10

CHAPTER ONE: INTRODUCTION

and when to have them; the right to have information and means to regulate one’s fertility; the right to “control one’s own body” that is bodily autonomy (Dixon-Mueller, 1993).The right to have reproductive decision making and the right to have information is based on philosophy of human rights, while the issue of bodily autonomy have feminist leanings.

Wang (2004) argued that the rights orientation emerged from:

• The observation that the absence of rights or the violation of rights frequently has negative health consequences. • The assertion that if women have the right to make important choices about their reproductive lives, they will pursue strategies that, whatever else they do, maximize their own and fetuses'/children's health.

1.2.3 Legal Dimension Within the legal and statutory dimension it is the state which plays a crucial role in promoting reproductive health. Addressing social vulnerabilities is crucial for reproductive health. One of the major strategies to addressing this is through legislative measure. The legal dimension attached to reproductive health cannot be overlooked. In India, state has provided several legislations like Pre-Conception and Pre-Natal Diagnostic Techniques Act, 1994 (PCPNDT) and Medical termination of pregnancy act, 1971 to promote reproductive health at the same the abuse of the same statutory could be equally exploitative towards the reproductive health status of women. The issue of abortion rights for which the western women fought for long but their Indian counterpart got it on the platter. In case of India abortion is legalized through act which is no doubt is abused in terms of sex selective abortions. Maternity Benefit Act is another statutory measures which highlights the legal dimension attached, there are various other statutory measures related to reproductive health. The state may also respond to the political pressure brought upon it by women who fully participate in the decision-making process of initiating new reproductive rights provisions. 11

CHAPTER ONE: INTRODUCTION

1.2.4 Clinical Dimension The definition of reproductive health by ICPD clearly articulates clinical dimension attached to reproductive health. Under clinical dimension there are various indicators of reproductive health like antenatal care, child delivery, post natal care, mortality, family planning particularly sterilization, sexually transmitted disease, etc. In fact all those indicators which require clinical intervention and a clinical setting fall under clinical dimension. Contraception also finds its place within this dimension which is required for fertility regulation and to surmount the anxiety of pregnancy. Even the issue of maternal well being is significantly attached to contraception. The definition of reproductive health given by Fathalla (1988) asserts the clinical dimension which has dominated the reproductive health particularly before ICPD. Further, the clinical dimension could also be understood as a matter of service delivery and quality of care. However, since reproductive health as a concept and approach is so complex that various dimensions and indicators are interlinked like issues of institutional delivery, family planning, abortion, etc. are not only a clinical matter but has major socio-cultural implication particularly in a country like India where the status of women is significantly linked to her fertility. So any aspect attached to her fertility should be seen in broader socio cultural spectrum. Like the issue of RTIs and STDs looks like more of a clinical issue, primarily seen in terms of symptoms and service delivery. But it is important to understand these clinical issues cannot be detached from the social environment in which women live. We cannot negate and ignore that women are socialized in such a way that there is self denial and diffidence when it comes to acknowledge a health problem, and particularly a gynaecological problem, in such situation these gynaecological, sexual problem is not merely a matter of symptoms and services. Women’s health seeking behavior particularly their decision-making, freedom of movement has significant implication on major clinical indicators. But there is also a tendency to overemphasize the clinical dimension. In such a situation it is imperative to understand that such dimension also problematizes the concept by overtly promoting medicalization which is based on biomedical concept, often used to refer to a process of mystification of social inequalities. With such discourse, the body is seen as unique and this uniqueness is attributed to biology by 12

CHAPTER ONE: INTRODUCTION

ignoring the socio-cultural and spiritual factors (Holen, 2003). It becomes imperative to understand the interlinkages of various indicators of reproductive health rather than looking at one single indicator separately.

1.3 The Debate The concept of reproductive health generated intense debate across the world. In this section an attempt is made to capture the major points of this debate. There are scholars who have whole heartedly applauded the concept of reproductive health appreciated it as a paradigm shift, watershed, remarkable, etc. and there are others who refused to believe in its goodness. They rather consider it a mere euphemism to family planning, old wine into new bottle. To have clear understanding of the concept it is imperative to analyze both the academic positions related to reproductive health. The reproductive health approach is a radical shift from the demographically driven, technology-based, directive, top-down approaches to program planning and implementation which had dominated the population field erstwhile. It is indeed a paradigm shift from the earlier family planning and maternal and child health approach where the total fertility rate and the contraceptive prevalence rate was an important marker towards these approaches (Farah, 2005). Reproductive health brings about a demedicalized notion of health through the inclusion of social, economic and psychological components. Reproductive health is also designated to emphasize women as human beings where their needs are placed in socially negotiated space in which women live (Balakrishnan, 1996). It recognizes the certain enabling conditions, which is instrumental for women’s overall reproductive health status. Whereas earlier, women were treated primarily as reproductive beings whose fertility need to be curtailed without any recognition to their socio-cultural milieu (Bandrage, 1997).

Bergman (1986) also holds similar opinion when she view reproductive health rest on the recognition on the imperativeness to address the inequities within societies; elimination of gender-based discrimination and promotion of women empowerment. The unequal power relations between men and women profusely influence sexual behavior and

CHAPTER ONE: INTRODUCTION

reproductive choices. Reproductive health clearly acknowledges the discriminatory gender based practices which is critical for reproductive health status of a woman. With uneven and gendered social structure, empowerment of women not only becomes an answer to address the disproportionate power dynamics but is the key to facilitate women to be an active agent in matters related to reproductive process.

The Reproductive health approach clearly articulated and accommodated the reproductive rights perspective which is basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have information and means to do so and the right to make decision concerning reproduction free of discrimination, coercion and violence as expressed in human rights documents (IPCD, 1995).

Reproductive health is determined by people’s exercise of their reproductive rights as a matter of fact reproductive rights act as an essential prerequisite for better reproductive health status (Turmen, 2000). However, to believe that the concept offers all goodness and is beyond any interrogation would be equally misleading and deceptive. There is plethora of literature available which doubts the credibility of the concept and which cannot be overlooked.

There are scholars who have serious reservations in accepting the inherent goodness and novelty of reproductive health. Rao (2004) totally rejects the epithet ‘paradigm shift’ given to reproductive health and argues that there is nothing new or novel to this concept it is old wine into a new bottle and has dedicated whole chapter in his book discussing it in detail. He argues that it is a mere euphemism to family planning program, a tactical move to overcome the criticism of the family planning program. He also questioned various powerful institutions like World Bank and other population control lobbies. He viewed that with the concept of reproductive health these powerful establishments have actually politically rationalized the much condemned family planning program (ibid.). It is equally interesting to note that even the family planning enthusiasts have vehemently 14

CHAPTER ONE: INTRODUCTION

criticized the concept by arguing that the vertical family planning programs which were yielding results particularly in curtailing fertility are far more competent than comprehensive reproductive health approach. They argue that with inadequate resource availability, dealing with the problem of population should not to be stretched to social engineering - that is, gender equity, empowerment, and rights proposed by the concept (Germain, 1997). Further, reproductive health is often conflated with family planning, it strengthens the heteronormative versions of sexuality where sex primarily and necessarily is allied to reproduction and reproduction to “families,” and a slightest deviation from is bracketed into atypical socially, psychologically and even pathologically. Such categorization positions the issue of sexuality into the medical domain. The recent issue of Indian athlete Pinky Parmanik is one big example of such medicalization of sexuality.

It is intriguing that in spite of the emphasis on ‘empowerment’ and ‘enabling conditions’ for which the concept is applauded for is heavily influenced by the notion of ‘biological vulnerability’ of women (Das Gupta, Krishnan, and Lincoln, 1994) because of which the social process of bearing and rearing children turned essentially a biological event which also comfortably accommodates and provide ample space to modern medicine which is overtly hegemonic.

Reproductive health is also questioned for its universalistic assumptions which has peripheralized the health issues of women of color and conveniently merged all into universal reproductive health and rights issues (Qadeer, 1998). Commenting on the discriminatory practices affecting women’s health Petchesky (1987) argues that the conditions under which choices are made more important than the content of women’s choices. She vigorously pointed that the “right to choose' means little when women are powerless” (Petchesky, 1987).

Reproductive health was indeed a paradigm shift; it was a divergence from the earlier demographically driven programs and policies. It was a radical shift at least in rhetoric. It did recognize the various socio-cultural factors affecting women’s lives, hence it has

CHAPTER ONE: INTRODUCTION

given prominence to women empowerment which was earlier not only overlooked but was rather negated.

It would be really unfair to expect socio-cultural overhauling from reproductive health as the critics are pointing. But at the same time there is need to have an understanding that the subjective experience of women should not be neglected and their voices should be included at program level. It should have an understanding that power relationships between sexes within socio-economic context constantly impinges and alters power relations within families (Adams and Castle, 1994).

1.4 Indicators of Reproductive Health WHO has developed 17 indicators for global monitoring of reproductive health (WHO, 2006) (for detail, see Chapter 2, The Realities (2.2), however, it is be beyond the scope of this study to study all the indicators of reproductive health. This study focuses only on fertility, antenatal care (ANC), institutional delivery and contraceptive practices.

1.5 Objectives This study aims to analyze reproductive health of women in slums. The study proposes to realize its broader aim through certain research objectives. The following are the research objectives which this study intends to achieve to arrive at the broader aim of this study. 1. To examine fertility trend of women in slums.

2. To investigate the nature and extent of ante natal care utilisation among women in slums.

3. To explore the extent of institutional and home delivery among women in slums.

4. To understand the contraceptive practices among slum dwellers

5. To analyze and assess the influence of socio-economic correlates namely caste, education of women and occupation of the husband on fertility, ante natal care utilisation, institutional delivery and contraceptive practices of women in slums.

CHAPTER ONE: INTRODUCTION

The review of literature on reproductive health suggests that there are numerous factors which affect reproductive health (for details, see Chapter 3). The present study tries to look into the effect of certain socio-economic variables, namely, education of women, caste of women and husband’s occupation on reproductive health.

Education is considered one of the major indicators affecting reproductive lives of women. There are numerous studies which have looked into the relationship between women’s education, husband’s education and indicators of reproductive health. However, there are few studies which have taken education of women and its effects on reproductive health of women in slums and that too women in slums of smaller cities like Aligarh.

Caste is one of the unique features of Indian social structure and all human behaviour is affected by caste affiliation as each caste has its distinctive social customs, traditions, practices and rituals. Urban sociologists have commented that cities are multicultural and heterogeneous site which leads to breakdown of rigid social composition. It is assumed that the effect of caste gets flattened and mollified in urban setting, but caste is an important social reality in India. There are numerous studies which have looked into the effects of caste on reproductive behavior of women (for detail, see Chapter 2), but majority of them have focused in rural societies. There is dearth of studies focusing on the impact of caste on reproductive lives of women living in slums. Rao (2004) in his book provided an exhaustive review of studies on reproductive behaviour of women. He concluded that the social differences were not analyzed in these studies on fertility, family planning and contraceptive practices in India. In his review of 550 studies only 11 studies had looked into the difference in reproductive behaviour through caste or education of women. There are very few studies which have explored the effect of husband’s occupation on reproductive behavior of women and in those few studies most of them were of rural societies. There is absence of studies focusing on husband’s occupation and reproductive behavior in slums in India

CHAPTER ONE: INTRODUCTION

The study proposes to study the slums of Aligarh district but because of the unavailability of data on slums in district Aligarh, the study focuses only on slums of Aligarh city, data of which is available with Aligarh Municipal Corporation. After numerous visits to municipality office of Khair and Beswan the researcher came to know that there was no data of slums available of the two urban agglomerations of Aligarh. Similarly, the other urban agglomerations of Aligarh district also did not have data records of slums. The researcher made repeated visits to district headquarter and municipal offices even as recent as February, 2017 but the data was not available. The researcher therefore focused this study on the slums of Aligarh city instead of district Aligarh after much contemplation and deliberation.

1.6 Conclusion

Following the inquiry into the concepts, definitions, and dimensions of reproductive health, in this chapter, we saw that reproductive health is a departure from the top down approach to family planning. It is indeed a paradigm shift and has accommodated the qualitative aspects of women’s life and emphasizes the socio-cultural space in which a woman lives. These issues have significant bearing on reproductive health of women. It can be concluded that reproductive health is not merely about reproduction rather it should be seen as a dynamic concept incorporating socio-economic, cultural and political dimensions that are inextricably linked to women’s reproductive lives.

The chapter has also looked into various debates on reproductive health and reached to the conclusion that it is a unique concept. Ironically, however, at the policy and program level it remains as the extension of the earlier techno-centric and quantitative driven family planning programs.

CHAPTER TWO

REPRODUCTIVE HEALTH IN POLICIES AND REALITIES

2.0 Overview This chapter offers discussion on reproductive health in policies and realities. The chapter starts with deliberation on policies and programs on reproductive health in India (2.1) which includes family planning program (2.1.1), reproductive and child health (RCH) program (2.1.2) and population policy (2.1.3). The next section deals with realities (2.2) where the indicators of reproductive health are discussed. National statistics (2.2.1 to 2.2.13) on these indicators are provided to see them in perspective.

2.1 Policies and Programs in India Since independence, several policies and program interventions have been formulated to address the issues of reproductive health in the country which are indicative of the shifts in the government’s priorities and commitment vis-à-vis reproductive health issues. The first decade after independence was dominated by the clinical approach in reproductive health which was preceded by the extension-education approach before the political disillusionment caused by the Emergency period which was overshadowed by draconian population policy of 1977 and the abuse of forced sterilization. The subsequent policies and programs took lessons from the aftermath of military usage of targets in reproductive health approach. But the real shift came in the 1990s when existing policies and programs underwent significant changes by adopting client based approach, respecting the need of the people. These include, notably, the Family planning Program, National Population Policy (2000) and Reproductive and Child Health Program.

2.1.1 Family Planning Program With the dawn of independence, the realization that population was a major problem the government launched the “rubric of family planning program” (Desai, 1980), a comprehensive multi sided program to control population growth. It achieved the

Chapter Two: Reproductive Health in Policies and Realities

distinction to be the first government to adopt Family planning as an integral part of its socio-economic development plans in 1952 (Mitra, 1978). So the conclusion can be drawn that right from the beginning family planning program was envisaged as an integral part of a comprehensive social development program (Zodgekar, 1996). The program has since evolved with different direction, emphasis and strategies. Family planning Program now a Family welfare Program had changed its orientation on multiple occasions, sometimes as a subset of health, at times as set with health and also a time came when family planning became equivalent to health but superseded with huge funds for family planning (Mitra, 1978). Even the approach and methodologies kept on changing from clinical to extension education and then came a period when the government had target fixation syndrome making target an end in itself not the means to bring decline in fertility. Finally, with ICPD came the client centered target free approach and comprehensive reproductive health approach (Bose and Desai, 1989). However, family planning is a multi disciplinary field and hence cannot be categorized as one single domain in fact Bose (1988) asserted the need to look into the qualitative aspect of family planning and in fact criticized Indian family planning program of being a monolithic program.

The family planning program during the first five year plan period primarily based on clinical approach which was passive based on the assumption that there existed sufficient unmet demands for family planning services. The family planning program envisaged in the first five year plan meant to educate people not inform on methods of family planning. It is also interesting to note ‘active and innovative role’ played by the international agencies like Ford Foundation and others right from the beginning (Rao, 2004).

The second plan period viewed population totally isolated from the issues of health, survival, food, employment, incomes and so on. It presumed population as an impediment to economic development (Dreze and Sen, 1987). It is quite evident that the second plan viewed population growth as an independent variable and economic development the dependent one .The second plan received increased allocation. It was

Chapter Two: Reproductive Health in Policies and Realities

during the second plan period when the central family planning Board, chaired by the Minister of health was set up and the state family planning committees were established in all states. During this period, the institutional structure for a powerful, separate and vertical program was established (ibid).

It is important to note that the operational strategy of family planning program during the first two plan periods was informed by the international planned parenthood movement (Banerjee, 1976). During the third plan period the Mudaliar committee report of 1961 recommended that ‘if the family planning program is to produce early and effective results, it has to be a mass movement. It also recommended that family planning should be the essential part of the activity of all health agencies (Government of India, 1961). This plan period also witnessed the change in the nomenclature of ministry of health and it became ministry of health and family planning it was not merely a semantic move but indeed suggested the utmost importance attached to family planning.

The limitations of the clinical approach of first two plan periods became apparent. The director of family planning was suggested by a Ford Foundation consultant to initiate reorganization (Demerath, 1976). The reorganized program emphasized extension education approach with greater availability of contraceptive supplies and less dependence on clinical approach. The move was a clear shift from the passive clinical approach to active more extension approach again influenced by the community development movement in the US (Banerji, 1985). During this period in 1965 United Nations advisory mission visited India and suggested the launch of the reinforced program and suggested IUCD program, an intensified sterilization and the promotion of the use of condoms through wider availability via commercial channels as a course of action (Raina, 1988). This was based on the assumption that family planning is a result of contraceptive technology singularly and there exist an unmet need for technology driven, provider dominated contraception among the majority of agricultural based poor people of India which was later on enforced and strengthened by the plethora of KAP (Knowledge Attitude Practice) studies that were undertaken. This was also the period which was marked by greater foreign donors and international expert’s involvement (Rao, 2004).

Chapter Two: Reproductive Health in Policies and Realities

During the period of 1966-69, India had several annual plans; family planning received its attention in these annual plans also. With the fourth FYP the severity of population as a problem got further intensified and family planning program received the highest priority (Government of India , 1969). This plan proposed to step up the target of sterilizations and IUCD insertions and to popularize the acceptance of oral and inject able contraceptives (Government of India , 1969). So the fourth plan was similar to third plan with little alteration in a sense that now vasectomy came to occupy the centre stage in the family planning program instead of the earlier IUCD approach which failed. This plan is also marked with the passage of the Medical Termination of Pregnancy Act (MTPA), 1971 which legalized abortion by recognized practitioners on medical grounds. The abortion right for which the western women fought for over a century, the Indian women had it on platter. It was not a matter of entitlement for Indian government rather the overriding philosophy behind this progressive legislation was the government’s urgency to control fertility (Rao, 2004).

In the fifth five year plan the program for family welfare planning received the same high priority as it had in the fourth plan (Government of India, 1974). Though the strategy adopted was to integrate family planning services with those of health, maternal and child health (MCH) and nutrition. The motive was to convert the vertical program workers into multi-purpose workers who are supposed to pay special attention to family planning. But this was also the period of political disillusionment of Emergency which finally facilitated the passage of the draconian population policy in 1977 (Batabyal, 2004). The policy suggested host of incentives and harsh disincentive, increased monetary incentives for sterilization like grant of government permits, rural credit and even fertilizer conditional on sterilization certificate ;refusal to school admission to children of parents with more than two children and so on (Ministry of Home Affairs, 1978). The political atmosphere of that time provided an atmosphere which compromised citizenship with fertility, advocated compulsory sterilization and involvement of state machinery to achieve what had hitherto been thought of as ‘unthinkable’ (Minkler, 1977). The unpopularity of forced sterilizations, led to the electoral defeat of Congress Party in 1977, which signaled the end of coercive anti democratic family planning policies. To conclude

Chapter Two: Reproductive Health in Policies and Realities

the fifth plan period witnessed the failure of another approach of family planning that was coercion.

The sixth five year plan stressed the need integrating the problems of public health and proper coordination of activities of different departments having a bearing on family planning such as maternal and child care (Government of India, 1980). The plan also took note that the family planning program has to be made part of the national effort to provide a better life to people’s and highlighted the plan’s anti poverty program and programs for literacy, particularly female literacy and nutrition programs in this regard. It is in this way that the female literacy got thus significance, not in fact as a matter of rights and gender justice. The sixth five year plan is also important as it was during this period India had its first health policy much later than the first family planning program. During the sixth plan female sterilization received prominence with somewhat military zeal. This period also witnessed trials of injectables (NetEn, Depo), implants (Norplant) and vaccines which were doubtful in the UK and the US. Depo was in fact banned in the US (Rao, 2004).

The seventh plan noted that the performance of the MCH Component, immunization and ante natal care was not satisfactory lack of infrastructural facilities was attributed for this poor performance (Government of India, 1985). The plan recommended strengthening of the health infrastructure and the vigorous implementation of the program particularly in the poorly performing north Indian states, the plan also emphasized the need to pay greater attention to maternal and child health (MCH) to enhance child survival. During this plan in 1986 a new population policy was pronounced which asserted the importance of family planning as a requisite for country’s growth and development. The policy articulated the government commitment to promote voluntary two child norm. For this the policy committed to curtail morbidity and mortality rates particularly early childhood mortality through strengthening of health services, enforcement of law related to age at marriage, health and population education and employment facilities for women and so on (Rao, 2004). Over the period of seventh plan the program was pursued with renewed vigor, focusing or rather targeting the most vulnerable sections of India’s population – poor women (ibid). After the release of eighth five year plan, the government itself

Chapter Two: Reproductive Health in Policies and Realities

recognized and publicly acknowledged the inherent constraints in state-administered social-sector programs in general, and the limited impact of the family welfare program on birthrates in particular (Visaria, Jejeebhoy, and Merrick,1999).

During the eight five year plan period Indian government decided to abolish method- specific family planning targets throughout the country and in 1997, India reoriented the family welfare program and radically shifted its approach. The Department of Family Welfare initiated the Reproductive and Child Health (RCH) program aimed at providing integrated health and family welfare services to meet health care needs of women and children. The new approach involved a more comprehensive set of reproductive and child health services with emphasis on client choice, service quality, gender issues and underserved groups. The reorientation in the family welfare program was the also the result of the pressure exerted by the women’s group and the ‘paradigm shift’ brought about by ICPD, 1994.The eighth five year plan period marked the removal of method specific targets and asserted the client based approach. But Rao (2004) asserted that removal of target was restricted to policy makers at the centre. The states were skeptical and thus target free approach became a mere rhetoric.

The ninth Plan received priority to meet the felt needs of for contraception, and to reduce the infant and maternal morbidity and mortality to achieve desired reduction in fertility level. This period also saw the announcement of two important policy documents, National population policy 2000 and National Health policy, 2002 both the policies has accommodated private sector in big way.

The Tenth Plan operationalized the paradigm shift, which began in the Ninth Plan and it was the Tenth plan that illustrious national rural health mission was launched in 2005 throughout the country with special focus on 18 states, including eight Empowered Action Group (EAG) States, the North-Eastern States, Jammu and Kashmir and Himachal Pradesh. Under the National Rural Health Mission, 2005 various program were launched to ensure safe delivery and child survival along with the emphasis on family planning.

Chapter Two: Reproductive Health in Policies and Realities

The eleventh Five Year Plan emphasized need to improve the sex ratio for age group 0–6. It suggested State-specific goals from ensuring effective implementation of the Pre Conception and Pre-Natal Diagnostic Techniques (PC and PNDT) Act. It also sought to create public awareness measures against relentless use of Pre Conception and Pre-Natal Diagnostic Techniques (PC and PNDT) Act. The Eleventh also introduced National Urban Health Mission (NUHM) on the similar lines of National Rural Health Mission. NUHM aims to improve the health status of the urban population in general, particularly the poor and other disadvantaged sections by facilitating equitable access to quality health care, through a revamped primary public health care system, targeted outreach services and involvement of the community and urban local bodies.

Twelfth FYP also viewed family planning as a central strategy to address not just the issue of population stabilization but also socioeconomic development, and improving the health indicators for women, mothers and children alongside. It proposes to reduce IMR and MMR, TFR, sex ratio and child sex ratio. It emphasizes spacing method of contraception, post partum contraception, male involvement in contraception and information and services through Public-Private Partnership (Planning Commission, 2013).

2.1.2 Reproductive and Child Health (RCH) Program India was one of the first developing countries that started a national Family Planning program in 1952 which was dictated by demographic concerns of lowering birth rate and population growth rate. The 1960s is identified as the period with method-specific family planning targets, where the major focus was on sterilization. Later on the program evolved into Family Welfare Program which included family planning and maternal and child health services along with child survival and safe motherhood (Visaria, Jejeebhoy, and Merrick, 1999). However, the real shift came after ICPD at Cairo in 1994 when the GOI responded with the adoption of Reproductive and Child Health (RCH) Program. Rao (2004) noted one of the major consequences of ICPD was the formal removal of method specific targets in April 1995 on an experimental basis from Kerala and Tamil Nadu and from 17 districts in other states. In April 1996, targets were removed from all over the

Chapter Two: Reproductive Health in Policies and Realities

country. Hereafter (April 1996), the family welfare program is being implemented on the basis of Community Needs Assessment Approach (CNAA) which later on culminated into Reproductive and Child Health (RCH) program in 1997 (Ministry of Health and Family Welfare, 1997). The RCH program integrated and strengthened all the existing interventions under Child Survival and Safe Motherhood interventions and also included the component of Reproductive Tract Infection (RTI) and Sexually Transmitted Infections (STIs).The RCH program intended to provide need based, client centered, demand driven, high quality and integrated RCH services to the beneficiaries (Ministry of Health and Family Welfare, 1997). It is clearly evident that Indian Family welfare program profoundly altered its approach from passive clinical to comprehensive reproductive and child health approach where all targets were removed ; incentive payments to both providers and acceptors of family planning methods were phased out; emphasis on increased utilization of existing facilities rather than creating new structures; and incorporated the voluntary and private sectors to increase access to services and fill gaps left by public-sector providers (Visaria, Jejeebhoy, and Merrick, 1999).

The 2nd phase of RCH commenced in 2005 which continued with the client-centered, quality driven, reproductive health approach. The focal point of the RCH II program was to reduce the Maternal and Child Mortality and Morbidity with emphasis on rural health care. Essential Obstetric Care and Emergency Obstetric Care with focus on institutional Delivery and safe delivery received prominence in RCH II. Towards the essential Obstetric Care and Emergency Obstetric Care it is important to have proper functioning of Primary Health Centers (PHCs) and all Community Health Centers (CHCs). The operationalization of PHCs and CHCs as 24-hour delivery centers and Emergency Obstetric Care with Operational First Referral Units along with the strengthening of referral system is the major strategies of RCH II. The issue of safe abortion also received prominence in RCH II. The management of unwanted pregnancy through early and safe MTP services as envisaged under the Medical Termination of Pregnancy Act is an important component of RCH II. Based on the assumption of democratic decentralization under RCH II the states also received more flexibility to plan their own interventions to

Chapter Two: Reproductive Health in Policies and Realities

realize the goals. RCH II envisaged a bigger role of the private sector in service delivery. The private sector plays a significant role particularly in curative health services in the country. The engagement of the private sector especially in family planning services would potentially expand the coverage of quality services. In this direction public-private partnerships is seen as a catalyst to meet demand and have a synergistic impact of the RCH II. This public-private partnership is guided by monitoring and regulatory mechanisms for efficient and quality service delivery (Ministry of Health and Family Welfare, 2008).

RCH II also introduced innovative strategies and programs to stimulate demand for safe delivery and other RCH services. Janani Suraksha Yojana (JSY) is one such program. JSY is a modified version of the National Maternity Benefit Scheme. It is a program launched under the National Rural Health Mission (NRHM) in 2005, the Government of India's flagship health program JSY is a cash incentive safe motherhood scheme which intends to reduce maternal and infant mortality by promoting institutional delivery. It provides a cash incentive to mothers who deliver their babies in a health facility and also provide cost reimbursement for transportation. JSY recognized the Accredited Social Health Activist (ASHA), as an effective and valuable link between the Government and the community member and offers incentives to ASHA for encouraging mothers to go for institutional delivery. With the introduction of ASHA it was intended to bridge the gulf between the provider and the client, thereby motivating women and their families to seek delivery care at a health facility. The scheme is implemented in all states and Union Territories (UTs), with special focus on low performing states. The scheme also accommodates private sector by giving accreditation to willing private hospitals/nursing homes for providing delivery services (Ministry of Health and Family Welfare, 2008).

1996 was a historic moment when the Indian government decided to overhaul its demographically driven family welfare program. The introduction of RCH program in 1997 is considered a major step towards client centered, target free, quality driven services. Now the question arises whether it was mere policy rhetoric like it is accused of or is it indeed a comprehensive, choice based program? Datta and Misra (2000) assert

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that RTIs is the only inclusion to the existing program after Cairo, which is seen as an obvious manifestation of the medicalized notion of reproductive health. RCH is widely applauded for being comprehensive but as a matter of fact a wider range of reproductive needs of people didn’t figure out in the program like infertility, adolescent needs and the reproductive needs of older women. Thus it remained the same like it was, RCH too primarily concern with the needs and demands of the childbearing women. What is more problematic and debatable in the RCH program is inclusion of child health in reproductive health. It raises many issues why women always viewed in their reproductive capacity i.e. in maternal role (i.e. with children) by policymakers in India. Why cannot a woman be treated as an independent individual who could need reproductive health services without being a mother? But the women’s reproductive trajectory is still considered instrumental in country’s demographic future by the policy makers. Another important and remarkable feature of RCH program is women empowerment for which it should be applauded also. However, it is equally important to see and analyze women empowerment for whom, here also the policy makers view empowerment as a means not an end (Datta and Misra, 2000). Despite the various criticism of the RCH program discussed here what cannot be negated is the fact the RCH program is indeed a new start towards more democratic, comprehensive, more inclusive program which respects women’s needs and aspirations.

2.1.3 Population Policy In order to locate the descent of population policy in India it is important to look at the policy scenario before ICPD. How was the population policy in India, what were the philosophical bases of the policy. Efforts towards an official policy and program were first made in early decades of the 20th century, way back in 1938 Indian National Congress established the National Planning committee which had a separate subcommittee dedicated to population. The second effort in this direction was the famous Bhore committee in 1943 which recommended state assistance in birth control movement for the health of the mother and on economic grounds, in the interest of individual and community (Government of India, 1946). Later on the political emergency declared by the Prime Minister Indira Gandhi facilitated the passage of the National population policy

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in 1977 by then Minister of Health and Family Planning, Karan Singh who abandoned his own statement of “development is the best contraceptive” given at Bucharest, Batabyal (2004) termed it a “draconian population policy”. This Population Policy gave liberty to state legislature to pass policy making sterilization compulsory. The policy made family planning performance the criteria for financial allocation in the states and suggested host of incentives and harsh disincentive, increased monetary incentives for sterilization; grant of government permits, rural credit and even fertilizer conditional on sterilization certificate ;refusal to school admission to children of parents with more than children and so on (Ministry of Home Affairs, 1978). The policy had set targets for sterilization at various administrative levels and also recommended freezing of parliament seats based on the states performance of family planning. Actually the political atmosphere of that time provided a fertile ground for adoption of such policy which compromised citizenship with fertility, advocated compulsory sterilization and involvement of state machinery to achieve what had hitherto been thought of as ‘unthinkable’ (Minkler, 1977).

With the unpopularity of forced sterilizations, the Congress Party’s had sweeping electoral defeat in 1977, which signaled the end of coercive anti democratic population policy. When Indira Gandhi returned to power in 1980, after learning the lessons of her electoral demise, she asserted that, in order to achieve the target of family limitation, “persuasion” was preferable to “coercion” (Véron, 2006). With this the democratic spirit was uphold but whether it was merely rhetoric or democratic values are actually intact at execution and implementation level is another thing. People’s mind fresh with the abuse of the forced sterilization created a fertile ground to demand a people oriented population policy and in 1986 a new population policy was pronounced which asserted the importance of family planning as a requisite for country’s growth and development. The policy articulated the government commitment to promote voluntary two child norm. For this the policy committed to curtail morbidity and mortality rates particularly early childhood mortality through strengthening of health services, enforcement of law related to age at marriage, health and population education and employment facilities for women and so on (Rao, 2004).

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With the growing pressure exerted by women’s groups and health groups in the country demanding for a radical reconsideration of the family planning program the government of India appointed an Expert Group to chart out a new population policy. The Report of this group, commonly known as the Swaminathan Committee Report, proclaimed a policy that it described as pro-poor, pro-nature and pro-women. The Committee proposed a holistic approach visualizing overall social development as the goal. It proposed the idea of merging family planning with the health department; vehemently rejected both the target and the incentives for which the Indian family planning program was synonymous for and flagged the importance of using institutional arrangements for development offered by the 73rd and 74th Amendments to the Constitution. This actually had happened months before ICPD and in 1996, based on the recommendations; the government of India announced a Draft Statement on National Population Policy (Government of India , 1996). In February, 2000 this draft was modified, accepted by parliament and National Population Policy (NPP) 2000 was announced.

The policy “affirms commitment of the government towards voluntary and informed choice and consent of citizens while availing of reproductive health care services, and continuation of the target free approach in administering family planning services” (Government of India, 2000).The immediate objective of the NPP is to meet the unmet need for contraception and health infrastructure and to provide integrated service delivery for basic reproductive and child health care. The medium term objective is to bring the total fertility rate to replacement levels by 2010 through inter-sectoral action and the long-term objective is to achieve a stable population, consistent with sustainable development, by 2045. In pursuance of these objectives, the NPP formulated certain National Socio-Demographic Goals to be achieved in each case by 2010 which included.  Making school education free and compulsory up to age 14.  Reducing IMR to below 30 per 1,000 live births.  Reducing the maternal mortality ratio to below 100 per 1,00,000 live births.  Promote delayed age at marriage.  Achieve 80% institutional deliveries and 100% deliveries by trained persons.

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 Universal access to information and counseling, and services for contraception with a wide basket of choices 100 % registration of vital events – births, deaths, marriages and pregnancy.  Prevention and control of communicable diseases, especially AIDS.

The strategies to achieve these goals include decentralized planning and implementation through panchayati raj institutions (PRIs); convergence of health services at the village level; empowering women for improved health and nutrition; ensuring child survival interventions; involving diverse health care providers; mainstreaming Indian systems of medicine and Homeopathy; emphasis on under-served population groups which includes urban slums, tribal communities, hill area populations and displaced and migrant populations, adolescents and increased participation of men; developing increased partnership with NGOs and the private corporate sector; Providing support for the Older Population; strengthening IEC and finally, encouraging a range of clinical, laboratory and field research on maternal, child and reproductive health care issues.

The National Population Policy (NPP), based on the ideas of the Swaminathan Committee Report is an effort to move away from the demographically driven target- based approach. However NPP do have a subtle disincentive approach in the sections dealing with the institutional arrangements for delivering the policy. At the same time, the NPP also emphasized the importance of high quality social development services at the ground level as being the most crucial arrangement for enabling people who would like to have fewer children to exercise that will (Rao, 2001). One of the most striking aspects of NPP is that it had absolutely no links with health policy and other livelihood issues. Population after all cannot be looked into isolation it cannot be separated from health, drinking water and sanitation, broadly to livelihood issues. These together, and in a synergistic manner, have to be combined with other inputs such as income, employment, education. Rao (2004) argues that imbricate in a population policy ought to be a vision for development, with macro-issues of income, employment, food, health and rights as the focus and not merely strategies for generating. He went further and interrogated population policy without tracing these linkages is a

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population policy or merely a family planning policy. He also questioned the tools to attain the goals of the NPP, specifically the move to induct long acting, provider- controlled and women centered hormonal contraceptives in some states and policies of incentives and disincentives in all of them. It is often said that the NPP is inspired by the rights discourse of ICPD but it is surprising that NPP failed to mention the word rights even once. It is as a matter of fact fundamentally at variance with policies of incentives, disincentives and targets adopted by various states as a part of their population policy (Rao, 2001).

Though the philosophy of voluntary and informed choice and target free approach of NPP needs to applauded along with the decentralization through PRIs but it is necessary to distinguish between the philosophy and the actions. The population policy should include besides demographic concerns, larger issues of sustainable and equitable development. Within this perspective it is necessary to spell out the links between macro- economic policy and population. There is need to link population policy to equitable health policy and NPP failed to tap that linkage. The NPP envisaged a bigger role for private sector which is often unregulated .There is an urgent need to regulate the private sector that is currently not accountable to any institution. Though the NPP have disregarded disincentives, incentives and targets but various state population policies have made these parts of their policy. There is need to understand that disincentives, incentives and targets have no place in a family welfare program it not only contribute to false data generation but also is a drain on already resource crunched system. It also estranges people from serious government efforts. 2.2 The Realities Reproductive health as a concept aims for attainment and maintenance of good health along with the prevention and treatment of any morbidity. However, when reproductive health is a comprehensive and inclusive concept it becomes difficult to gauge the performance of program goals without having any concrete indicators. So, indicators are important to assess the status, service provision or resource availability, designed to enable the monitoring of service performance or program goals. There are various organizations, institutions, and academicians who have developed various indicators to

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assess the reproductive health status of a particular population. These indicators are suggestive of the health status, service provision or resource availability in a particular population. WHO has developed 17 indicators of reproductive health. WHO developed 17 indicators of reproductive health for global monitoring of reproductive health (WHO, 2006).

1. Total fertility rate 2. Contraceptive prevalence 3. Maternal mortality ratio 4. Antenatal care coverage 5. Births attended by skilled health personnel 6. Availability of basic essential obstetric care 7. Availability of comprehensive essential obstetric care 8. Perinatal mortality rate 9. Prevalence of low birth weight 10. Prevalence of positive syphilis serology in pregnant women 11. Prevalence of anaemia in women 12. Percentage of obstetric and gynaecological admissions owing to abortion 13. Reported prevalence of women with genital mutilation 14. Prevalence of infertility in women 15. Reported incidence of urethritis in men 16. Prevalence of HIV infection in pregnant women 17. Knowledge of HIV-related preventive practices

In this section status of reproductive health in terms of the above discussed indicators would be provided, however there are some indicators for which the data is not available for India like availability of comprehensive essential obstetric care, prevalence of positive syphilis serology in pregnant women, prevalence of women with genital mutilation, reported incidence of urethritis in men.

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2.2.1 Total Fertility Rate (TFR) TFR measures average number of children born to a woman during her entire reproductive period. In India the total fertility rate (TFR) has declined from 2.8 in 2006 to 2.4 in 2012 which is a decline of more than 14%. According to Sample Registration System, 2012 The TFR in rural areas is 2.6 in 2012 whereas in urban areas it is 1.8 in the same period. It is observed that the TFR in urban areas remained at the same level 1.9 during 2010 and 2011 after remaining at 2.0 for four consecutive years (2006-2009) and decreased to 1.8 in 2012. Tamil Nadu, West Bengal, Punjab and Himachal Pradesh have the lowest TFR of 1.7 and the highest TFR recorded is 3.5 for Bihar. Eleven states out of 20 bigger states have achieved the replacement level of fertility i.e. TFR of 2.1 in 2012 viz. Andhra Pradesh (1.8), Delhi (1.8), HP (1.7), JandK (1.9), Karnataka (1.9), Kerala (1.8), Odisha (2.1), Maharashtra (1.8), Punjab (1.7), Tamil Nadu (1.7) and West Bengal (1.7). Only Tamil Nadu has same TFR for both Rural and Urban Population (1.7) during 2012, otherwise all other bigger States exhibit higher TFR in rural areas than urban. But this difference is difference is negligible in Andhra Pradesh, Delhi, Kerala and Punjab. The difference in Rural and Urban fertility rate is noticeable in six states viz. Madhya Pradesh (1.1), Chhattisgarh, Bihar (1.1), Jharkhand, Assam and Uttar Pradesh (1.0) It have been observed in SRS, 2012 that there exist a clear relationship between fertility rate and literacy, it exhibited a descending trend as the literacy level increases TFR decreases. Age of women and age at marriage among female is also an important factor in determining the fertility levels. Age at effective marriage (Female) is also an important demographic predictor as it relates to number of years a couple exposed to pregnancy and the family size. The data reveals that there is no significant change in the Mean Age at Effective Marriage in India as it increased from 20.5 years in 2006 to 21.2 in 2012. Jammu and Kashmir (24.6) had the highest and Jharkhand (20.2) had the lowest mean age at effective marriage. Fertility reduction takes place as the age at effective marriage (Female) increases. The data reveals that the percentage of females who had the effective marriage in the age group of <18 years and 18-20 years dropped while it increased in the 21+ age group.

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It is also perceived that there is significant relationship between women’s participation in the paid labor force and their fertility. It is observed that wherever women have a substantial productive role, fertility may be lower because women marry later and they can assertively make choices related to reproductive matters (Safilios-Rothschild, 1982). There is a negative relationship between women's employment and fertility levels, but this relationship is very evident and remarkable in developed countries than in developing countries (Mason, 1987). The studies based in South Asia did not provide decisive and categorical evidence of existence of adverse relationship between women's labor force participation and fertility (Jejeebhoy, 1986).

Taking into account the TFR among various socio religious communities, NFHS 3 reported that the TFR for Muslims is 3.4 and for Hindus it is 2.6. The TFR for Muslims is 0.8 children higher than the TFR for Hindus, but both of these groups have higher fertility than other major religious groups. The TFR is 3.1 for the scheduled tribes, 2.9 for the scheduled castes, and 2.8 for the other backward classes. This Hindu -Muslim fertility differential is the focal point of the saffron demography. But the question arises whether Muslims are a homogenous category uniformly exhibiting high fertility and whether religion is such an important factor affecting fertility. On this issue Jeffery and Jeffery (2006) writes that this is merely an essentialization to believe that the high fertility among Muslims is based on religious beliefs only and ignores their larger socio-economic position. It needs to be understood that Muslim is not a uniform category rather there exists class based, regional, rural-urban heterogeneity and variance. It is to be noted that majority of Muslims live in the demographically ‘backward’ north Indian states of Bihar and UP whose demographic indicators are very different from the rest of India. (Jejeebhoy, 1997). It has much to do with the demographic dynamics of the northern part of India which in general exhibit higher fertility in comparison to the rest of India irrespective of religion (Jeffery and Jeffery, 2000).

Jeffery and Jeffery (2000) asserted that education of women and economic positions have significant correlation with fertility than religion which was also insisted by NFHS 3 (2005-06). NFHS 3 (2005-2006) emphasized the significant relationship between education and household wealth and fertility. It exhibited that women in the poorest

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households have two more children than women in the richest households. It also noticed that the TFR sharply shrinks with the advancement in household’s wealth which is evident in TFR of 3.9 in the lowest wealth quintile to 1.8 in the highest wealth quintile. Similar relationship is also noticed with education and fertility by NFHS 3, also that the TFR is 1.8 children higher for women with no education than for women with 12 or more years of education. Meaning by there is adverse relationship between women’s education and fertility.

2.2.2 Contraceptive Prevalence Rate (CPR) CPR is defined as percentage of currently married women age 15-49 years who are currently using a contraceptive method or whose husbands are using a contraceptive method. It is one of the principal determinants of fertility.

NFHS 3 (2005-06) noted that the contraceptive prevalence rate for currently married women in India is 56%. Taking into account contraception NFHS 3 (2005-06) reveals that knowledge of contraception is almost universal in both men and women. NFHS 3 (2005-06) reported that contraception through any modern method among currently married women is 48.5% that means still more than half of the married women are untouched by any modern method of contraception. For limiting purpose sterilization is reported at 38.3% which is dominated by female sterilization of 37% and only 1% men prefer to sterilize themselves. For spacing condom is the most preferred method followed by IUCD. Like any other indicator of reproductive health contraception use too display a clear south north divide where Andhra Pradesh tops the chart where any modern method of contraception usage by currently married women is 67% which is dominated by 65.8% of sterilization with 62.9% female sterilization and only 2.9% male sterilization but contraception for spacing is abysmally low i.e. only 1.3% (Indian Institute of Population Sciences (IIPS) and Macro International, 2007). In the northern part of India Bihar and UP have the lowest figures related to family planning any modern method usage is 28.9% in Bihar and 29.3% in UP, here also sterilization is leading with 24% and 17% in which the share of female sterilization is maximum with 23.8% and 16.3% in Bihar and UP respectively and male sterilization is as low as 0.6 and 0.2 in Bihar and UP. With these

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statistics it is clearly evident that sterilization primarily female sterilization rules the dynamics of contraception and there are doubts and issues regarding male sterilization. It also gives an insight how female bodies are used and targeted to control fertility as if men don’t have any role and responsibility in conception. The usage of the spacing method is highest in Punjab with 23.9% among the bigger states and in fact lower in Andhra Pradesh. It is to be noted here that at policy level right from the beginning, family program in India dominated by demographic concern, even the method specific targets were the part of the program which was abandoned as a response to the ICPD by Indian Government and it introduced RCH which was target free and choice based but whether the idea of choice is really implemented is debatable particularly when we are observing that female sterilization is dominating family planning methods. The question here arises that it is it a matter of contraceptive behavior only, Pachauri (2004) noted that female sterilization is a dominant method used by even by married adolescent girls, though it was reported by negligible group but keeping in mind the data we cannot ignore such claims. India is the only Asian country where such trend exist (Santhya, 2003). Pachauri (2004) asserted that the concept of contraceptive choice is in fact a choice of the provider and is not the choice of the client.

NFHS 3 (2005-06) also presented a religious based statistics on contraceptive prevalence which is highest among Jains (75%), followed by Buddhists/Neo-Buddhists (68%), and Sikhs (67%). Contraceptive use ranges from 46 to 58% among Muslims, Hindus, and Christians. By caste or tribe, contraceptive prevalence is highest among women who do not belong to any scheduled caste, scheduled tribe, or other backward class (62%), followed by women belonging to the scheduled castes (55%) and other backward classes (54%). Contraceptive use is lowest among women of scheduled tribes (48%). Wealth also positively influences contraception contraceptive prevalence among married women in the lowest wealth quintile is 42% while in the highest wealth quintile it is 68%.

There is huge debate on higher Muslim fertility which is attributed to their lower use of contraception supposedly because of their religious belief. These presupposition is nothing but overgeneralization, trivialization and in fact problematization of Muslims.

Chapter Two: Reproductive Health in Policies and Realities

Interestingly, when the contraceptive prevalence is low among scheduled tribes we attribute it to their low socio-economic status but when it is low among Muslims we fail to buy the same argument and hurriedly attributed it to their religious beliefs. If this is to be believed, how could fertility decline in Muslims majority Indonesia be explained? It was possible through vigorous family planning which is well-integrated in the healthcare provisions in the country (Bhagat, 2004). The same is seen in Bangladesh also (Das Gupta and Narayana, 1997). The academia fail to emphasize the role of factors like education, type of occupations, access to jobs in the organized sector and access to quality family planning services in explaining contraception.

The unmet need for both spacing methods (like condom, IUD and pill) and terminal methods (sterilization) is higher among Muslims than Hindus. It is therefore evident that the demand for family planning among Muslims is less satisfied and it is wrong to believe that Muslims are not willing to accept family planning on account of their religion. Further, more Muslims than Hindus get family planning services from private sources (Mishra, 2004). This brings two important issues one it interrogates the responsibility of the state in making the family planning services accessible to the larger Muslim population and another is that why Muslims prefer to go to private source for family planning services.

Contraceptive prevalence also varies greatly with parity; first increasing from 34% for women with one child to 74% for women with three children, and then declining to 63% for women with 4 or more children. It is also to be noted here that the contraceptive dynamics also get influenced by son preference it is noted in NFHS 3(2005-06) that at each parity, women who have sons are much more likely than women who have no sons to be using contraception.

DLHS 3 (2007-08) noted urban rural divide in any modern method contraception usage apparently in U.P. and Bihar. DLHS 3 (2007-08) also noted that the unmet need for family planning is 20.5 where for spacing it is 7.2% and for liming it is 13.3%. The unmet need for family planning is highest in Jharkhand with 23.1% preceded by Bihar - 22.8% and UP-21% and is least in AP. The differential rural-urban unmet need is very

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evident in Jharkhand, U.P. and Bihar particularly; similar trends were reported by NFHS 3 also.

2.2.3 Maternal Mortality Ratio (MMR) MMR is the number of women who die during pregnancy and childbirth, per 100,000 live births. Deaths due to pregnancy and during the child birth are common among women in the reproductive age groups. Reduction of mortality of women has thus been an area of concern and the Government has set time bound targets to achieve it. India has made impressive achievement in MMR over the years. According to the latest SRS (2012) estimates, the Maternal Mortality Ratio (MMR) of India is 178 per one lakh live birth (2010-12) as compared to 212 in 2007-09. Some states like Kerala (66), Tamil Nadu (90), and Maharashtra (87) have made remarkable progress in 2010-12 while others are lagging behind. The MMR in the highest in Assam (328) closely followed by Uttar Pradesh/Uttarkhand (292) and Rajasthan (255). Kerala is the best performing State with MMR of 66.

MMR among different socio-religious groups the Reproductive and Child Health Survey- 2 reported slightly lower percentage of maternal deaths for Muslims. It reported out of the 611 deaths reported; only 10% of them included Muslim women, though their share in the survey population was 12.2%. All other religious groups such as Hindus (84.3% of deaths, 82.4 population share) and Christians (3.9% deaths, 2.3 population share) as well as social groups such as SCs (26.7% deaths, 18.9 population share) and STs (16.7 % deaths, 8.8 population share) reported a higher share of maternal deaths compared to their share in population. Mari Bhat (2002) in his study using sisterhood method estimated that the maternal mortality ratio is high in women belonging to scheduled tribes and scheduled castes in comparison to women of other castes, similar trends were also reported by ICMR (2003) conducted pilot study (2003). Considering the religious affinity, it is observed that Hindus have higher maternal mortality deaths than either Muslims or women of other religions (Mari Bhat, 2002). However, he remained baffled on the reasons of low maternal mortality among Muslim women but he probes that perhaps the reason is spatial; Muslims generally live in larger villages which have better

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access to emergency obstetric care. But interestingly here scholars do not attribute this phenomenon to Muslim religious beliefs. Tanweer Fazal (2013), also stated that lower rate of maternity-related deaths among Muslims is difficult to explain particularly when antenatal care among Muslim women is low. The Reproductive and Child Health Survey-2 also indicated a slightly lower percentage of maternal deaths among Muslims. Mari Bhat (2002) also asserted a strong relationship between mother’s education and maternal mortality, he reported that maternal mortality is higher among illiterate women compared with those who had attended primary school or passed middle school. It is also important to note that the preexisting health condition of the mother like anaemia get aggravated in pregnancy and during child birth and causes maternal deaths. It is important to understand that these preexisting health conditions are not merely clinical and pathological conditions but it lies to general malnutrition among women which could be significantly attributed to adverse food allocation practices within the Indian household. Mari Bhatt (2002) also reported that there exists a significant relationship between access to health care and maternal mortality. But we know how women’s health seeking behavior is substantially related to women's autonomy.

2.2.4 Antenatal Care (ANC) Coverage ANC is the systemic medical supervision of women during pregnancy. Its aim is to preserve the physiological aspect of pregnancy and labor and to prevent or detect, as early as possible, all pathological disorders. Early diagnosis during pregnancy can prevent maternal ill-health, injury, maternal mortality, foetal death, infant mortality and morbidity. AHS 2012-13, reported 27.7 million women got registered for ANC checkups and 20.7 million underwent 3 ANC check-ups during the pregnancy period.

DLHS 3 (2007-08) informed that in India 75.1% women go for any ante natal check-up during their pregnancy, whereas 70.5% of rural women and 87.1% of urban women sought any ante natal check-up. It is the maximum In Kerala where almost all the women have any ante natal check up the picture is not very different in other Southern states. It is reported minimum 55.8 in Jharkhand with very marked rural-urban divide, the other northern states like Bihar, and Rajasthan is also on the same pedestal.

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The other differential of ante natal care, at least three ante natal checkups is 50% with 43% and 63% of rural-urban statistics. Here also the southern states did fairly well in comparison to their northern counter parts. 95.2% women in Kerala had at least three ante natal checkups, similar is the trend in other southern states, while it is as low as 23% in UP and Bihar Rajasthan is not far very on this trend. However if we look into the data on consumption of IFA tablets, here even the better performing southern states flunked badly except Kerala where 80% women consume IFA and it is lowest to the extent of 5.6% in UP and Bihar. Even the recent AHS (2012-13) report attributed low performance in IFA consumption as the main reason for sluggish full ANC. On administration of two or more TT injection during pregnancy, it is 66.6%, here also Kerala is the best performing states with other southern states slightly behind Kerala, while the northern states, the minimum is reported in Rajasthan preceded by Bihar and UP.

The NFHS 3 (2005-06) data on ante-natal care gave insight into the existing inconsistency on the basis of religion on the women having received ante-natal care .It is to be noted that 73% of Muslim women, 78% of Hindu and 90% of Sikh women received ante-natal care. Visit to the doctor was found to be least among Muslims 48% in comparison to women of other communities. Thus, more than a quarter of Muslim women, during the course of their pregnancy, have no access to any ante-natal care. In fact the likelihood of having received ante-natal care at all, as well as ante-natal care from a doctor, increases sharply with the household’s wealth index. Among mothers in households with the lowest wealth quintile, 59% received ante-natal care of which only 23% received it from a doctor. By contrast, among mothers in households in the highest wealth quintile, 97% received antenatal care of which 86% received it from doctors.18 By religion, births to Jain mothers (93%), Buddhist/Neo-Buddhist mothers (59%), Sikh mothers (58%) and to a lesser extent Hindu mothers (39%) are most likely to take place in a health facility. Births to Muslim mothers (33%) are least likely to take place in a health facility.

2.2.5 Births Attended by Skilled Health Personnel In this category we can look into two important variables DLHS 3 (2007-08) reported 47% institutional delivery with 38% and 70.4% of rural urban variation. Kerala is the

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only state in India where almost all the women opt for institutional delivery with Tamil Nadu slightly behind it. Jharkhand and Chhattisgarh are the worst performing states on this ground where still only 17.7% and 18% of women go for institutional delivery, the picture is not different in UP and Bihar.

Safe delivery i.e. delivery attended by doctor/nurse/lady health visitor/other health personnel is 52.3% as reported by DLHS 3 (2007-08), where almost all the women in Kerala sought health professional assistance in delivery, whereas it is least in Jharkhand(25%) followed by Chattisgarh, UP and Bihar.

NFHS 3 (2005-06) noted a strong association between mother’s age, education, household wealth index, religion and ante natal check-ups. The proportion of births occurring in a health facility is higher for mothers under 20 years of age and age 20-34 years than for mothers age 35-49. It could also be concluded that births delivered in a health facility decreases as birth order increases. Institutional deliveries, particularly in private facilities, increase sharply with the mother’s education and with the household wealth index. By religion, institutional delivery is highest among Jains and lowest among Muslims but if we analyze it we could be easily deduced that among the socio religious groups it is the Muslim women who are less educated and are from lowest wealth index group, they are the one who are least likely to receive antenatal care and these are the factors significantly affecting the likelihood to deliver in a health facility rather than their religious beliefs per se.

NFHS 3 (2005-06) noted that among women receiving antenatal care for their most recent birth, 72% had an abdominal examination, 64% had their blood pressure checked, and 63% had their weight measured. Blood and urine tests were conducted for 60 and 58% of women, respectively. All of these tests are actually part of essential obstetric care or are required for monitoring high-risk pregnancies. All of these measurements or tests were much more likely to be performed for women in urban areas, younger women (under age 35), women having lower-order births, more educated women, Jain and Sikh

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women, women in households in the higher wealth quintiles, and women who are not from scheduled castes, scheduled tribes, or other backward classes.

2.2.6 Availability of Basic Emergency Obstetric Care Services The coverage of provision of Basic Emergency Obstetric Care services in the country is 74% (Ministry of Family Welfare Statistics, 2013).

2.2.7 Peri-natal Mortality Rate It is the number of still births plus deaths within 1st week of delivery per 1000 births in a year. Sample Registration System (SRS), 2012 reported 28 per 1000 births in a year with 31 births in rural area and 17 in urban area. The Peri-natal Mortality Rate significantly varied across the States. Kerala with 10 is the best performing State, Odisha (37) is the least performing State during 2012.

SRS (2012) do not contain data on perinatal mortality rate of socio religious communities, neither it contain data on the basis of education wealth index. For this we have to rely on NFHS 3 (2005-06) which reported lowest perinatal mortality (43-44) when the mother’s age at birth is 20-39 years. It is substantially higher for mothers giving birth at age less than 20 years (67) and at ages 40-49 years (51). The interval between the previous pregnancy and the current pregnancy has a strong negative effect on perinatal mortality. The perinatal mortality rate is 71 when the interval is less than 15 months, but only 30-31 when the interval is 27 months or more. The perinatal mortality rate is also high for first pregnancies (66). Perinatal mortality is also half as high for households in the highest wealth quintile as households in the lowest wealth quintile. Among the four largest religious communities, Hindus have the highest levels of perinatal mortality (49), followed by Muslims (47), Christians (40), and Sikhs (31). Interestingly, scheduled tribes reported lower levels of perinatal mortality (41) than scheduled castes (55), other backward classes (49), or others (45).

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2.2.8 Low Birth Weight NFHS 3 (2005-06) reported among the 34% of births that were weighed at birth, over one in five i.e. around 22% were of low birth weight (less than 2.5 kg). It is reported maximum in Haryana (36%) and minimum in Kerala (16%). The proportion is slightly higher in rural areas (23%) than in urban areas (19%). The proportion of births with a low birth weight is greater among children born to Jain women, young women (age at birth <20 years), Sikh women, and women who use tobacco. The proportion of births with a low birth weight declines with increases in the wealth quintile and with increasing education.

It is intriguing to observe that among the socio religious communities it is the Jain women having highest contraceptive prevalence rate, highest education of women, highest median age at marriage, almost 100% receive antenatal care, 93% institutional delivery, they are most likely to receive post natal checkups after delivery and they are the maximum belonging to the highest wealth quintile but still the Jain mothers are contributing maximum to the low birth weight babies. Seeing this trend in among the Jains it is refuting the significance of antenatal care, institutional delivery, mothers education, etc however to accept such argument would be merely oversimplification and impressionistic rather it requires rigorous and close scrutiny on this matter. It is also to be noted that a woman with poor nutritional status, as indicated by a low body mass index (BMI), short stature, anaemia, or other micronutrient deficiencies, has a greater risk of having a baby with a low birth weight. The risk of having a baby with a low birth weight is also higher for mothers who are short.

2.2.9 Prevalence of Anaemia in Women NFHS 3 (2005-06) observed that 55.3% of Women age 15-49 are, anaemic this figure increases to 59% with pregnant women. Although the prevalence of anaemia varies considerably among the states, it is widespread in every Indian state with Kerala having least prevalence of anaemia and Bihar with highest prevalence. More than half of women are anaemic in every group except for women in households in the highest wealth quintile, women with 10 or more years of education, and Jain and Sikh women. By

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marital status, anaemia is lowest for women who have never been married and highest for women who are widowed, divorced, separated, or deserted. The prevalence of anaemia is similar throughout the age range. Anaemia tends to increase with the number of children ever born and decreases with education and the household’s wealth. Anaemia is more prevalent for women who are breastfeeding (63.5%) and women who are pregnant (59%) than for other women (53%). The prevalence of anaemia is also high for rural women, women from scheduled tribes, women who smoke, and women belonging to “other” religions.

2.2.10 Percentage of Obstetric and Gynaecological Admissions Owing to Abortion NFHS 3 (2005-06), DLHS 3 (2007-08) and Census 2011 does not provide data on abortion, however, the recent AHS (2012-13) gives an account of abortion but it primarily focuses on 9 EAG (Empowered action groups states) which generally have poor health indicators. Even the data EAG states would give us fair idea about the trends related to abortion. It has taken into account pregnancy resulting in abortion, which is reported minimum in Chattisgarh 1.4% and maximum in UP 7%, though in the last survey it was Assam having highest abortion 7.6%.The survey has also looked into abortion taking place in institution which is reported minimum in 34% Chattisgarh and maximum in Assam 72%.

Abortion performed by skilled health Personnel is another variable which the AHS has taken where it is minimum 43% in Chattisgarh and maximum 75% in Assam. The survey noted that More than 50% of the abortion is performed by skilled health personnel in all the states except Chhattisgarh and Odisha.

2.2.11 Prevalence of Infertility in Women There is no detailed description of infertility in women in NFHS 3 but it reported only 2% of currently married women age 45-49 have never given birth. This suggests primary infertility (which is the proportion of couples who are unable to have any children) is in fact low in India. But with the dearth of data on infertility we cannot assertively put

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forward that infertility is in fact low in India, this needs to be verified through quality data.

2.2.12 Prevalence of HIV Infection in Pregnant Women While the rate of HIV infection in pregnant women has been shown to be a reasonable proxy for the level in the combined male and female adult population in a number of settings (WHO and UNAIDS, 2000), there are several well recognized limitations in estimating the HIV rate in the general adult population from data derived exclusively from pregnant women attending selected antenatal clinics. First, the ANC data do not provide any information on HIV prevalence in non-pregnant women. They also do not provide any information on HIV prevalence for pregnant women who either do not attend a clinic for pregnancy care or who receive antenatal care at facilities not represented in the surveillance system. Hence it seems problematic to consider HIV prevalence among pregnant women only; it would be more conclusive to consider HIV prevalence among women of reproductive age group i.e.15-49.

NFHS 3 (2005-06) reported the percentage of HIV positive women in 15-49 age group in five high HIV prevalence states is 0.05% and in men in is 0.10%. The five high HIV prevalence states include Andhra Pradesh, Karnataka, Maharashtra, Manipur and Tamil Nadu. Nationwide, the HIV prevalence rate for the population age 15-49 is 0.28%. This translates into 1.7 million HIV positive persons age 15-49 in India in April 2006, the midpoint of the NFHS 3 survey. The HIV prevalence rate is 0.22% for women and 0.36% for men age 15-49. The prevalence rates for the six states are: Manipur: 1.13%; Andhra Pradesh: 0.97%; Karnataka: 0.69%; Maharashtra: 0.62%; Tamil Nadu: 0.34%; and Uttar Pradesh: 0.07%.

2.2.13 Knowledge of HIV-related Preventive Practices HIV/AIDS prevention program centered on promoting three prevention behaviors: delaying sexual debut among young persons (abstinence), limiting the number of sex partners/staying faithful to one partner (being faithful), and use of condoms (the ABC message). Knowledge of HIV/AIDS prevention methods differs drastically between

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women and men. NFHS 3 (2005-06) noted that approximately 4 in 10 women and 7 in 10 men know each of the three ABC methods. As with knowledge of AIDS, differentials knowledge of prevention methods by age is not nearly as great as differentials by most other background characteristics. Nonetheless, it is notable that knowledge of each of the three methods of HIV/AIDS prevention is more common in urban areas than in rural areas among both women and men, and the differentials are more pronounced among women than men for all three prevention methods. While it is to be expected that knowledge of each prevention method would rise with increasing education and wealth quintiles, the differentials are stark, and again, even more pronounced among women. Knowledge of each prevention method rises from a clear minority to a clear majority with increasing education. No more than 18% of women with no education have heard of each of the three prevention methods, while over 80% of women at the highest level of education have heard of each prevention method. Only 12% of women with no education and 33% of men with no education have heard of using condoms as a means of preventing HIV/AIDS, compared with 81% of women and 93% of men with 12 or more years of education.

2.3 Conclusion In this chapter family planning and reproductive health programs in India are examined. The success and failure of these programs and policies are analyzed through the performance of various indicators of reproductive health, like TFR, MMR, CPR, institutional delivery etc, as proposed by WHO. Review of literature suggests a wide variation in these indicators among different regions, socio-religious communities and socio-economic background of women. Factors like husband’s occupation, caste affiliation, education of women, etc. also effect reproductive health of women. The next chapter studies reproductive health of women in Indian slums.

CHAPTER THREE REPRODUCTIVE HEALTH OF WOMEN IN INDIAN SLUMS

3.0 Overview This chapter focuses on the status of reproductive health in Indian slums and provides a review of literature to the present study. It begins with the definitions of slum (3.1) as given by various scholars and institutions; and also deliberates upon the complexities and ambiguities of those definitions. The next section (3.2) moves on to discuss the growth of slums and observed that slum growth is interlinked with urbanization, a claim substantiated by the Census 2011 statistics. The succeeding section (3.3) is centered around the living conditions in slums. The next section deliberates upon urbanization and slums in Uttar Pradesh (3.3). The final section (3.4) gives a deep insight into reproductive health of women by focusing on studies of reproductive health in Indian slums.

3.1 Defining Slum The concept of slum is of western origin, it emerged in the wake of living condition in cities created by industrial revolution. However, the concept is not uniformly defined; its definition varies from country to country and from one institution to another within a country. The first published definition of ‘slum’ occurred in the James Hardy Vaux's (1812) ‘Vocabulary of the Flash Language’, in which slum was viewed synonymously with "racket" or "criminal trade." Later on Charles Booth, a social reformer, stated that slums are characterized by a combination of overcrowded shabby housing, disease, poverty, and vices. These early viewpoints about slums and their characterization are largely informed by the nineteenth-century Victorian middle class morality. Hunter (1964) defined slum as “a residential area in which the housing is so deteriorated, so substandard and so unwholesome as to be a serious threat to the health, safety, morality or welfare of the occupants.” In this definition slum is seen in terms of poor housing and the problems in slum is primarily because of poor housing. Though poor housing is one of the major characteristics of slum but to believe that slum is only about substandard and poor housing would be equally misleading and in fact such definitions overlook the complexity of slum and trivialize it. Anderson (1970) on the basis of the definition used Chapter Three: Reproductive Health of Women in Indian Slums

by ‘Urban Land Policies of the United Nations’ described slum as a building, group of buildings, or area characterized by over-crowding, deterioration, unsanitary conditions or absence of facilities or amenities which, because of these conditions or any of them, endanger the health, safety or morals of its inhabitants or the community” (1960). Even in this definition apart from the physical characteristics moral deprivation of the slum dwellers is an important feature which is again a manifestation of the Victorian morality.

The Challenge of Slums, a path breaking report published in October 2003 by the United Nations Human Settlements Program (UN-HABITAT) departed from the Victorian misinformation and misrepresentation centered merely on moral dimension. The Challenge of Slums (UN-HABITAT, 2003) defined slums as an area characterized by overcrowding, poor or informal housing, inadequate access to safe water and sanitation, and insecurity of tenure.

In India also slum is not defined uniformly and there are various agencies like local municipalities, state government, Census and National Sample Survey Organization (NSSO) which defines slum. Government of India enacted Slum Areas (Improvement and Clearance) Act in 1956. Slum Areas (Improvement and Clearance) Act 1956 defined slum as predominantly those residential areas where the dwellings are in any respect unfit for human habitation by reason of dilapidation, overcrowding, faulty design of buildings, narrowness or faulty arrangement of streets, lack of ventilation, light or sanitation facilities or any combination of these factors which are detrimental to safety, health and morals.

Census 2001 defined slums in the following terms. (i) All specified areas in a town or city notified as ‘Slum’ by State/Local Government and UT Administration under any Act including a "Slum Act" are ‘Notified’ slums (ii) All areas recognized as ‘Slum’ by State/Local Government and UT Administration, Housing and Slum Boards, which may have not been formally notified as slum under any act are ‘Recognized’ slums 49

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(iii) A compact area of at least 300 population or about 60-70 households of poorly built congested tenements, in unhygienic environment usually with inadequate infrastructure and lacking in proper sanitary and drinking water facilities are ‘Identified’ slums.

Census 2011 took a step ahead and categorized slums as Notified, Recognized and Identified based on the three features used by Census 2001 to define slums. Another organization of government of India, NSSO collects baseline information about social economic life every five years. NSSO for its survey (2002) defined slums as a “compact area of 20 households with a collection of poorly built tenements, mostly of temporary nature, crowded together usually with inadequate sanitary and drinking water facilities and unhygienic conditions”.

Census in its definition of slums has emphasized the physical characteristics of slums and has viewed slums as cluster of overcrowded dwellings with limited civic amenities which makes the life in slum extremely suboptimal and unhygienic. This definition has pointed out the physical attributes of slums but has overlooked the social dimension of slum life which tremendously affects the life of people living in slums. But the important thing to look here is that the definition given by Census emerges from the distinction it make from slum and non slum population in such situation it is more straightforward to point out the physical attributes and the social dimension get glossed over and often lead to ambiguity.

The definition of NSSO, overcrowded, absence of basic amenities, insecurity of tenure are the features of slums emerging dominatingly and these are the commonalities emerging from all the definitions discussed above whether of western scholars or Indian agencies. The conclusion can be drawn that slums are all those over congested residential areas lacking one or more basic civic amenities like drinking water, sanitation, electricity, sewerage, streets etc and all of which have damaging effect on overall wellbeing of its occupants.

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On the basis of the definition of slums given by NSSO and Census five categories of slums emerge which are following.

1. Notified: All specified areas in a town or city notified as ‘Slum’ by State/Local Government and UT Administration under any Act including a "Slum Act" are ‘Notified’ slums 2. Recognized: all areas recognized as ‘Slum’ by State/Local Government and UT Administration, Housing and Slum Boards, which may have not been formally notified as slum under any act are ‘Recognized’ slums 3. Identified: a compact area of at least 300 population or about 60-70 households of poorly built congested tenements, in unhygienic environment usually with inadequate infrastructure and lacking in proper sanitary and drinking water facilities are ‘Identified’ slums 4. Declared: Declared slums are all those areas declared by local municipalities, corporations, local bodies and development authorities. 5. Undeclared: Undeclared slums are those areas of 20 households living in overcrowded area with insufficient drinking water, sanitation facility in unhygienic condition. The categories of slum given by Census and NSSO both are comprehensive and broad incorporating all the those areas specified in any act or by any government agency of slum but it limits it to at least 20 household in case of NSSO and to 60-70 households or 300 population in census, however sometimes it is possible that lesser number household living in similar condition and in such situation they would be left out to be considered as a slum household, however to include slum with lesser number of household is difficult for large scale surveys like Census or NSSO. 3.2 Growth of Slums in India India is still predominantly a rural society where about 70% of its population lives in villages and only 31% of its residents live in cities, however, there is huge increase in the urban population from 17% in 1951 just after independence to 31% in 2011. The 20th century has witnessed unrelenting population growth coupled with industrialization and

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urbanization. Urbanization and proliferation of slum are closely linked phenomenon. Urbanization and mushrooming growth of slum exhibit the process of economic development especially in times of globalization. The shift of labor force from the rural economy to urban centers and its subsequent absorption in urban sectors have resulted stressful living conditions in cities and towns with limited basic services. In India urbanization has resulted in unprecedented urban growth with this huge influx of population, these cities and urban centers have limited physical infrastructure and inadequate civic amenities like housing, drinking water supply, drainage, sanitation etc. to support this huge influx lead people to live in substandard and inhuman condition of slum. The growth of slum is intertwined with the growth of urban population. In India urban population is expected to reach the mark of 590 million by 2030. It is projected that 6 new megacities would grow with more than 10 million, 13 cities with more than 4 million, and 68 with more than a million residents. (McKinsey Global Institute, 2011) With inadequate affordable housing facility there is massive growth of slums in the urban areas of the country. It is anticipated that urbanization in India would be much faster in the coming decades and would cause urban poverty in substantial ways. The growth of slums is observed in almost all Indian cities. (Ministry of Housing and Urban Poverty Alleviation (MUHPA), 2013)

Table 3.1 Decennial Growth of Urban Population S.No Census Year Percentage of Urban Population to Total 1 1991 25.7 2 2001 27.8 3 2011 31.2 Source: (Office of the Registrar General and Census Commissioner, India, 2011) In the last decade (2001 to 2011) the share of urban population has increased 4 points, from 27.78% to 31.16%. It was observed in Census 2011 that urbanization has spread across India impacting almost all the states however the rate of urbanization is not uniform across the country, it varies from state to state. This is the first time the country has five large states (NCT of Delhi, Maharashtra, Gujarat, Tamil Nadu, Kerala) that have more than 40% of their population living in urban areas (Registrar General of India, 52

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2011). With such an increasing rate of urbanization it forces a large number of people in cities to live in slums with limited civic amenities. It is seen that the pace at which the slums are expanding as a result of unplanned urbanization in the country multiplies the slum problems at a rate much faster than they could be resolved or taken care of (Sawhney, 2013 ). More than half of the population in Mumbai lives in slums. The detail of slum population in India is presented in the following Table (3.2).

Table 3.2 Slum Population in India S.No Number of Towns Urban Slum Households Non Slum Households Households

1. Total Slum Reporting Number Percentage Number Percentage Towns (in Lakh) (in Lakh) 2. 7933 2453 788.7 137.5 17.4 651.2 82.6 Source: Census of India 2011: Tables on Housing, Stock Amenities and Assets in Slums

Census 2011 reported that there are 7933 declared towns or cities or urban localities in India representing 31% of total country’s population, out of these 7933 towns slums are reported in 2453 towns representing 17.4% of total urban population. The northeastern states and Chandigarh reported significantly low presence of slum in these regions. The situation was more or less similar in 2001 Census where the slum population constituted 18.3% of total urban population. The number of urban dwellers in India accounted for about 10 % of the world’s slum population and 21% of Asia’s slum population (Registrar General of India, 2011).

Rapid and haphazard urbanization stimulated by increasing rural migration to urban areas is considered main reason for rapid proliferation of slums. Census 2011 also asserted that urbanization catalyzed by rural migration is the primary reason for escalating growth of slums. It is observed that with increased production in the secondary/tertiary sector in comparison to the primary sector cities and towns are viewed as favorite destination for economic growth and job opportunities. For rural population cities exemplifies higher standard of living and better opportunities which looks a distant dream to rural people.

Chapter Three: Reproductive Health of Women in Indian Slums

This results in large scale migration from rural to urban areas. With job opportunities shrinking in rural areas, people in search of better job prospects migrate to urban areas and urban areas with limited infrastructure to support such influx, led people to live in substandard, overcrowded dilapidated conditions of slum. As we already have discussed the trends of urbanization where it is seen that after independence the urban population was just 17% which has now increased to 31% and the significant increase in level of urbanization is seen particularly after 1990 which is the period marked by globalization, end of license permit raj and opening of multinational corporations (MNCs). So it is seen that the process of urbanization and the growth of slums is interwined and hence should be looked with broader perspective, a quick fix approach won’t work in such situation it demand deeper understanding of people’s live and their aspirations. There exist huge interstate variations in proliferation of slums across the nation in different states as presented in table below.

Table 3.3 Slum Populations in States

S.No States Percentage of Slum population to total slum population in India 1 Maharashtra 18.1 2 Andhra Pradesh 15.6 3 West Bengal 9.8 4 Uttar Pradesh 9.5 5 Tamil Nadu 9 6 Madhya Pradesh 8.7 7 Karnataka 5 8 Rajasthan 3.2 9 Chattisgarh 2.9 10 NCT of Delhi 2.7 11 Gujrat 2.6 12 Haryana 2.5 13 Odisha 2.4 14 Punjab 2.2 15 Bihar 1.9 16 Other states/UT 3.8 Source: Office of the Registrar General and Census Commissioner, India, 2011

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Source: Office of the Registrar General and Census Commissioner, India, 2011

Census 2011 have presented detailed state wise slum demography where it is seen that Maharashtra contains the maximum share of slum dwellers out of the total urban population, followed by Andhra Pradesh, West Bengal and Uttar Pradesh. However Kerala reported to have the lowest percentage of urban population living in slums. The situation was no different in 2001 Census where Maharashtra had maximum slum population of around 23% of total urban population followed by Andhra Pradesh (12%) and Uttar Pradesh (11%).It is seen in the present table that in Bihar has only 1.9% of total slum population in India here it should not be concluded that since Bihar has very little presence of slum household so the standard of life in Bihar would be better than other states showing bigger percentage of slum population, such conclusion would be very misleading as we know that growth of slum is interconnected with urbanization and migration which seen as manifestation of better economic opportunities available in the region. U.P is the most populous state of India with total population of 199.81 million in Uttar Pradesh (UP), it shares 16.2% of total country’s population and with 44.5 million urban population it has 11% of total urban population and 9.5% of total slum population

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in India. In U.P Agra, Kanpur, Meerut, Luknow and Varanasi are the five cities with more than a million population. In Agra 9.5% of total population lives in slum, Kanpur has 14.4% slum population, and in Luknow 8.2% and Varanasi it is 12.6%, however whopping 44% of total population in Meerut lives in slums. Similar statistics was reported by NFHS 3 (2005-06) also where it was seen that 43% population in Meerut lives in slums.

3.3 Living Conditions in Slums There might be divergent definitions of a slum but substandard and unsanitary living conditions (like absence of drainage system and electricity), lack of basic institutional services (like health, education, banking and postal services) and high density of inhabitants are often the defining attributes of a slum.

With such epithets it is evident that slums are places of squalor and misery and with low income generation, due to lack of access and availability to institutional support, it is often plagued with higher rates of illegal and criminal activities. They are marked by congenital and gripping poverty, with high rate of unemployment and lesser opportunities to income generation. Consequently, they become ghettos were people from similar socio-economic and social class are placed together. Due to open defecation, unsanitary conditions and lack of hygiene, slums provide perfect place for deadly contagious disease, like cholera, jaundice and diarrhea to spread unchecked and unabated. Qualitatively, slums are described as localities with adverse living conditions where life is described as suboptimal, inhuman, congested, etc. However, quantitatively it is described on the basis of certain objective indicators like literacy, work participation and housing condition. The question arises who are the people who inhibitate slums that too, in such a subhuman condition. It is seen that among the social groups it is the sc and Muslims who live in slums. Census 2011 reported that 29% of total SC urban population lives in slums similar observations were also made by studies (Sidhwani, 2015). Victor D’souza (1979) in his study of slums in India noticed that slums are the permanent habitations of the Scheduled Castes and for persons belonging to the higher castes, slums

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serve merely as entry areas for the people who have their relatives, friends in the non- slum areas and who eventually manage to move out of the slums. Another Study titled ‘Urbanization exclusion and climate challenge’ conducted in three cities in India noted that slums are overpopulated by dalits, Muslims and recent migrants (Sahoo, 2016). It also observed that even cities like Pune which is thought of as a planned city than other cities also exhibited this trend of residential segregation. This study has also highlighted that slums with large number of Muslims and of recent migrants are more likely to face greater level of discrimination and institutionalized apathy in the context of basic services (ibid.). Such findings interrogate the cosmopolitan and liberating character of the cities. The Muslims are the most urbanized social group in India and their ghettoization also questions the development pathway which goes through urbanization.

According to census 2011popualtion density of India is 382 per square kms, the slum areas have higher population density than the urban population density. Mike Davis (2006) in his book Planet of Slums commented that the population density is increasing in all the Third World slums. He attributed this increase to land inflation coupled with declining formal employment. Mumbai’s famous Dharavi slum Mumbai, has a maximum density Roy Lubove (1962) believed were the ‘most crowded spots on earth’.

Cities are considered the reservoirs of skill and capital and the sources of diverse formal and informal sector employment opportunities. The slum population contributes significantly in the labor supply of the economy (Government of India, 2013). According to 2011 Census the work participation rate is 36.4%, where male work participation rate is 54.3% and female work participation rate is 17%. Percentage of slum workers to total worker is 86.5%, male workers are 89.4% while female is 76%. The ratio of slum worker with total workers is significantly high. But it does not show the quality of work and income of the dwellers. Generally slum dwellers are engaged in menial and low paid occupation. It is also reported in 2011 census that out of total slum workers 13.5% are marginal workers were 10.6% are male marginal workers and 23.6% female marginal workers. Here it is interesting to analyze female marginal workers are more than the male

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marginal workers. NFHS 3 (2005-06) also concluded that with few exceptions, women in slums are more likely to be employed than women in non-slum areas although the differences are small in some cities. NFHS 3 (2005-06) also noted striking differences in the occupational distribution of female workers between slum and non-slum areas. In every city, female workers in slum areas are heavily concentrated in production and service occupations, whereas those in non-slum areas have a more varied occupational structure in professional, production, and service occupations. The Challenge of Slums (UN-HABITAT, 2013) raised this point that cities are viewed as manifestation of economic growth and affluence but they have turned into a ‘dumping ground for surplus population’ who are employed in unskilled, unprotected and low-wage informal and unorganized sector. A study on slums of Allahabad and Jaipur in India revealed that even the slums of smaller cities tend to be even more informalized, with three-quarters or more of their workforces existing in the shadow lands of the off-the-books of the economy (Rondinelli and Kasarada, 1993).

There is general consensus among the scholar that slum lack basic civic amenities like drinking water, toilet, electricity, etc. Census 2011 reported that 57% slum dwellers have drinking water facility within their premises and 74% have access to tap water as main source drinking water. However this figure does not provide us the detail of the quality of the water and hence it needs to be examined particularly when we know that slum is also characterized by faulty sewage, open drainage system and open defecation. There are scholars who have pointed out the ubiquitous contamination of drinking water and food by sewage and waste defeats the most desperate efforts of slum residents to practice protective hygiene. The study of slums in Calcutta pointed at the contamination of water and the author pointed out that "the stinking mess around the bustee's privy is washed straight into the ponds and tanks of water in which the people clean themselves and their clothes and their cooking utensils (Chaplin, 1999). Census 2011 also noted that 66% of slum households have latrine facility within their premises and 34% do not have latrine facility in their premises where 22% use public toilets and 18% slum households compelled for open defecation in absence of toilet facility. But again having toilet facility

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within household is one thing and using that is another. On drainage it is seen that 36% have closed drainage 44% have closed drainage and 18% have no drainage at all. Alone the drainage facility tells the dilapidated living condition in slum where considerable 18% do not have drainage and 44% have open drainage which account for around 62% of total slum household (Office of the Registrar General and Census Commissioner, India, 2011).

Slums not only lack basic civic amenities but also the basic institutional services like schools, health centre, banks, etc. NSSO (2009) pointed that 86% slums have nearest primary schools within 1km. range. But the issue of governance is more important than the availability of a primary school. On the issue of governance, the Indian government’s Draft National Slum Policy recognized that, “mobilizing the community and use of resource persons from within the community to supervise and monitor the educational activity would greatly enhance the delivery of this service. The slum dwellers have also internalized the institutionalized apathy towards them and there is also deterrence in demanding those services even. NSSO (2009) reported that in 30% of the slums the nearest health center available was 2 km. away.

But what is more importance is to initiate the primary health centers in the slums and carry out IEC campaigns to create demand for health services. Again availability of health services and accessing the health services are different. Accessing the health services depends not only on availability of health services but also on quality of services, availability of doctors, behavior of the doctors and paramedical staff, etc.

3.4 Reproductive Health of Women in Indian Slums The slum dwellers experience widespread social isolation, are often illiterate and lack negotiation skills to demand improved public services. In particular, they are vulnerable to many health issues that occur as a consequence of poor living conditions. It is generally perceived that the increasing number of health service providers in urban areas, would eventually cater to the needs and demands of urban population. However, rapid urbanization coupled with relentless growth of slum population created acute disparity

Chapter Three: Reproductive Health of Women in Indian Slums

within cities and made this supposition a distant dream (Rossi-Espagnet, 1984). Though it is true that the urban population has better availability and accessibility of health care services because of better-developed health infrastructure this is more evident in case of large cities. But it is equally true that the accessibility to these services and the quality of the services vary significantly between cities and within cities (O'Donnell and Doorslaer, 2007; Lalou and LeGrand, 1997).There exist considerable amount of literature to suggest that the slum population is more vulnerable in terms of their health than the rest of the urban population and is in fact no better than their rural counterparts (Islam, Montgomery, and Taneja, 2006; Montgomery and Hewett, 2005; Fotso, Ezeh, and Oronje, 2008).The situation becomes worse with women’s health and more specifically their reproductive health. Life in unhygienic, unsanitary condition in slums with low level of education, low social status attached to slum living adversely affect their health and this magnifies in case of reproductive health.

3.4.1 Fertility and Contraception Base line survey conducted by Poona Municipal Corporation found out that there is huge difference in contraception in slum and non slum population. This difference becomes acute particularly in spacing methods, the use of spacing methods in non-slum areas is about three times higher (31.8 %) compared to slum areas (Poona Municipal Corporation, 2000). A study conducted by Gulati, Tyagi and Sharma (2003) found that the fertility level in slum is significantly higher than the fertility level in non slum. They pointed out in their study that fertility increases along with age of women. The study concluded that age of women is an important demographic factor affecting fertility apart from other socio-economic and demographic factors. The study also has pointed out a significant relationship between standard of living and fertility trend and construed that fertility depicted significant linkage with household’s living standard rather than with its income. NFHS 3 (2005-06) in its study of eight cities in India concluded that with the exception of Meerut, fertility levels in these cities are already at the replacement level (with total fertility of 2.1children per women) or well below the replacement level. The national average of TFR is 2.4, higher than the fertility in slum areas. NFHS 3 (2005-06) reported

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that the TFR is higher in slum areas than in non-slum areas in every city except Nagpur. Teenage pregnancy is considered one of the major reasons for higher fertility levels teenage pregnancy at national level i.e. 12% is higher than those in slums i.e. 5% as reported by NFHS 3.

A study of slum women in Visakhapatnam (Ramana, 2002) found out that the total fertility rate in slum areas of Visakhapatnam is 3.2 which is quite high comparing the national average.

A baseline survey of Uttar Pradesh pointed out that there exist disparities in fertility and contraception between slum and the non slum population of urban India. (Nanda, Achyut, Mishra and Calhoun, 2011). It is highlighted in the study that the difference in fertility can be attributed to additional barriers faced by the urban poor in achieving their desired fertility. Other access barriers also contribute to unmet need for family planning, such as direct and indirect cost. Direct costs might be experienced in the form of fees for services and supplies at private providers. Indirect costs included expenses and loss of income a person must incur in order to obtain a service, such as transportation costs and lost wages. Reddy (1984) in his study of Hyderabad city came across that contraception was significantly higher among the non-slum residents than the slum dwellers. He also found that among the current contraceptive users in both non slum and slum majority had undergone sterilization and there exists huge unmet demand for contraception for spacing. Gulati, Tyagi and Sharma (2003) in their study reported that use of contraception in slum areas is lower than that of non slum areas of Delhi. Use of permanent method of contraception is higher than the temporary method of contraception. NFHS 3 (2005-06) reported that the CPR at national level is 56% and in slums of eight cities it is 59-77 %. In seven of the cities, the contraceptive prevalence rate is lower in slum areas than in non-slum areas. The contraceptive method mix differs substantially between slum and non-slum areas of these cities. Women in slum areas are much less likely to use modern spacing methods but are generally more likely to use

Chapter Three: Reproductive Health of Women in Indian Slums

permanent methods. The use of modern methods of contraception is generally lowest among poor women.

Ramana (2002) in her study of Women in slums of Vishakhapatnam found that around half of the women in slum use contraception and here also majority of them preferred permanent method and that too female sterilization and negligible percent of males have gone for sterilization. Here the author has concluded that perhaps the men prefer to be away from the burdens of the problems or at least do not take the risk or bear the possible pain of the operation. She also has mentioned that in some cases they are cautious about their virility also. The study has pointed that the demand for spacing method is low among slums dwellers in Vishakapatnam. The author has observed that people are not averse to family planning but fear of medical procedures involved particularly in sterilization and IUCD insertion, ignorance and illiteracy are major the major impediments in contraceptive usage among slum women. Study of slum dwellers in six cities of UP found that unmet need for family planning among women in the urban slums is much higher than those living in non-slum areas (Speizer, 2012)

3.4.1.1 Factors Affecting Fertility and Contraception The review of literature on factors affecting fertility and contraception can be categorized into socio-demographic, access to reproductive services and socio-cultural factors.

3.4.1.1.1 Socio-demographic Shaw (1988) analyzed the fertility and child spacing among the urban poor in a third world city, the case study of Calcutta, India. He pointed that fertility studies in the third world have viewed fertility trend based on two factors i.e. income and education. In this study author has pointed that, caste and family type have a significant effect on the numbers of surviving children. As regards child spacing, the woman's age is of paramount importance. Chaudhury (1996) analyzed interstate variations in fertility in relation to certain aspects of female status and the survival status of children by analyzing the NFHS 3 data. In this study he has looked into fertility relationship with women’s employment, education, infant mortality and child mortality with fertility. He concluded 62

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in his study that state where there is higher female participation in labor force and where women are more educated there fertility is lower. He also asserted with this study that the state with higher infant and child mortality have higher fertility.

3.4.1.1.2 Access to Reproductive Services It also has significant effect on all major indicators of reproductive health. Access to reproductive services could be analyzed into four dimensions namely availability, geographic accessibility, affordability and acceptability (O’Donnell 2007).

Hazarika (2010) in his study raised this point that in spite of having no difference in the knowledge related to contraception between slum women and non slum women, it was found that women living in the slums were less likely to use modern contraceptives. The author insisted that mere increase in the awareness not necessarily translate into increased utilization. The author has attributed that the lack of access to services is one of the reason for low contraception in these communities.

There are several studies which have looked into the geographical accessibility of contraceptive services. Bertrand, Seiber, and Escudero (2001) in their study found a close correlation between the geographical location of the health facility and use of contraception. In another study of Bangladesh, the authors found that the likelihood of contraceptive usage diminishes if the travel time to the facility is more than 30 minutes (Levin, Caldwell and Khuda, 2000).

Donald and Harvey (1992) in their study of Haiti, found that the increase in the prices of modern contraception lead to decease, which could also be presumed to have decrease in usage as well. Divergently in another study in high income area it was observed that increase in price of the family planning product resulted in increase in its usage as the more expensive products were considered to be of higher quality (Levin, Caldwell and Khuda, 2000).

Chapter Three: Reproductive Health of Women in Indian Slums

It is also observed that women often have to undergo unnecessary medical procedures which doo not have any evidential support for its relevance (Cottingham and Mehta, 1993). It is also observed that sometimes service providers also have their own prejudices about the client, method of family planning or its delivery (Campbell, Nuriye and Potts, 2006). In a study of Pakistan it was concluded that unavailability of contraceptive, cost, long waiting hours at the, absence of the female staff affected negatively in contraceptive usage (Shah et al., 2008).

3.4.1.1.3 Socio-cultural David G. Mandelbaum (1973) in his study of human fertility in India asserted that the behavior related to fertility is moulded by a person's culture and involves some of his most compelling social relations. Mahmood Mamdani (1972) in his famous Khanna study has placed the fertility in broader socio-cultural context by way of understanding the living and working conditions of the population in their social context. He pointed that for farmers with small land holdings children are the hope for future hence, has economic utility as they provide extra hands to work in fields because these farmers cannot afford outside paid labor. This study has also refuted the tall claims of famous Khanna study which attributed higher fertility to their unawares an unwillingness to use family planning.

Tulsi Patel (1994) in her ethnographic study of fertility behavior in Rajasthan noted that social norms of fertility and repository of experiences of past and present fertility and mortality continue to influence people’s behavior in favor of high fertility. Khan (1979) in his study of reproductive behavior of Muslims in urban setting aptly pointed out that all human behavior is governed by the social cultural milieu and reproductive behavior is no exception.

Brault, Schensul and Bankar (2017) in their study of Mumbai noticed that women growing up in families having equitable gender norms are seen to assert their sense of agency in reproductive matters later in life particularly in delaying marriage, pregnancy, and spacing between two pregnancies.

Chapter Three: Reproductive Health of Women in Indian Slums

3.4.2 ANC and Delivery Study of Visakapatnam (2002) slums found that 60% women in slums utilized antenatal care where the majority went for administering TT injection. Study of Delhi slums (2003) found out that ANC utilization is 80% comparing ANC utilization in non slum areas of Delhi. It also brought that among those who are availing ANC the share of TT injection utilization is maximum. Even the AHS (2012-13) also have given similar details and have cited the under consumption of iron folic acid tablets responsible for sluggish performance of ANC utilization in 9 EAG states. It is seen in NFHS 3 (2005-06) that slums in every city except Meerut, more than three-quarters of women had at least three antenatal care visits. Almost all women in Chennai had at least three antenatal care visits, followed by Mumbai and Hyderabad (91% each). The proportion of women who received three or more antenatal care visits is lower in slum areas than in non-slum areas, but the difference is only marginal (less than 3 percentage points) in Meerut, Chennai, Hyderabad, Indore, and Mumbai. Delhi has the largest difference in antenatal care visits between slum and non-slum areas (more than 20 percentage points). Griffiths and Stephenson (2001) in their study of slums of Mumbai also pointed that ANC utilization is low among slum dwellers. Godbole and Talwalkar (1999) also concluded that the difference between slums and non-slums is quite high, especially for three or more ANC check-ups. He asserted that slums consistently report lower coverage than non-slum areas. He also pointed that the IFA tablet consumption is lower among slum women.

NFHS 3 (2005-06) raised this point that at least 60 % of deliveries took place in health facilities, except in Meerut where only 46 percent of deliveries were conducted in health facilities. Institutional deliveries were nearly universal in Chennai, and were almost as high (92 %) in Hyderabad. All indicators of delivery and postnatal care were consistently better in non-slum areas than in slum areas in all cities except Indore and Chennai. The utilization of delivery and postnatal services was lowest among slum women in all cities except Chennai, where these services are almost universal in every group. The differences are particularly striking in Meerut and Delhi.

Chapter Three: Reproductive Health of Women in Indian Slums

A study of slums in Delhi concluded that women in slums preferred home delivery with the assistance of traditional birth attendants (TBAs) reason for such preference were cited that they were economical, accessible and the TBAs also helped women with household chores (Sharma, 1990). Another study conducted in slums of Allahabad to inquire about childbirth practices among women in slum areas brought that the majority of the women favored home delivery taking the help of the untrained dais living in the same area (Khandekar, 1993). Ramana (2002) in her study established women in slum prefer home delivery and go for institutional delivery where majority of the women deliver in government institution and in private facility. The author has pointed out that slum women perceive delivery as a routine event and give no special significance for consulting a doctor. The author has provided two possible reasons for home deliveries first is the economic reason the cost involved in delivering in hospitals and second the availability of dais in slum areas, in whom they have great trust. The author found that 76% deliveries in the slum are conducted by untrained dais. On this issue Khandelkar (1993) also pointed out in his study that the majority of slum dwellers have no faith on hospitals. They prefer and trust the untrained dais who belonged to the same socio- cultural milieu. Gulati, Tyagi and Sharma (2003) in their study of Delhi slums described that only 37% women in Delhi slums go for institutional delivery comparing 70% in non slum areas of Delhi. The authors were surprised to note that safe delivery in Delhi slum is 96% which is 74% in non slum population. The authors have pointed out the significance role of dais in slum areas. It is important to point here that institutional delivery is important to ensure safe delivery but at the same time needs and aspiration of people cannot be overlooked. Hollen (203) in her study of Tamil Nadu found that women delivering in an institution not necessarily have enriching experience rather they complain of doctors, nurse and other paramedical staff of their apathetic attitude towards their pain on the other hand these traditional dais who are from the same community have known them long consoles the mothers, sympathizes with them and that makes the process more soothing and easy.

Chapter Three: Reproductive Health of Women in Indian Slums

A recent study of slums in Aligarh reported that majority (67%) of the women in slums preferred to deliver at their homes, the motivation behind home delivery is economic and normalcy in pregnancy (Khan et.al, 2013).

3.4.2.1 Factors Affecting ANC and Child Delivery The review of literature on factors affecting ANC utilization and child delivery can also be categorized into socio-demographic, access to services and socio-cultural.

3.4.2.1.1 Socio-Demographic Women’s education, husband’s education, birth order and interval, pregnancy, age of women at marriage or at pregnancy, religion, caste and ethnicity, family size, and knowledge of family planning and ANC are the major socio-demographic indicators. Most of the literature available on ANC utilization and child delivery points a strong association with women’s education. In fact, women’s education is the considered the most robust indicator associated with ANC and institutional delivery. The more the woman is educated the more likely she is to utilize ANC services (Nielsen, Hedegaard, Liljestrand, Thilsted and Joseph, 2001), (Erci, 2003). It was also pointed out in the studies that the women who are educated also starts accessing ANC services earlier than more women who are not educated (Miles-Doan and Brewster, 1998), (Matthews, Mahendra, Kilaru and Ganapathy, 2001). The significant relationship between husband’s education and ANC utilization is also highlighted in several studies which indicated ANC usage increases with husband’s educational level. Navaneetham and Dharmalingam (2002) in their study of utilization of maternal health care services in southern India found that in Andra Pradesh (AP) husband’s education act as a catalyst towards ANC utilization and institutional delivery, but the same was not found in neighboring state Karnataka (Navaneetham and Dharmalingam, 2002).

Studies also have asserted relationship between parity and ANC utilization. Higher birth order is considered an impediment in accessing ANC services (Erci, 2003), (Sharma, 2004). But, women’s early utilization of ANC is higher among women with higher parity. 67

Chapter Three: Reproductive Health of Women in Indian Slums

Birth interval has also found to have significant effect on ANC. Births occurring within two years of the previous birth is less likely to receive ANC services than those with more than three years of interval (Matthews, Mahendra, Kilaru and Ganapathy, 2001).

Age at marriage is also seen as significantly attached to ANC utilization. In rural north India it was observed that there is positive relationship between age at marriage and accessing ANC (Pallikadavath, Foss, and Stones, 2004).

Studies also have pointed showed close relationship between ethnicity, caste and religion and ANC utilization. It was noted that schedule caste women are less likely to utilize ANC in India (Navaneetham and Dharmalingam, 2002), (Pallikadavath, Foss and Stones, 2004). It was also seen that Muslims were much more likely to seek routine ANC in India than other religions (Bhattia and Cleland, 1995). However, Navaneetham and Dharmalingam (2002) in their study noted that religion was not a statistically significant predictor of antenatal check-ups in India. Studies have shown that ANC utilization is closely associated with the availability of the service or a healthcare worker and the time period spend on waiting for the services to avail (Nielsen, Hedegaard, Liljestrand, Thilsted, and Joseph, 2001). Griffith and Stephenson (2001) in their study of Mumbai slums pointed that availability of healthcare workers in the local community encouraged women to use ANC services.

3.4.2.1.2 Accessibility Accessibility to the ANC services primarily place of residence, distance and transport to the healthcare facilities affect ANC utilization. Studies have found that place of residence is an important factor in ANC utilization. Sharma (2004) highlighted that women in urban areas are more likely to use ANC than the rural women. Contradictorily Navaneetham and Dharmalingam 2002 noticed that women in rural areas are more likely to utilize ANC services than women living in urban areas. Study by Griffiths and Stephenson (2001) has also pointed that the distance to services or physical access were barriers to ANC services utilization.

Chapter Three: Reproductive Health of Women in Indian Slums

3.4.2.1.3 Affordability There are empirical work which has insisted on significant relationships between economic factors like cost of services, socio-economic status or income of the household, occupation of woman/husband, employment and use of ANC services.

The limited financial ability is one of the major hurdles in accessing ANC services. Griffith and Stephenson (2001) concluded that transportation cost coupled with cost of required medical test emerged as major impediments in utilizing ANC services. Griffith and Stephenson 2001 also pointed out in their study that women who assume ANC in private hospitals are of better quality than services available in public health facility, they are less likely to utilize ANC services because of high cost of ANC services in private hospitals.

There is found to be positive relationship between household economic status and the use of ANC. Sharma (2004) observed that women having higher economic status are more likely to receive ANC. Navaneetham and Dharmalingam (2002) suggested that women in paid employment more possibly would use ANC services than women who are not. However in another it was indicated that ANC utilization through healthcare facilities was higher among non-working women than working women in India (Pallikadavath, Foss, and Stones, 2004).

3.4.2.1.4 Socio-Cultural Women’s autonomy was positively related to use of ANC in rural north India. Social support from family members significantly affected use of ANC (Erci, 2003). Older women, especially mothers-in-law did not consider ANC essential during pregnancy and often discouraged their daughters-in-law from attending ANC. Griffith and Stephenson (2001) in his study highlighted the perception of pregnancy as intrinsic aspect of womanhood and ANC is required when there is medical condition.

Griffith and Stephenson (2001) also have pointed that the deterrence for non usage of ANC, particularly in first trimester was the traditional belief that the early period of 69

Chapter Three: Reproductive Health of Women in Indian Slums

pregnancy was most vulnerable to witchcraft. It is also seen that that there is sense of embarrassment of being pregnant and this also act as deterrence including visiting the health facility (Mathole, Lindmark, Majoko and Ahlberg, 2004).

There is variation in the interplay of factors and ANC utilization, factors affecting ANC utilization in one country or culture may not work in another. Utilization of reproductive health services is affected by individuals perception of their bodies, their health and available healthcare which driven by the existing cultural norms and values. Stephenson and Tsui (2002) in their study raised this point that the use of preventive services like ANC is still considered extraterrestrial because healthcare services are still thought of as for curative purposes only.

3.5 Conclusion In this chapter we saw that slums are the areas characterized by ‘overcrowding, poor or informal housing, inadequate access to safe water and sanitation, and insecurity of tenure’. The Census of India (2011) differentiated slums as notified, recognized, identified, declared and undeclared. However, all of them are characterized by insufficient drinking water, lack of amenities, prevalence of disease, poor sanitation and unhygienic conditions. The reproductive health of women in Indian slums reflects a physical and economic environment where provision of ante natal care (ANC) and other facilities is simply inadequate. They are often not available, geographically inaccessible, too expensive or culturally unacceptable.

NFHS-3 (2005-06) has pointed out the inter-city disparities in the indicators are much sharper than the intra-city disparities by residence or by economic status. The health status of even slum dwellers in some cities in demographically and socially more advanced states is not only better than the health status of slum dwellers in cities in less developed states but is also better than the health of non-slum dwellers in these cities. NFHS 3 (2005-06) has pointed out the disparity in the slums of a city and between slums of different cities but has not commented on the exclusive reasons of having poor performance of the indicators of reproductive health and its relationship with other socio- economic indicators. The next chapter discusses the setting and design of the study. 70

CHAPTER FOUR

THE SETTING AND DESIGN OF THE STUDY

4.0 Overview In this chapter the setting and design of the study is presented. Brief account of socio- economic and historical details of Aligarh district is offered at the beginning (4.1) of this chapter along with its population and health status. The next section (4.2) deliberates upon the details of Aligarh city, (4.2.1) which includes a discussion on population and health status of the city (4.2.2) and information about health infrastructure available in the city. The following section (4.3) provides a detailed account of the slums in the city. The subsequent section (4.4) reflects upon the design of the study which includes the research design, selected indicators of the study and socio-economic correlates used in the study. The next section (4.5) presents the objectives of the study. The succeeding section provides a description of the sampling design (4.6) adopted in the study followed by description of the method of investigation (4.7). Next, the discussion moves to the research instruments (4.8) used in this study. It includes interview schedule (4.8.1), focused group discussions (4.8.2) and case studies (4.8.3). The section is followed by a discussion on pilot study (4.9) which is conducted to check the validity of research instruments to be used in this study and the subsequent modification or changes, if required, to the research instruments. Following the discussion on data processing and data analysis (4.10), limitations of the study (4.11) are discussed. The chapter concludes with a deliberation on the challenges faced while conducting the study (4.12).

4.1 Aligarh District Aligarh is one of the seventy one districts of Uttar Pradesh (U.P.), the most populated state of northern India. It is situated in the western part of U.P., in the middle of doab – the land between the Ganga and Yamuna rivers. Aligarh shares common boundaries with districts of Bulandshahr in the North, Etah in the East, Mathura in the West and Hathras Chapter Four: The Setting and Design of the Study

in the South. It is separated from Faridabad district of Haryana by the Yamuna while the Ganga separates it from the district of Badaun in the North-East. The district spreads 62 Kms. from North to South and 116 Kms. from East to West. Census 2011 reported 5019 sq. Kms. as the total geographical area of the district. In terms of total area the district stands at 27th position and in terms of population it stands at 13th among all other districts of U.P. Aligarh is well connected to other parts of India through railways and road transport. Three national highways pass through Aligarh, namely, GT road, Bharatpur- Pilibhit Route and Chandausi-Tantpur-Jot Route. Aligarh is situated on the Delhi-Howrah Railway route of North Central Railways. New Delhi, the capital of India, is 133kms. away from Aligarh and the two are connected through the National Highway (NH-91). Lucknow, the capital of the state, is at a distance of 400Kms.

Source: mapsofindia.com Aligarh has a rich and fabulous history. It is fertile and was strategically important for rulers in the medieval India. The area was known as Kol or Koil until the 18th century. Kol or Koil was a fortress built near the city of Aligarh. Depending on who ruled the place, it was called by different names, namely, Mohammadgarh, Sabitgarh, Ramgarh, and Aligarh. The name Aligarh was conferred on it by Najaf Khan during the last 18th

Chapter Four: The Setting and Design of the Study

century and when the British occupied this region in 1803, they continued with the same name in fact they extended the name of the fort to the whole city. From then onwards it is known as Aligarh (Mann, 1992).

Koil, as a prominent center of administration, military and commerce, emerged in the references of the Muslim historians as early as 12th century AD. It first emerged as an epicenter of Muslim military garrison and remained so throughout the medieval period and later on was made a Shiq (district) by the Sultans of Delhi. It received more importance during Mughal period and was made a sarkar of Agra suba or province by the Mughal emperors. Aligarh was both fertile and strategically important because of its proximity to Delhi; and was considered a valuable Zamindari for the Muslims, the Marathas and the British. Both Akbar and Jahangir visited Kol on hunting expeditions. The 14th century traveler Ibne Batuta also visited Koil and described it as a beautiful city with numerous gardens and mango trees. In the 18th century the region became a Jat stronghold, who defeated the Rajputs. Many battles were fought between Najaf Khan, Afsariyab Khan and the Marathas to control the region, but it was the British who finally took control of the region by capturing the fort of Aligarh on 4th September 1803 and formed the district of Aligarh in 1804 (Mann, 1992).

Aligarh, today, is known for its university and for its lock manufacturing Industry. The university, known as Aligarh Muslim University, is one of the central universities of India. It was established due to the efforts of Sir Syed Ahmed Khan, a great educationist and social reformer. Sir Syed Ahmed Khan established Mohammadan Anglo Oriental College in 1872 which was elevated to the status of a university in 1920.

The lock manufacturing industry originated during the colonial period and is the source of employment for thousands of people of the area; however, Aligarh is still primarily an agriculture dominated area.

Chapter Four: The Setting and Design of the Study

Aligarh district is divided into five Tehsils and 12 development blocks. They are presented in the table below.

Table 4.1 Tehsil wise Distribution of Blocks Tehsil Block Koil Lodha, Jawan, Akrabad and Dhanipur Khair Khair and Tappal Gabana Chandaus and Jawan Atrauli Atrauli, Bijloi and Gangiri Iglas Iglas and Gonda Source: Directorate of Census Operations, U.P. Aligarh includes 1180 villages and 12 urban agglomerations, namely, Aligarh city (Municipal corporation), Atrauli and Khair (Municipal Board), Beswan, Iglas, Vijaygarh, Pilakhna, Kauriaganj, Jalali, Harduaganj, Charra and Jattari (town areas).

According to Census 2011, the population of Aligarh district is 3,673,889, with 53% male and 46% female population and contributes 1.84% to the total population of U.P. The Census observed a change of 22.78% in the population of the district when compared with 2001 Census. The density of population for 2011 was 1,007 people per sq. km. Aligarh district consists of 67% rural and 33% of urban population. With 79% of the total population, Hindus makes up the largest community, while Muslims contribute 19.8% to the population. The remaining comprises of Christians (0.21%), Sikhs (0.16%), Buddhists (0.07%) and Jains (0.08%). Average literacy rate of the district in 2011 was 67.52 compared to 58.48 in 2001, where male and female literacy rate stood at 77.97 and 55.68 respectively.

Despite being agriculturally fertile and having small scale industries like lock manufacturing, electrical goods, and other artifacts, Aligarh is a backward district on various indicators of health and demography. Some of those indicators are showcased in the table below.

Chapter Four: The Setting and Design of the Study

Table 4.2 Indicators of Health and Demography of Aligarh District S. No. Indicators Figures 1 Sex Ratio (Census-2011) 882 2 Child Sex Ratio (Census-2011) 877 2 Total Fertility Rate (Census-2011) 3.7 3 Maternal Mortality Rate (AHS 2010-11) 371 4 Any method of family planning (%) (DLHS-3) 36 5 Any modern method of family planning (%) (DLHS-3) 29.6 6 Female sterilization (%) (DLHS-3) 15.4 7 Male Sterilization (%) (DLHS-3) 0.3 8 Women who received ANC check-up (%) (DLHS-3) 71.6 9 Women who received 3 or more ANC (%) (DLHS-3) 20.2 10 Women who received full ANC (%) (DLHS-3) 3 11 Home Delivery (%) (DLHS-3) 65.4 12 Institutional Delivery (%) (DLHS-3) 32 Source: District Census Handbook Aligarh: Village and Town wise Primary Census Abstract, 2014 District Level Household and Facility Survey (DLHS-3), 2007-08. Uttar Pradesh Annual Health Survey (AHS), 2010-11

The statistics in the table above shows that Aligarh substantially lags behind on almost all the indicators like sex ratio, child sex ratio, maternal mortality, family planning, ANC and institutional delivery.

Aligarh district has 12 urban agglomerations, the slum populations in these urban agglomerations other than that of Aligarh city are not available. Details of slum populations in Khair and Beswan are under compilation for the first time, but are yet to be released and made available. The researcher has made several visits to the District headquarter and Municipal office to get data on slums in Khair and Beswan but the data is still not released.

Chapter Four: The Setting and Design of the Study

4.2 Aligarh City The headquarter of the district is Aligarh city. It spreads over 6000 hectares of land; however, its municipality covers only 4985 hectares and divides the city into seventy wards. The city is broadly divided into two parts, namely, the old city and the civil lines. The dividing line between the two is the Delhi-Howrah railway track. Today both parts of the city have grown enormously due to the emergence of satellite localities. The division of the town is not merely physical but also social and economic. Civil Lines is in the east of the railway line which was initially the area of government offices, AMU campus, and residences of Hindu and Muslim Zamindars and wealthier businessmen. The old city is in the west of the railway line and has also grown enormously in recent years. Density of the population in old city is very high and lanes and by lanes are narrow in this part of the city. There is acute problem of water logging during rainy season and the sewer lines are the source of unhygienic conditions and diseases. Mann in his book described the old city as “… the town is characterized by four things makkhi, machchar, nale, tale; flies, mosquitoes, locks and drains” (Mann, 1992).

4.2.1 Population and Health Status of Aligarh City The population of the city, according to Census 2011, is 8.7 lakhs which is 20% of the population of the district. Majority of the population is Hindus (55.36%), followed by Muslims (42.64%), Christians (0.53%), Sikhs (0.36%), Jains (0.28%) and Buddhists (0.05%).

The sex ratio of the city is 894, which is 12 points higher than the district average, 18 points lower than the state average (912) and 46 points below the national average of 940 per 1000 males. Similarly, child sex ratio of the city is 885, which is 8 points higher to district average, 17 points lower than the state and national average. AHS (2010-11) noted 44% prevalence of modern method of family planning, at the district level the same is 29.6%. AHS (2012-13) reported that home delivery was 69% in Aligarh city and institutional delivery was 32% which was more or less similar to the district level data as reported by DLHS 3 (2007-08)

Chapter Four: The Setting and Design of the Study

4.2.2 Health Infrastructure in the City The city has significant number of government hospitals, health posts and huge network of private clinics and nursing homes spread across the city. There are around 13 urban health posts and 7 health and family welfare sub centers, located in various parts of the city to provide primary health care facility in the city. There are three district hospitals in the city Malkhan Singh District Hospitals, MLG District Women Hospital and Deen Dayal Upadhyay Joint Hospital managed by the state government. Apart from that JN Medical College Hospital, Railway Hospital and ESI Hospital are other government hospitals present in the city. The city also has wide availability of private clinics and nursing homes spread across the city, there are around 130 private nursing homes/clinics.

4.3 Slums of the City Aligarh Municipal Corporation has divided the city into seventy wards. There are numerous slums spread across seventy wards of the municipality. According to Aligarh Municipal Corporation there are 57slums with a total population of 2.5 lakhs. There are numerous localities which have slum population but are not recognized by Aligarh Municipal Corporation. Some of these slums over the period have become developed colonies.

We have discussed in chapter two, that the definition of slums are defined by local municipalities, state government and other agencies differently. The definition of a slum varies from agency to agency and from state to state. In Aligarh city there are two sets of list of slums, one is prepared by Aligarh Municipal Corporation and the other one is by District Urban Development Agency (DUDA). There is huge difference in total slum population in these two lists. According to Aligarh Municipal Corporation the total slum population in Aligarh city is around 2.5 lakhs whereas according to DUDA estimates total slum population in Aligarh is around 7 lakhs. The present study would take into consideration the list of slums in Aligarh city prepared by Aligarh Municipal Corporation. The following table gives detailed account of slum population spread across Aligarh city in its 70 wards. It is evident from the table that Pala Sahibabad is the area that has the highest slum population of 12035, around 5% of total slum population of the

Chapter Four: The Setting and Design of the Study

city. Dori Nagar, Jamalpur and Chuharpur are other areas that have more than 10000 slum population. Apart from these bigger slums there are many small slums with less than 2000 population like Sarai Rehman Lankram Kothi, Begpur, Nagla Mahtab. Chandaniya is the slum with the lowest population of 610.

4.4 The Design of the Study The design of the study provides tentative strategy for research to obtain methodical and meaningful conclusion (Lal Das, 2005). It provides detailed plan outlining how the research would be carried out. Research design addresses certain key issues like how the sample would be collected, how many samples would be studied, what methods and techniques would be used to collect the data and how it would be organized to provide meaningful conclusion.

The present study is a descriptive study aimed to describe reproductive health of women in selected slums of Aligarh. Descriptive research design offers an accurate depiction of characteristics of individual, situation or group. Descriptive studies find out new meaning, describe what exist and determine the frequency with which something occurs. Descriptive studies discover associations or relationships between or among selected variables.

In this study reproductive health of women is investigated on four selected indicators, namely, fertility, ANC, child delivery and contraception. This study does not begin with any hypothesis rather it started with certain assumptions, deduced from the review of studies on reproductive health in Indian slums (for review, see chapter 2). The studies have explicitly shown that reproductive health is affected by many factors, however the present study intend to analyze the effect of socio-economic correlates like education of women, caste of women and occupation of the husband on indicators of reproductive health, namely, fertility, ANC, child delivery and contraception.

Education of Women: Among all the socio-economic correlates, education of women significantly affects reproductive lives of women. There are numerous studies which have looked into this relationship. However, there are few studies which have taken education

Chapter Four: The Setting and Design of the Study

of women and its effects on reproductive health of women in slums and that too women in slums of smaller cities like Aligarh.

Caste: Caste is a complex and distinctive feature of Indian social structure. Caste is an omnipresent reality of Indian society. Mandelbaum (1970) commented on the ubiquitous nature of caste ‘the institution of caste provides a common cultural idiom to Indians: wherever one may be in India one is in a universe of caste.’ Each caste has its own customs, traditions, practices and rituals. The institution of caste has its own informal rules, regulations and procedures. It is generally assumed that caste affiliations get mitigated in urban settings. It is being argued by the urban sociologist that heterogeneous and cosmopolitan nature of cities causes breakdown of rigid social structures (Wirth, 1938). But, Victor S. D'Souza (1970) in his study of slums in Chandigarh asserted that caste is an important aspect of slum living. Therefore, to study any kind of social behavior it is important to assess and analyze the effect of caste on reproductive health of women (Khan, 1979).

There are numerous studies which have looked into the effects of caste on reproductive behavior of women (for detail, see chapter 2), but majority of those studies are primarily of rural societies. There is a dearth of studies focusing on impact of caste on reproductive lives of women in cities and towns.

Occupation of the Husband: Mohan Rao (2004) in his book has reviewed 550 studies during 1951-1974 and pointed out that indicators like fertility, family planning and contraceptive practice were poorly linked to the social differences. There are only 11 studies which had emphasized the social differences in fertility by analyzing differences either on the basis of caste or education of women. Mamdani (1972) who revisited Khanna village justified the large families of peasants on the basis of the socio-economic conditions. Nankarni (1976) in his study also noted large families among cultivators than non cultivators. Both of these studies are of the rural population, there is scarcity of studies which have focused on occupation of the husband as an important factor affecting women’s reproductive health in slum populations.

Chapter Four: The Setting and Design of the Study

4.5 Objectives of the Study The present study intends to analyze the reproductive health status of women in slums. The study proposed to realize its broader aim through certain research objectives. The following are the research objectives which this study intends to achieve to arrive at the broader aim of this study.

1. To examine fertility trend of women residing in slums. 2. To investigate the nature and extent of ANC utilisation among women in slums 3. To explore the extent of institutional and home delivery among women in slums. 4. To understand the contraceptive usage among slum dwellers. 5. To analyze and assess the influence of socio-economic correlates namely caste, education of women and occupation of the husband on fertility, ante natal care utilisation, child delivery and contraceptive usage.

4.6 Sampling Design In this study, multi-stage sampling design was adopted to select a representative sample which ensures that the selected sample is sufficiently representative of the population.

There are two lists of slums available. One is prepared by DUDA and consisted of 187 slums and the other is by Aligarh Municipal Corporation and had only 57 slums. There was a huge difference in population of slums in these two lists. During the Pilot study it became difficult to trace the slum localities mentioned in the DUDA list. The study therefore relies on the list of slums prepared by Aligarh Municipal Corporation. At stage one, out of the total 57 slums of Aligarh city, 06 slums were selected by using systematic random sampling. Every 10th slum from the list of slums of Aligarh Municipal Corporation was selected. At stage two, 30 households from each selected slum were chosen through simple random sampling. At stage three, one sample (i.e. one woman) was collected from each selected household for in depth study. There are three inclusion criteria for the sampled women. One, the woman should be married. Two, she should be in 15-49 age group. Three, she should have at least one child. The total sample size for the study thus reached was 180.

Chapter Four: The Setting and Design of the Study

The following are the steps involved in data sampling.

1. A sample size (N) of 180 women from the slums of Aligarh was to be selected.

2. Selection of 6 slums through systematic random sampling.

3. Selection of a sample of 30 households from each selected slum through simple random sampling

4. From each household, selection of one married woman of 15-49 age group with at least one child.

5. Selection of Case Study through purposive sampling

The in depth study is categorized into three sections. Part one presents profile of the selected slum. The description of the selected slum is based on the information provided by the key informants like ward members, anganwadi workers, school teachers, doctors, etc. The depiction of slum discussed in the section is also grounded on information from the people residing in the area and personal observation of the researcher. Part two provides profile of the household. Part three provides information of the selected participants from the selected household.

4.7 Method of Investigation The research study uses both quantitative and qualitative methods of investigation. Rao (1974) commenting on the earlier fertility studies, majority of which were quantitative studies, pointed that human behavior as complex and personal like fertility cannot be comprehended by quantitative techniques only. Qualitative mode of investigation like participant observation, case studies, and group discussions help to get insight into the deeply personal and sensitive aspect of human life-reproductive health. Similarly, Caldwell, Caldwell and Caldwell (1987) also emphasized the importance of participant observation and extended personal contacts in the field of study. Later on, Patel’s (1993) study of Rajasthan village is an assertion of this supposition. Djurfeldt and Lindbergh (1976) also pointed out that the quantitative data supports the rich narrative of the qualitative data. This study therefore combines both the quantitative and qualitative methods of study.

Chapter Four: The Setting and Design of the Study

4.8 Research Instrument As the present study relies on both quantitative and qualitative mode of inquiry, it uses both Survey method and Focus Group Discussions (FGDs). Survey method is used to obtain quantitative data. The Pilot tested structured-interview schedule is used for this purpose. FGDs along with the case studies are used as part of the qualitative method.

4.8.1 Interview Schedule

The interview schedule used in this study is divided into five sections.

1. General Information: it includes 07 basic questions on the general information of the household.

2. Nature of Habitation and Basic Amenities: it enquires about the nature of habitation amenities available in the household.

3. Socio-Economic and Demographic Profile: it contains 07 questions on the socio-economic and demographic profile of the participants.

4. Antenatal Care and Child Delivery: this part has 22 questions and aims to seek information on antenatal care and child delivery.

5. Contraception: This part inquires about contraception use, different methods of contraception adopted by the participants and the problems related to contraception use if any.

4.8.2 Focused Group Discussion (FGD) FGDs illustrate community attitudes and perception towards any social phenomenon. A total of six FGDs were conducted with women of reproductive age group 15-49 with at least one child. The focus group discussions provided rich information on women’s experiences, their perceptions regarding fertility, ante natal care, child delivery and contraception.

4.8.3 Case Study Case study is a detailed study of the few selected individual cases to draw conclusions about the sampled population. It involves comprehensive and extensive observation of a social unit. Case study method incorporates the process of a particular social unit. The

Chapter Four: The Setting and Design of the Study objective of the case method is to provide comprehensive, integrated description of the important and significant features of the cases undertaken and then from case study, generalizations and inference can be made (Kothari, 2004). In this study case studies are undertaken to have detailed and intensive study of the reproductive health of women living in slums. The present study has total six case studies to have a deeper insight into women’s reproductive lives.

4.9 Pilot Study A pilot study was undertaken, prior to final data collection and its analysis. This was done to test the adequacy of the research instrument. The researcher personally interviewed the participants selected from the universe with the help of interview schedule. Pilot study with 30 sample size was conducted which helped the researcher in making necessary changes in the interview schedule.

4.10 Data Processing and Analysis The purpose of data processing and its analysis is to organize and summarize the completed observations in such a manner that they yield answers to the research questions (Bhandarkar and Wilkinson, 2002). The data collection from field was followed by rigorous scrutiny of the interview schedules for the errors and inconsistencies in process of data collection. The scores were transferred to the master chart as codes, and then to the computer using statistical package, SPSS (windows version 20.0). Finally, analysis and interpretation of data was made according to the objectives of the study. It involved formulation of frequency distribution tables followed by re-categorization of variables to develop cross tables for analysis.

4.11 Limitations of the Study There are many limitations of this study. First, it is a study of Aligarh city instead of Aligarh district because of the unavailability of data on slums in other urban agglomerations of Aligarh district. Second, out of 57 slums in the city, it is a study of only six slums of the city because of time and resource constraints. Third, out of 17 indicators of reproductive health as proposed by WHO, the study is limited to only four indicators, namely, fertility, ANC, child delivery and contraception. Finally, only three

Chapter Four: The Setting and Design of the Study

socio-economic variables, namely, education of women, caste of women and occupation of the husband were taken.

4.12 Challenges Faced During Data Collection The availability of data on slums in district Aligarh came as a big challenge in this study as the researcher intended to study the slums of district Aligarh but the data on slums of the district was unavailable. The municipal office in the district and municipality of Khair and Beswan had no data of slums. The researcher therefore focused this study on the slums of Aligarh city instead of district Aligarh. The availability of the slum data prepared by two different agencies one by Aligarh Municipal Corporation and the other by District Urban Development Authority (DUDA) left the researcher perplexed. There was huge difference in the slum population in data of these two agencies. At the beginning there was huge mistrust and hesitation among the population and it took time for the participants to open up. It was difficult to get responses from the women who were comparatively well off. In spite of the odds it was an enriching experience to talk to these supposedly uneducated women who have opened up to share their most intimate aspect of their lives to a complete stranger with warmth and love. These women were actually the repository of knowledge; they described social phenomena the way no social science book ever could.

4.13 Conclusion In this chapter a brief history of Aligarh district and Aligarh city, its demography, health status and health facilities are discussed. An account of Aligarh’s slum is also provided. One of the limitations of this study is that out of 17 indicators of reproductive health as proposed by WHO, the study is limited to only four indicators, namely, fertility, ANC, child delivery and contraception. Three socio-economic variables, namely, education of women, caste of women and occupation of the husband were taken. The chapter has emphasized the relevance of mix method adopted for data collection i.e. both quantitative and qualitative to investigate personal and sensitive issues like fertility, child delivery and fertility preferences etc. a pilot study was run to test the accuracy of the research instrument used and necessary modifications were made. The next chapter provides profile of selected slums, households and participant in this study.

CHAPTER FIVE SLUMS, HOUSEHOLDS AND PARTICIPANTS: A PROFILE

5.0 Overview This chapter presents a description of the selected slums, households and participants. This chapter is divided into four parts. The first part (5.1) of the chapter provides profile of the selected slums of Aligarh city. The second part (5.2) provides detailed account of the household condition and basic amenities available in the slum household. The third part (5.3) provides socio-economic and demographic details of the participant’s. The concluding part (5.4) of the chapter throws light on health care utilization among the slum dwellers.

5.1 Profile of the Selected Slums 5.1.1 Jangalgarhi Jangalgarhi is situated to the south of the old city and falls under ward number 10 of Delhi gate police station. Bhujpura and Shahjamal are two other slum clusters which are close by. Aligarh Railway station and district hospital Malkhan Singh are around 3kms. away of from Jangalgarhi. The roads in the slum are metalled with pucca drainage, however, the by lanes are kuchcha with open drainage. According to Aligarh Municipal Corporation the total population of Jangalgarhi is 5220 with 3% of SC population. Majority of the inhabitants in the area are Muslims of different castes but Qureshi and Pathan are the dominant ones. Towards the end of Jangalgarhi in the by lanes, there are a few government quarters inhibited by SC families, primarily Valmiki who are employed as sweepers in Aligarh Municipal Corporation. A considerable number of people in Jangalgarhi are involved in meat and its allied industry; some are casual labourers supplying meat from one place to another, while the others are simply involved in slaughtering cattle and supplying it to meat factories. The meat business is very much evident in the by lanes of Jangalgarhi. A lot of people in the area are also factory workers, working in nearby lock manufacturing units. There are a few grocery stores, vegetable and meat shops, medicine shops; etc. but the locality does not have any Chapter Five: Slums, Households and Participants: A Profile

organized and planned market. The women residents of the area are predominantly housewives, still lot of them are also involved in lock making at their homes.

With the roads unkempt with heaps of garbage lying here and there, choked, overflowing and open drainage breeding mosquitoes, the area typifies a slum living. There are Sarkari Nals at various locations, however, people complained of stinking water. With no government schools, educational facilities are poor in the area. An Anganwadi Kendra is all they have for education, where children upto 6 years of age visit and engage themselves in learning. Numerous poor quality private schools are found and people in the middle income group send their wards to them. There are private clinics, mainly with doctors who have BUMS degrees or who are RMPs (Registered Medical Practitioners).

Communal riots are common and frequent, in fact police patrolling is a regular event. Two days prior to this researchers visit there had been a communal incident in the area.

5.1.2 Shastri Nagar Shastri Nagar is located in the extreme south of the city, in ward number 9 and it comes under Gandhi Park police station. It lies in Naurangabad, GT Road. Naurangabad Chawni is in the north of Shastri Nagar while Dori Nagar one of the most populated slums in Aligarh is in the South of Shastri Nagar. Varshney College is at 1 km from Shastri Nagar and Malkhan Singh district hospital is at 4kms. from it.

Shastri Nagar is well connected with the city, the roads in the area are wide and metalled with pucca and closed drainage, though by lanes all roads are not metalled. According to Aligarh Municipal Corporation total population of Shastri Nagar is 2980. Higher caste particularly Brahmin and Thakur constitute around half of the population of the area. They are mainly located on the roadside which is attached to Naurangabad, GT Road. Around half of the population in Shastri Nagar is SC, it shares 48% of the total population of the area. Among the SCs, Jatavs and the Valmikis are the two dominant categories. They are residing mainly in the lanes and by lanes towards the end of the north of Shastri Nagar.

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Majority of the people particularly of higher caste in the area are small shop keepers, vendors, regular salaried class employed in private and government sectors. Among the SC population quite a sizeable number of them particularly Valmikis worked as sweepers in various government and private enterprises. The women from the Valmiki families also work as cleaners and collect garbage from higher caste household in the area. There are no government schools in the area but have many private schools ones. With no government hospital and functional anganwadi centre, numerous private clinics, primarily run by Vaids, have emerged in the locality.

5.1.3 Chuharpur Chuharpur is in the north of the city in ward number 11 which comes under Banna Devi police station. In the north of Chuharpur is Barula by pass road and in the east is ITI road. Exhibition ground is within a kilometre away. Chuharpur is also surrounded by some of the upmarket residential colony of Aligarh like Risal Singh Nagar, Jawahar Nagar and Sidhartha Nagar Malkhan Singh district hospital is located at around 3kms. from Chuharpur. The roads in Chuharpur are wide, cemented and metalled with pucca and closed drainage, even the lanes and by lanes are clean and well lit, something very unlikely for slum habitation. In fact it is well planned, well developed residential colony with broad, clean pavements and there were no signs of any garbage disposal on roads and by lanes. According to Aligarh Municipal Corporation the total population of Chuharpur is 10300 with majority (i.e. 91%) belongs to the SC category. Among the SCs Jatavs and the Valmikis are the two dominant categories found in the area. There are a few Muslim families also residing but other Hindu caste category is a rarity in this area.

Majority of people in Chuharpur are labourers in nearby hardware manufacturing units. A lot of women in the area also work in the hardware manufacturing units. There is one government school and many private schools. There is one functional public library named Dr. Bhimrao Ambedkar Library. There are 3 Anganwadi Centres and one urban primary health care centre catering to the needs of the population, the urban primary centre at Banna Devi is also less than a kilometre away from Chuaharpur. There are plenty of private clinics, primarily ayurveda doctors or Vaids.

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People in the area are very conscious of education which is evident in the utilization of the public library available here. People are aware of the welfare schemes available and do not hesitate to knock at the doors of official to redress their problems like garbage dumping, water logging, etc.

5.1.4 Rambagh Colony Rambagh Colony is situated in the east of Civil Lines area which comes under ward number 24. The area is divided into eight streets ‘Gali’. Aligarh Railway station is about 1km. away from the area. Deen Dayal Upadhya Hospital is less than a kilometre from it. Maharani Ahilyabai Holkar Sports Stadium is also located in Rambagh Colony. According to Aligarh Municipal Corporation the total population of the area is 1672, a Hindu dominated slum cluster with 39% SC population. There exists wide caste diversity among Hindus living here like Pandit, Baniya, Thakur, Lodha, Khatik, Baghela, Jatav, etc. Inside the slum the roads are metalled with pucca drainage. It does not feature slum living especially gali no. 5-8 which are well developed with big houses and majority of the higher caste people like Pandit, Baniya belong to higher income group. From gali no. 5-8 the roads, bylanes are asphalted, drainages are closed and pucca and there is no trace of garbage dumping on roads. Gali no.1-4 represents slum living with kuchcha roads, open drainage, water logging and dumping of garbage on roads and in by lanes. Gali no.2 and 3 are in most dilapidated condition even the level of the roads in these two streets are very low. In gali no. 2 and 3 people of OBC and SC categories reside like Baghela, Lodha, Jatav. In gali no. 1 and 4 the population is mixed with Pandit, Thakur, and Lodha inhabiting them; however, the SCs are confined to gali no. 2 and 3.

People in gali no.5-8 are majorly employed in service sector like doctors, engineers and government employees. While in gali no. 2 and 3, majority are labourers employed in nearby factories and many of their women work as maids and cooks in houses of gali no.4-8. The general housing condition in gali no.1-4 is congested with small, kuchcha or semi pucca houses. The situation is little better in gali no.1 and 4.There are around 35 municipal water supply connection or Sarkari Nals in Zakir Nagar.

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5.1.5 Zakir Nagar Zakir Nagar is a part of ward number 39 located at the extreme north east of the city in Civil Lines. It is adjacent to another densely populated slum cluster Jeevangarh. AMU campus and Medical college of AMU is around 1.5 km. from Zakir Nagar whereas Aligarh Railway station and district hospital Malkhan Singh is at distance of 3kms. The roads are metalled with pucca drainage. According to Aligarh Municipal Corporation the total population of Zakir Nagar is 1770 and it shares 15% of total population of the ward. Zakir Nagar is predominantly a Muslim slum cluster however 10% of the population in Zakir Nagar are SCs. Muslims of Zakir Nagar belong to various castes like Teli, Rajputs, Thakurs, Idreesi, Alvi Syeds, Saqqe, Mewati etc.

Majority of the people in Zakir Nagar are casual labourers, engaged in electroplating units of hardware industry popularly known as Polish ka kam, rickshaw pullers, vendors, fourth grade employee at the university etc. while majority of women are housewives, however, many of them are engaged in home based income generation activities like patti ka kam, cut work, patch work, paper bag making etc.

The general housing is overcrowded and dilapidated, the by lanes are dingy but the drainage is pucca. There are around 35 municipal water supply connections ‘Sarkari Nal’ in the locality, electrification is100%. But it does not have a single government school; in fact the whole ward number 39 does not have any government school, however, there are a few poor quality private schools. The area has an urban primary health centre and a number of private clinics, mainly BUMS degree doctors and RMPs (Registered Medical Practitioners).

People are friendly and cordial and helpful. However, lately drug addiction has emerged as a big menace, causing considerable anxiety among community members. Banned medicines and those that are supposed to be sold only on prescription are sold as a cheap substitute for drugs. They are easily available over the counter.

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5.1.6 Maulanaazad Nagar Maulana Azad Nagar is in the north-east of Aligarh city which comes under ward number 53 in Civil Lines police station. Shahanshahbad is another slum situated near Maulana Azad Nagar. The populations of the two slums are clustered along the Aligarh-Bareiley railway track. It is 3 kilometer from Aligarh Muslim University and 5 kilometer from the District head quarter. According to Aligarh Municipal Corporation data the total population of Maulana Azad Nagar is 8865. It is a Muslim dominated community (95%) where majority is OBC. Among OBCs ‘Malik’ is the dominant caste category. Maulana Azad Nagar also has 5% SC population.

The roads in Mualulana Azad Nagar are cemented, metalled, inter-locked with pucca and closed drainage. Majority of people in Maulana Aazad Nagar are labourers, vendors, rickshaw puller etc. Most of them work in nearby hardware manufacturing units and meat factories. A substantial number of women are engaged in home based embroidery work (patti, karchobi ka kam) in Maulana Aazad Nagar. There are more than 20 private schools and madarsas in the vicinity. But there is no government school. There are two anganwadi centres and one urban primary health centre. There are many private health clinics run by local medical practitioners but there are no qualified doctors in the area.

5.2 Household and its Basic Amenities This section provides information on the nature of household, ownership of the house, type of habitation and the headship of the household. The section also throws light on basic amenities available in the household like drinking water, toilet facility, electricity connection, LPG connection, etc.

The households are classified into nuclear and joint. Nuclear household is composed of husband and wife (or any one of them) and their unmarried children. Joint family comprises of more than one nuclear household. It clear from the Table 5.1 that the number of nuclear family (65%) is more than the number of joint family (35%) in slums of Aligarh. Various studies found that the nuclear family is more prevalent in slum areas

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as generally they are the migrant populations who have left their extended family back home.

Table 5.1 Household: Type, Ownership and Habitation Type of Ownership Type of Household Frequency Percent of House Frequency Percent Habitation Frequency Percent Nuclear 117 65 Own 125 69.4 Kuchcha 9 5.0 Joint 63 35 Rented 45 25.0 Pucca 106 59.0 Total 180 100 Temporary 10 5.6 Semi 55 30.6 housing on Pucca vacant land Total 180 100.0 Jhopri 10 6.0 Total 180 100.0 Source: Survey

It is also evident from the Table 5.1 that number of male headed (76%) household is significantly higher than that of female headed (24%) ones. It is also seen in this study that 69% household live in their own house while 25% have rented house and around 5.6% live in temporary shanty houses located on a vacant land. In chapter 2 we have discussed in detail what is meant by slum living and temporary nature of habitation emerged as one of the important feature of slum. However, in this study we found that majority of people owned their houses, only 30.6% do not have their own houses and they live either in rented house (25%) or in makeshift houses (5.6%) made of polythene sheets, rags, straws, etc.

Type of habitation is also an important criterion to describe slum life which exhibits the socio-economic condition of household in a slum. The sampled households are categorized into four categories i.e. Pucca, Kuchcha, Semi- Pucca, and Jhopri. A ‘Pucca’ house is one which is constructed with cement brick and concrete whereas a ‘Kuchcha’ house is made of clay. ‘Semi- Pucca’ has both constructions of cement and concrete as well as clay. ‘Jhopri’ is a makeshift house made up with bamboo, grass and tarpaulin, etc. Type of habitation across slums is presented in the above table which shows that 59%

91 Chapter Five: Slums, Households and Participants: A Profile have pucca houses, 30.6% have semi-pucca houses, 5% have kuchcha houses and only 6% live in jhopri.

Table 5.2 Availability of Kitchen, LPG Connection and Toilet LPG Separate Kitchen Toilet Connection Frequency Percent Percent Frequency Percent Yes 120 66.7 Yes 78.9 Yes 172 95.6 No 60 33.3 No 21.1 No 8 4.4 Total 180 100.0 Total 100.0 Total 180 100 Source: Survey

Basic amenities available to a household are crucial indicators to have insight into the socio-economic condition of the household. This section gives information on the basic amenities available in the household like separate kitchen, drinking water, toilet facility, electricity connection, LPG connection, etc. Table 5.2 shows 66.7% households have separate kitchen and 33% do not have separate kitchen of which majority cook either in their balcony, verandah or angan and also in many household cooking is done in the room only. It is also observed that 79% households have LPG connection and 21% do not have LPG them. However, among those who have LPG connection, a substantial number (35%) of them also use cow dung cakes, wood and coal for cooking. It is observed that 95.6% households have separate toilet facility and only 4.4% household do not have toilets. Around half (54%) of the toilets in the household are flush latrine/septic tank, however, many of them have ‘dabbe wala’ i.e. instead of a tank plastic drums are used. Large numbers of households who have toilet facilities, the outlet of their latrines are linked to the outlet of the drainage which makes the surrounding extremely unhygienic. The households that have no toilet facilities go to open fields for open defecation. Interestingly, many who have toilet facilities at home even they also go for open defecation, especially in households who have ‘dabbe wala’ toilet. For many of them toilet at home is for emergency, young adolescent girls, newly married women who cannot go for open defecation for on regular use the drum will be filled soon and would overflow. Rambagh Colony which is a Hindu dominated slum pocket observed this

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practice but not any other Hindu concentrated slum. The other Hindu concentrated slums are densely populated there is no open field or space to be used for open defication. Rambagh Colony has open fields in abundance. In Muslim dominated slums especially Maulanaazad Nagar, households that do not have toilet facilities their men go for open defecation but women go to their nearby relatives place or neighbor’s because of the strict pardah system in the community. Open defecation and religious differentials is found by all the three rounds of the National Family Health Survey (NFHS) and pointed that Muslims in India are more likely to use a latrine than Hindus. A Study on open defecation in rural north India has pointed out socio-cultural meaning attached to open defecation and the deterrence to use available is primarily because of socio-cultural reasons. In this study the author has argued that people perceive open defecation is important for good health and helps in leading a wholesome community life. The study has pointed that people perceive open defecation with being diligent; rising early walk a while to find space to relieve themselves and this provides an opportunity to have fresh air (Coffey, 2014). This study also observed similar attitudes during informal discussions with the people.

Table 5.3 Drinking Water, Electricity Connection and Ration Card Source of Type of Drinking Electricity Ration Water Frequency Percent Connection Frequency Percent Card Frequency Percent Municipality 116 64.4 Yes 178 98.9 APL 95 52.7 supply tap water Summersible 52 28.9 No 2 1.1 BPL 34 18.8

Hand pump 12 6.7 Total 180 100.0 None 51 28.3

Total 180 100.0 Total 180 100.0 Source: Survey

Table 5.3 shows only 16% sampled households do not have drinking water in their households against 84% who have drinking water. Majority of them have water facility within their dwelling. Among those who have drinking water facility in their household, majority of them have municipal supplied tap water. Around 29% of the sampled household has submersible pumps and

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6.7% have hand pumps in their household. The number of households who have submersibles is highest in Maulanaazad Nagar not because habitants in this slum is economically well of but because many households there is no municipality water supply in this area.

All the sampled households have electricity connection except two. However there is rampant use of illegal electricity consumption even though they have electricity connection. This was particularly visible in Zakir Nagar, Jangalgarhi and Maulana Azad Nagar and parts of Rambagh Colony

Government categorizes households into Above Poverty Line (APL) and Below Poverty Line (BPL) and accordingly issues ration cards to them. BPL households are further classified into two simple and poorest. Ration card of orange color is issued to APL households whereas ration card of red color for simple BPL households. It is seen that 28.3% household do not any have ration card and those who have ration card most of them i.e. 52.7% have APL cards and only 19% have BPL cards. In fact during my interaction with participants word spread in the community that a Madam has come and she would help them to get BPL cards, many women gathered and requested to help them in getting BPL card. Request for helping them to get BPL card or get ration card were the common request the researcher received in all the slums except Chuharpur and Shastrinagar in these two areas majority has ration cards and many of them had BPL cards particularly in Chuharpur. It is also observed that the households without ration card are highest (77%) among Muslims, the reason for this could be manifold. What emerged out with the discussion in the field is the apathy of their political representatives, apathy of the officials and also the lack of awareness of the people themselves. Many people also complained that their ration card is taken when they went to government ration shop to get their monthly ration and they have not got it yet. It is also seen that households which are not below poverty line they have BPL cards and households which are BPL family have APL cards and they are availing the benefits of BPL ration cards.

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5.3 Socio-Economic and Demographic Profile of the Participants

This section provides detailed description of the socio-economic and demographic details of the participants. Here religion and caste wise distribution of the participants are presented along with the educational and employment status of the participants. The section also deliberates on the occupation of the husband and the demographic details of the husband.

The socio-religious profile of the population is one of the distinctive socio-cultural and demographic features which have received significance right from the first Census in 1872. Socio-religious background of the participants has important bearing on the socio- cultural existence of an individual. The socio-religious description of the studied population is as follows.

Table 5.4 Religion and Caste Category Religion General OBC SC Total Hindu 25 (29%) 19 (22%) 42 (49%) 86(47.7%) Muslim 32 (38%) 52 (62%) 0 84(46.6%) Christian 0 0 6 (100%) 6 (3%) Buddhist 0 0 4(100%) 4 (2.2%) Total 57 71 52 180 Source: Survey

Table 5.4 shows there are almost equal Hindu (47.7%) and Muslim (46.6%) representation. 3% are Christians and 2% are Buddhists.

Caste System is a complex, closed and rigid system of stratification prevalent in Indian Society. Caste is a hierarchical and endogamous microstructure of society in India. The origin of the caste system lies in Varna scheme – a cultural model of classifying Hindus into four social groups i.e. Brahmans, Kshtriyas, Vaishyas and Sudras and legitimized by Hindu doctrines of karma, dharma, rebirth, purity, pollution and so on. Caste system has both cultural features like pollution, purity and hierarchy and structural features like

95 Chapter Five: Slums, Households and Participants: A Profile institutionalized inequalities of status and power, restriction on marriage, occupation and social relationship.

The structural features of caste are also found among followers of other religions which are principally against institutional inequality. Sociologically there are numerous caste among Hindus and Muslims both however, administratively, they are classified into General, OBC and SC in Hindus and General, and OBC in Muslims.

The table also presents caste wise distribution and it is seen that 31.6% are from general category, OBC constitute around 39% and people belonging to SC category are 29%. If we look into the religious caste distribution then the share of Hindus and Muslims in general caste category is 44% and 56% respectively. The number of Muslims is substantially high i.e.73% in OBC category while Hindu OBCs are 27%. In the SC category 80% were Hindus. It is to be noted that the Christians and Buddhist also identified themselves as SC, however in Christians and Buddhist there is no caste system, but they were converted from Hinduism and still identify themselves with the idea of caste Mandelbaum (1970) rightly said that if one is in any part of India one is in a universe of caste.

The share of Muslims and SC in the total sampled slum population is 74%, it is to be noted here that the share of Hindus is 47% but, 49% of them are SCs and 22% are OBCs. Slums are generally inhabited by SC, OBCs and Muslims. Census 2011 reported that 29% of total SC urban population lives in slums. Sidhwani (2015) argued SC population spatially segregated in slums of the cities. Victor Dsouza (1970) in his study of slums in India also pointed that slums are the permanent habitations of the Scheduled Castes. ‘Urbanization exclusion and climate challenge’ study conducted in three cities in India noted that slums are overpopulated by dalits, Muslims and recent migrants (Sahoo, 2016). The present study confirms the findings of the previous study.

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Table 5.5 Women’s Education Women’s Education Frequency Percent Illiterate 76 42.2 Informal Education 27 15.0 Primary 36 20.0 Secondary 16 8.9 Senior Secondary 13 7.2 Graduation 9 5.0 Above 3 1.7 Total 180 100.0 Source: Survey

Table 5.5 presents women’s education among the sampled population, it is seen that 42% of the women among the sampled population were illiterate and among those who were educated the highest (20%) were up to primary level. Around 23% of the selected women were educated from secondary to above graduation. The share of graduation and above is miniscule (6.7%). The women who had never been to formal education systems know basic arithmetic, and among Muslims Urdu reading and writing and reading the Holy Quran.

The share of women who were informally educated is 15% of which 63% are Muslim women. In Muslim households it is a traditional practice to send their daughters to some elderly women who know reading Quran and reading and writing Urdu and these women also used to teach them basic manners and etiquettes which would help them in fetching good matrimonial alliances. There are few Hindu women as well but many of them shared that when their kids started studying they learnt reading and how to do their signature, they shared that it is humiliating for them that they have to put thumb impression whenever required that too in front of their kids. However, the education of the participants among the socio-religious group exhibits that the number of illiterate women among Muslim is higher than any other socio-religious group.

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Table 5.6 Working Status of Women Working Status Frequency Percent Yes 46 25.6 No 134 74.4 Total 180 100.0 Source: Survey

Table 5.6 provides data on working status of women, it is seen in this study that the number of women who are work is only 25.6% against 74.4% who do not work. Employment is one of the major indicators of empowerment of women but for women who are not educated, lower socio-economic background for them working status is not matter of entitlement rather an additional responsibility which they have to undertake because of lack of sustainable income of their male members in the family. This got substantiated when we looked into what are the kind of work they are employed into, majority of them are maid working in nearby localities, many of the SC women are working as cleaners in nearby factories and also number of women are also engaged in lock making and embroidery work. But none of them had any substantial livelihood opportunities except few who are educated and are from better socio-economic status.

Table 5.7 Occupation of the Husband

Occupation of the Husband Frequency Percent Casual labourer 31 17.2 Regular salaried (government servant) 29 16.1 Regular salaried (Private Sector) 69 38.3 Self-employed 48 26.7 Unemployed 2 1.1 Engaged in agriculture 1 0.6 Total 180 100.0 Source: Survey

Table 5.7 presents details about the occupation of the husband. Occupation of the husband is one of the three variables whose effect on the indicators of reproductive health is selected to study in this thesis. Majority of husbands (38%) are on regular salary

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employed in private sector. While regular salaried employed in government sector were 16%. Substantial number of the people was self employed (26.7%), casual labourers were 17.2%. There were only two cases of unemployment with one of them was involved in agricultural activities.

Among the socio-religious communities Muslims make up for the highest number of casual labourers. Salaried employed were mostly Hindu (78%). The share of Muslims in self employed category was also the highest (38%). Among the salaried class the SC participation is the highest, however, majority of them are employed in government sector and in private sector as sweepers and cleaners.

Table 5.8 Age of Women Age Frequency Percent 18-23 20 11.1 24-28 34 18.9 29-33 36 20.0 34-39 34 18.9 40-44 29 16.1 44-49 27 15.0 Total 180 100.0 Source: Survey

This study concerns only with married women in 15-49 age group. Six age categories were made for the analysis of the data. Table 5.8 shows distribution of the sampled women with respect to different age groups. The data is representative of women from all the selected age groups. Women in 24-39 age group contributes nearly 58% of the sampled population while their contribution in 40-49 age group is 30%. The least is in 18-23 age group, of whom majority were recently married. Many of them live with their mother-in-laws, who in a few cases refused the researcher to interact with the women. In one case the mother-in-law said.

‘in choti ladkiyon se tum bat karke kya karogi inhen kya maloom’

Trans: What you will get by talking to these tender age girls.

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5.4 Utilization of Health Care Facilities

Responding to the needs of the growing slum population primary health centers were created to provide health care facilities to the slum dwellers. The urban primary health centers were earlier called as ‘Health post D type’. Availability of health care facility is important but to assume that it would eventually translate into utilization of health facilities is not true. Utilization of health care facilities is dependent on numerous factors like cost of the health services, quality of health services, and perception of health services and distance of the health facility to name a few.

Table 5.9 Utilization of Health Care Facilities

Health Care Facility Frequency Percent Urban Primary Health 42 23.3 Centre District Hospital 36 20.0

Medical College 22 12.2

Private Health 80 44.4 Practitioner Total 180 100.0 Source: Survey

Table 5.9 presents information on utilization of health care facilities by participants in the selected slums. 23% of the participants utilize services rendered by Urban Primary Health Centre while 44% of the participants prefer private health practitioners over the government services. In this study private health practitioner is used as an envelope term referring to qualified doctors, registered medical practitioners as well as the local quacks. It is used as an inclusive term because of the women’s inability to distinguish qualified doctors from the unqualified ones, for the people all of them are doctors. Together Urban Primary Health Centre, District Hospital and Medical College Hospital cater nearly for 54% of the population. The figure might seem encouraging but during discussions people confided that they go to government health facilities because of inability to bear the cost of private health facilities. People believe that though private health facilities are exploitative yet they are better than the government health facilities. Many people were

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annoyed with long hours of wait at government health institutions leading to wage loss. Others are simply disappointed with the impoliteness, indifference, apathy and disrespectful attitude they receive at health institutions particularly that of the paramedical staffs.

People in the locality are highly resistant towards immunization and get skeptical and disillusioned with immunization drives because they think that their other basic health needs are ignored. They believe that officials and health workers are only concerned with immunization.

5.5 Conclusion A profile of the selected slums, its households and participants are presented in this chapter. From the discussions on the conditions and basic amenities available in the slum household the extreme level of poverty is evident among the slum population. Other socio-economic and demographic indicators point to the pathetic living conditions of the slum population. Although, there is lack of awareness of the people towards their health and other living conditions, it seems there is an acute apathy of political and district representatives and officials too.

101 CHAPTER SIX

REPRODUCTIVE HEALTH OF WOMEN IN ALIGARH SLUMS

6.0 Overview The present chapter provides a detailed account of the status of Reproductive Health of Women in Aligarh Slums. This account is based on the primary data collected and examined for indicators like fertility (6.1), ANC (6.2), child delivery (6.3), and contraception practices (6.4) among women in Aligarh slums. The chapter also deliberates upon the relationship of these indicators with education of the women, their caste category and occupation of their husbands. These variables are assumed to have significant bearing on reproductive health of women in slums. The following sections provide a description of the relationship of the indicators of reproductive health and how they are affected by various socio-economic variables.

6.1 Fertility As one of the major components of population growth, fertility studies witnessed a great deal of interest for research and policy prescriptions in the latter part of the 20th century. And since then, extensive studies have been conducted to examine the factors influencing human fertility.

Table 6.1 shows that 40.6% of the sampled women had more than three children at the time of interview. 27.2% of the women had three children, 18.3% had two and only 13.9% had one child. Among those who had more than three children, include 8.3% who had more than 5 children. All the women who had only one child at the time of interview wanted to have another child as compared to only 21% among those who had two children. But only a few women who had 3 or more than 3 children wanted to have another child. 48% of those who had two children had a son and a daughter. 49% of those who had three children had two sons and a daughter while 29% of those who had more than three children had two sons and two daughters. Chapter Six: Reproductive Health of Women in Aligarh Slums

FGD 1 and 2 were organized with women of 23-50 age group at Shashtrinagar and Jangalgarhi slum population to study desired fertility – desired family size and desired sex composition of children.

Table 6.1 Number of Children

Number of Children Frequency Percent 1 25 13.9 2 33 18.3 3 49 27.2 More than 3 73 40.6 Total 180 100.0 Source: Survey

The age of the participants seem to be a factor in shaping desired fertility of the studied population. One of the members in the group mocked the younger generation for their fascination for a small family and fewer children. The desire for smaller family was attributed to the lack of physical strength in their younger counterparts. The younger women’s awareness of the perils of more and frequent pregnancies and their fertility practices came for criticism from the women of higher age group, as they said:

‘Dam na hai inmen, bachche paida karne ke liye dam chahiye. Jane kya khilake bhejte hain ma bap, ek bachche ke bad aisi ho jati hain kutiya si’

Trans. They do not have the strength; you need strength to deliver children. Do not know what they were fed upon by their parents. They became like a bitch just after one child.

Many women particularly of the higher age group rationalized their desire for more children and high fertility based on safety and security concerns. They believed that more children would ensure to take care of them in their old age. This argument seems to find a parallel in Mamdani (1972), who refuting the claims of the famous Khanna study, asserted that for people with uncertain life chances children are assurance against old age.

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One of the members of the group, hitting out at the popular two child slogan, said:

‘Tum ye batao, “ye hum do ha mare do” se na bachche ke taya, chacha, na khala’

Trans. You tell me with this, “we two, our two” child would be deprived of the kinship relations – no uncles, no aunts.

This is an important and interesting commentary on the changing demography and social dynamics affected by the two child norm. However, the women of the lower age groups pointed to the rising inflation and the ever higher prices of the basic necessities which make it impossible to bear and raise large families. But even for them an ideal desired fertility is three, not two – two sons and a daughter.

The review of literature on fertility concludes that there exists strong son preference across all the socio-religious group and caste categories in India but it should not be assumed that daughters are not valued at all; in fact at least one girl child is considered important in a family.

CSN 1 and 2 were conducted at Shashtrinagar and Jangalgarhi to study the desired fertility – desired family size and desired sex composition of children.

It was found that there was a strong desire for male child. Nagina (refer to CSN 1), age 33 is an illiterate Muslim OBC. Her husband, age 40 is self employed and earns an average of Rs. 15000-25000 per month. As a nuclear family, they have eight daughters and a six month old son, but still they have a strong desire for another son. Nagina believes she needs at least another son to make the family complete. She argues families with fewer sons find it difficult to get their daughters, especially if one has too many, good matches. She says more sons ensure a warm wedding reception to the groom’s family. They also guarantee leverage over the groom’s family should there be disputes in future.

The desire to have at least one girl child, like has been found in FGD 1 and 2, is strong among the women. Likewise CSN 2 emphasizes a strong desire for a girl child. Zubaida

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(refer to CSN 2), age 50 is an illiterate general caste woman. Her husband is no more. She has eight sons. She remembers how she and her husband at each pregnancy of her’s used to pray for a girl child whom they would name ‘Fatima’. Their quest for a daughter ended up them having eight sons. She still tries to visualize what if she had a daughter, she would have been a strong emotional support, she adds. For a want of a daughter, she does not consider her family to be complete.

All the members of FGD 1 and 2 are unanimous to express:

‘Ladki to ma baap ka dil tatolti hai’

Trans. Daughters feel for the heart of their parents.

One of them said:

‘Ladke to haramme hain, lekin kya Karen, zaruri hain’

Trans. Boys are bloody useless, but what to do they are important.

There seems to be a remarkable display of the antithesis of male child preference. Many in the group said that boys, once married forget their parents, got busy with their own families. They remain of no use for the parents. But the daughters visit to their parents, share their joys and sorrows, share time with them despite their own family responsibilities. They say it’s the society that gives preference to sons, and we all are part of that society.

‘Ham samaj se alag to nahin hai’

Trans. We are not separate from society.

Cautioning about the perils of having only one son, one of the members said:

‘Ek anda aur vo bhi ganda’

Trans. One egg that too is soiled

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Patel (1994) also described a similar belief held by people, and quoted a teenage boy to prove her point:

‘ek ank mein ank nee, ne ek put mein put’

Trans. There’s no son in one, just as there’s no eye in one. Their preference for at least two male children seems not a matter of ignorance rather it was informed by their unique socio-economic and cultural-historical context in which they live. With high prevalence of infant mortality rate in their society, women had grown up with stories of children dying in their families, acquaintances and friends leaving the parents without any support, unattended in their advanced ages. These experiences provide them for their rationality to have more children, especially male ones. Desired fertility, desired family size and its sex composition like the ones seen in the FGDs above are attested in most of the studies, and it is observed that at least two male children are a common desire shared across all sections of the society (Bose, 1988).

One of the members in FGD 1 argued.

‘Ab tum ye batao agar teen char ladke honge koi na koi to ma baap ko dekhega ki sab nikamme ho jaenge. Aur agar kisi ke ladka ho aur nikamma howe to bolo kya guzeregi maa baap pe’.

Trans. Tell me if there are three sons, one or the other of them, at least, would look after the parents, or will all of them turn useless. But what grief will pass over the parents if their only son turns bad.

Commenting on the importance of male child in Indian culture, Blaikie (1975) highlighted several reasons for it. One of them is that sons provide economic and emotional security in old age. A similar observation was made by Mamdani (1972).

Khan (1979), in his study of Kanpur slums pointed that two male children and at least one girl child was the most desired fertility of the sampled population. Patel (1994) in her study also observed that though the birth of a son is celebrated but at least one daughter is considered ideal for the sex composition of a family.

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As to the sex of the first born, most members in FGD 1 desired a male child.

‘Lekin pehlauthi ka to ladka ho, agar ladki hoti hai to vo turant maa ke sath ki ho jati hai’

Trans. But the firstee needs to be a boy, if it’s a girl, then soon she grows up to look like her mother.

Patel (1994) in her study noted that a girl child is welcomed also as a first born, but a male child as a first born is a matter of more celebration. This is because fertility and reproduction in India more of a social than individual event and is closely watched and analyzed by the people around. It is observed in this study that the sex of the first born is also linked to the social status of the mother, if it’s a boy then women’s place in the family is raised but if it’s a girl then relatives and friends offer prayers for the next pregnancy.

Similar to what has been observed in CSN 1 and CSN 2, many members in FGD 1 linked the sex of the first born with the prospects of better wedding matches for their daughters. They argued that if the first born is a son, then he grows up to help in getting his sisters marry off, but there will be no support if it’s the girl. Talking about the monetary aspects, they said, weddings are getting expensive affairs each passing day, the dowry is high and sons are vital for financial support of their daughters’ weddings.

Table 6.2 Caste Category and Number of Children Number of Children

Caste Category 1 2 3 More than 3 Total General 8(14%) 15(26%) 15(26%) 19(33%) 57 OBC 8(11%) 4(5.6%) 19(26%) 40(56%) 71 SC 9(17%) 14(27%) 15(29%) 14(27%) 52 Total 25 33 49 73 180 Source: Survey

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Source: Field Survey

In Table 6.2 we see that 14% of the sampled population in general caste category had only one child at the time of interview. 26% in this category had two and the equal percentage had three children. 33% had more than three children. In the OBC category, 11% had only one child, 5.6% had two, 26% had three and 56% had more than three children. Among the SC category, 17% had only one child, 27% had two, 29% had three and 27% had more than three children. It is evident from Table 6.2 that the percentage of more than three children was found to be the highest among the OBC category in comparison to the general and SC category. 33% of the general caste category had more than three children compared to 27% in the SC category. Percentage of women who had three children was pegged similar for both the general and OBC category (i.e. 26%) but was reported three points higher among the SC category. The percentage of women with two children was found to be the lowest among the OBC category and was reported 26% and 27% among the general the SC category respectively. The percentage of women with only one child was the highest among the SC category (i.e. 11%) which was followed by the general (i.e. 14%) and was the least among the OBC’s (i.e. 11%).

The above fertility trends highlight a clear link between caste category and fertility which could in turn be attributed to contraception practices like sterilization which was found to

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Chapter Six: Reproductive Health of Women in Aligarh Slums be the highest among the SC’s. More on this will be discussed later in this chapter under the section of contraception practices among various caste categories.

As seen above, the share of OBC’s was the highest in the category of women who had more than three children. One of the probable reasons for this is the fact that the majority of the OBC’s were Muslims who generally have higher fertility. Another possible factor for higher fertility in the OBC category could be type of employment. Majority of the OBC’s were found to be self employed, who tend to have higher fertility than that of the salaried class (for occupation – fertility relationship, see Table 6.4).

FGD 1 and 2 also shed light on the relationship between caste category and fertility behaviour. One of the members from the OBC category said:

‘Hamare biradari men zyada bachche hote hain, tumhen kisi ke bhi do ya teen bachche nahin milenge’

Trans. We have more children in our caste; you will hardly find any women with two or three children.

This was not an overgeneralization. It was found that OBC’s indeed have higher fertility across all the caste categories. But there also was age as a factor that seems to shape the desired fertility. Women in higher age group across all the caste categories were shown to have higher desired fertility as compared to their younger counterparts who stressed the benefits of smaller families and fewer children. Economic variable was also seen at work in determining the desired fertility. More children in the OBC category seems to be influenced by the self employed nature of their occupation, for them more children means more hands to work. With children helping their parents in their work after their schools, they do not have to pay for the work. If they do not show interest in studies even then its fine, they help their father’s full time.

‘Ab hamare char ladke hain aur do ladkiyan. Charo ladke kama rahe hain thoda bahut ek jagah dete hain to ghar age badh raha hai. Jo kise ka ek ladka howe to uski to ek ki hi kamai hogi’

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Trans. Now I have four sons and two daughters. All the four sons are earning and all the income is compounded at one place for the household is to run. If there is only one son then there will be only one income.

Mamdani (1972) in his study also noted that caste and occupational structure are the important determinants of the desired fertility which got attested in this study as well.

Table 6.3 Education of Women and Number of Children Number of Children

Education 1 2 3 More than 3 Total Illiterate 3(4%) 8(10%) 24(31%) 41(54%) 76 Informal 3(11%) 4(15%) 5(18%) 15(20%) 27 Education Primary 11(30%) 8(22%) 8(22%) 9(25%) 36 Secondary 1(6%) 3(18%) 8(22%) 4(25%) 16 Senior 3(23%) 3(23%) 3(23%) 4(35%) 13 Secondary Graduation 3(33%) 6(66%) 0 0 9 Above 1(33%) 1(33%) 1(33%) 0 3 Total 25 33 49 73 180 Source: Survey

Table 6.3 presents the association between number of children and education of women. It was seen that the share of women with more than three children was found to be the highest among those who were illiterate. The number of children was seen to decrease with the increase in women’s education. None of the women who were graduated or above had more than three children, but their share was too low in the sampled population to arrive at any generalization. Interestingly, women with informal education, as compared to those who received primary, secondary or even senior secondary education, had reported lower percentage of those who had more than three children. Women with primary education had equal percentage (i.e. 22%) of both two and three children while 25% of them had more than three children. Similarly, women with

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Chapter Six: Reproductive Health of Women in Aligarh Slums secondary and senior secondary education had their highest percentage found in the column of more than three children. The positive relationship between fertility and education of women has been asserted by numerous studies. Rao (2004), for instance, asserted that the importance of women’s education has found its place in almost all policy documents related to family planning by Government of India. He further adds, that women’s education emerged not as a matter of entitlement rather it became a tool to curb fertility. This study might be attested when we see that the percentage of women who had more than three children was the highest among illiterate women, followed by those who had senior secondary, secondary and primary education. But what is startling was that women who were informally educated had their fertility 5 points lower than that of the primary and secondary level educated women and 15 points lower than that of the women with senior secondary education. The link between women’s education and fertility is ambiguous at best and leave us with no clear conclusion.

Table 6.4 Husband’s Occupation and Number of Children Number of Children

Husband’s Occupation 1 2 3 More than 3 Total Casual labourer 4 2 11 14(45%) 31 Regular salaried 4 16 7 2(7%) 29 (government servant) Regular salaried 15 14 25 15(21%) 69 (Private Sector) Self-employed 2 1 6 39(81%) 48 Unemployed 0 0 0 2 2 Engaged in agriculture 0 0 0 1 1 Total 25 33 49 73 180 Source: Survey

Table 6.4 presents the relationship between occupation of the husband and fertility. 81% of women whose husbands were self employed had more than three children. 45% of women whose husbands were casual labourers had more than three children but the figure was only 21% where the husbands were on a regular salary. It was the lowest (i.e.

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7%) where the husbands were government servant. The diversity in the relationship between husband’s occupation and fertility may possibly be due to the factor of education (however, see the section on women’s education and fertility above). In government sectors in India people have higher educational qualifications than in the private ones. This affects of fertility. However, it was also observed that people who were not (or less) educated but were employed as sweepers, cleaners, cooks, daily wagers at university campuses and other government offices in the city, too had lower fertility. One of the possible reasons for the lower fertility among them may be explained on the basis of socio-cultural context they work in. Most of the people employed in government sectors, no matter what education or qualifications they possess or what position they hold; try to imitate the behavior of their more educated colleagues and seniors. In this way the government offices are the unique sites, providing what we can call a melting pot effect, influencing each other’s behavior even the intimate ones like fertility and reproductive behaviour. The same cannot be said about private sectors and particularly the kind of private sector that is there in a small city like Aligarh. Firstly, the job insecurity in the private sector leads people to have only casual professional relationship in the offices, because they know that any time they may be asked to leave their jobs. In such a situation it is impossible to get affected by the colleagues and office mates like the way people are affected in government sectors. Secondly, in private sectors the kind of job majority of the people are engaged in, is generally the extension of the casual labourer’s work, the nature of the work is similar; the amount of remuneration is meager.

The higher fertility of the self employed and the casual labourer was also pointed out by Mamdani (1972), who in his study stressed that the rationale for contraception use cannot be uniform in all the class situations.

6.2 Anti Natal Care (ANC) 6.2.1 ANC Utilization Antenatal care is often defined to consist of undergoing at least three antenatal check-ups, 100 days IFA consumption and two TT injections (or Vaccinations). Antenatal care is an important indicator of reproductive health as it provides preventive services to pregnant women. It helps in identifying the complications and could minimize the risk factors at

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Chapter Six: Reproductive Health of Women in Aligarh Slums initial stages. ANC utilization also increases the chances of institutional delivery. In so doing it becomes instrumental in reducing maternal mortality and morbidity (World Health Organisation, 1996).

Table 6.5 ANC Utilization Number of ANC ANC Frequency Percent Check-Ups Frequency Percent Yes 120 66.7 2 7 3.9 No 60 33.3 3 104 57.8 Total 180 100.0 More than 3 9 5.0 Source: Survey

Table 6.6 Source of ANC Utilization Source Frequency Percent Urban Primary Health Centre 18 10.0 District Hospital 19 10.6 Medical College 20 11.0 Health Camp and Anganwadi Centre 35 19.4 Private Health Practioner 24 13.3 Any other 4 2.2 Nill 60 33.0 Total 180 100.0 Source: Survey

Table 6.5 presents the status of ANC utilization among the sampled population. It was found that majority of women (i.e. 66.7%) went for antenatal check up. 58% of women underwent for three antenatal check-ups. Similar findings were also seen in a Study of Delhi slums (Gulati, Tyagi, & Sharma, 2003) and the study of slums in Vishakhapatnam (Ramana, 2002). NFHS 3 (2005-06) also reported that ANC utilization was substantially high in all the cities except in Merrut. However, this study contradicts the findings of Griffiths and Stephenson (2001) in Mumbai slums where the authors have observed low level of ANC utilization. However, Griffiths and Stephenson (2001) made a comparative study between slum population and non slum population. They observed in their study that women in slums of Mumbai would only avail antenatal care services if they

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experience problems during their pregnancies. The latter relationship was not seen in this study and the merit of this argument seems debatable, because it is unlikely to assume that 67% of women who went for antenatal check-ups had problems and complications related to pregnancy. Godbole and Talwalkar (1999) in their study also concluded that the difference between slums and non-slums is quite high, especially for three or more ANC check-ups. They asserted that slums consistently report lower coverage than non-slum areas.

Table 6.6 provides details of the source of availing ANC services. Majority of the women sought ANC services from government institutions. Among the government sources the share of Anganwadi centers and regular health camps were the major sources of the ANC in slum areas. ANC utilization from private sources stood at only 13.3%. Considering these figures it might be concluded that higher ANC utilization from government health facilities is a restoration of people’s faith in government health services. However, many studies on ANC utilization pointed that place of residence, distance and transportation to the healthcare facilities affect ANC utilization (Glei, Goldman, & Rodriguez, 2003;(Magadi, Madise, & Rodrigues, 2000). In this study it was observed that ANC services were provided in the vicinity of beneficiaries at urban primary health centres, anganwadi centres and regular health camps. This study observed that travel time or distance to healthcare facilities negatively affects antenatal visits. It was pointed by participants that they utilized ANC services because of their availability and accessibility in their area otherwise earlier it used to take a lot of time, they had to wait in hospitals for long, they used to worry about their children back home and if they were employed it caused them loss of wage for a day. There are many other studies that have argued that the distance to health services or physical access to them are barriers to ANC services utilization (Chakarborty, Islam, Chowdhury, & Bari, 2003). This study also found links between economic limitation and ANC services utilization. It was observed that even women from higher income group used government health facilities for ANC utilization. Many argued that private health facilities ask for unnecessary medical tests. Griffith and Stephenson (2001) pointed out in their study, those women who believe that ANC at private hospitals are of better quality than what is available at the public ones, are less

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Chapter Six: Reproductive Health of Women in Aligarh Slums likely to utilize ANC services at all because of their high cost. The assumption that private health facilities provide better services serves as a constraint to ANC utilization. Table 6.7 TT Injection and IFA Tablet Utilization

TT Injection Frequency Percent 100 days IFA tablets Frequency Percent 114 63.3 Yes 46 25.0 Yes No 66 36.7 No 134 75.0 Total 180 100.0 Total 180 100.0 Source: Survey

Table 6.7 provides utilization of TT injection and consumption of IFA tablets for 100 days. It was observed that majority of the women who sought ANC also availed TT injection. But 75% of those who availed ANC did not consume IFA tablets for 100 days. This finding corresponds with the findings of the other studies in slums of different cities (Godbole & Talwalkar, 1999). The annual health surveys (AHS 2012-13) in the country have similar findings and cited the under consumption of IFA tablets as a factor for sluggish performance of ANC utilization in 9 EAG states. Majority of the women in India are anemic, around 4 in every 10 women (NFHS-3, 2005-06). Anemia is one of the major causes of mortality and morbidity among women in reproductive age group (Qadeer, 1998).

During FGD 3 it emerged that most of the women availed antenatal check-ups, TT injection and IFA tablets at government institutions. But majority of them complained that they did not receive IFA tablets for 100 days, but were provided only with a strip of IFA tablets and were told to buy the remaining themselves, which they do not. When the issue was brought up for discussion with the staff of urban primary health center, they claimed IFA tablets were provided for 100 days to all the women but only in installments, a claim that was negated by majority of the women. Many women shared in their FGD that taking IFA tablets caused their stools go black; they got scared and stopped taking the tablets. Many also complained that the tablets leave a metallic taste in their mouth; they stopped taking them any further. Women were also scared to take “takat ki goli” thinking that it would make the baby too big to be delivered normally.

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‘baccha bahut bada ho jayega phir ja ko pet cheer ke nikalo, bacchcha hone men davai favai ki kachu zarurat nai’.

Trans. The baby would be very big, then it had to be delivered through operation, there’s no need for any medicine for child birth.

One of the reasons for the women availing two TT injections but not the IFA tablets for 100 days could be that the anganwadi workers keep track of TT injection administration but not for the IFA tablets. They were not counselled enough for IFA, causing problems of anemia. It was supposed to be made available free of cost.

Table 6.8 Caste Category and ANC Utilization ANC Caste Category Yes No Total General 39(68%) 18(31%) 57 OBC 44(62%) 27(38%) 71 SC 37(71%) 15(29%) 52 Total 120 60 180 Source: Survey

The present study also intends to study the effect of caste, occupation of the husband and education of women on ANC utilization. Table 6.8 provides the effect of the caste on ANC utilization.

With 38% not availing ANC services, the OBC category stands lowest in their utilization of ANC. Women from general caste and the SC category were found at 31% and 29% respectively in their not availing of ANC services. However, there are different reasons for under-utilization of ANC for different caste categories. Navaneetham and Dharmalingam (2002) and Pallikadavath, Foss, and Stones (2004) noted that SC women are less likely to utilize ANC in India, a finding negated in this study. With 71%, ANC utilization in SC was the highest among all caste categories. One of the major reasons for this trend appears to be the availability and accessibility of health care facilities. It was observed in this study that the slums with SC concentrated population had better health care facilities than the slums with OBC concentrated population, for e.g. Chuharpur, with

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90% of SC population, had four anganwadi centers, two urban primary health centers and a district hospital at a stone’s throw. It was also observed that the awareness among women towards health facilities in their area was also high in the SC category than in the women from the OBC category. In OBC concentrated Maulanaazad Nagar they had two anganwadi centers and a primary health centre, and in Zakirnagar, the only anganwadi centre they had was not functional and the urban primary health centre was severely under staffed. It was also complained in Zakirnagar that the emphasis of the centre is on immunization (it later on came during the discussion with the CMO that the area continuously failed to achieve the immunization target, and is considered a red alert and embarrass them during their assessment).

Table 6.9 Husband’s Occupation and ANC Utilization ANC Husband’s Occupation Yes No Total Casual labourer 16 (51%) 15 (48%) 31 Regular salaried (government servant) 27 (93%) 2 (7%) 29 Regular salaried (Private Sector) 49 (71%) 20 (29%) 69 Self-employed 27(56%) 21(43%) 48 Unemployed 1 1 2 Engaged in agriculture 0 1 1 Total 120 60 180 Source: Survey

The link between ANC and occupation of the husband is illustrated in Table 6.9 above. It shows that 93% of women whose husbands were salaried class employed in government sector utilized ANC. Women whose husbands were salaried class and were employed in private sector, had a share of 71% in ANC utilization. In both the salaried section ANC utilization was substantially higher than that of the self employed and casual labourers. A similar observation was made in a study of ANC utilization in Turkey (Ciceklioglu, Soyer, & Ocek, 2005). The authors observed that women whose husbands were jobless or whose husbands were labourers had inadequate ANC utilization compared to those whose husbands were employed in other jobs. Though the study did not clearly spell out

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Chapter Six: Reproductive Health of Women in Aligarh Slums what were the other job categories. It could be argued that in the salaried class the likelihood of utilizing ANC is higher than that of casual labourers because of various reasons. One, the salaried class men were found to be more educated than the casual labourers, and education whether it is of the husband’s or of the wife’s significantly affects ANC utilization. Two, and as has been argued earlier in the chapter, among the salaried class even those who were not educated seem to emulate the behavior and practices of their bosses and colleagues who are more educated. Also, a considerable number of those were employed at various campuses of the university in the city. Many were employed at the Municipal Corporation. For them, accessibility to the university medical college hospital or district hospital Malkhan Singh was found to be comparatively easier than for the others. This may also had contributed in high ANC utilization in the salaried class employees in government sectors.

Table 6.10 Women’s Education and ANC Utilization

ANC

Education Yes No Total Illiterate 32 (42%) 44 76 Informal Education 20 (74%) 7 27 Primary 29 (80%) 7 36 Secondary 15 (93%) 1 16 Senior Secondary 12 (92%) 1 13 Graduation 9 (100%) 0 9 Above 3 (100%) 0 3 Total 120 60 180 Source: Survey

Table 6.10 illustrates the relationship between education of women and ANC utilization. It is evident from the table that ANC utilization increases with women’s education. Women who were not educated, their ANC utilization was reported at 42%, while those who had informal education reported 74% of its utilization. 80 % ANC utilization was reported among those who had primary education, but it increased to 93% and 92% in the

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Chapter Six: Reproductive Health of Women in Aligarh Slums secondary and senior secondary education category respectively. 100% ANC utilization was reported in the graduate category. Most of the literature available on ANC utilization pointed towards its strong association with the level of women’s education. In fact, women’s education is considered as the most robust indicator associated with ANC. Studies have asserted that the more educated a woman is, the more likely she is to utilize ANC services (Nielsen, Hedegaard, Liljestrand, Thilsted, & Joseph, 2001). On study also claims that women who are educated also start accessing ANC services earlier than the women who are not educated (Miles-Doan & Brewster, 1998; (Matthews, Mahendra, Kilaru, & Ganapathy, 2001)

6.2.2 Constraints in ANC Utilization FGD 3 was organized at Rambagh Colony with women in 25-45 age group. The focused group consisted of eight members. All the members of the group said that they did not utilize ANC services because of their lack of knowledge about the services. Many of them also said that these services required money and they had limited resources even to feed their families, how could they think of going for what they said the ‘fancy services’. They added that availing ANC services is not their individual choice but is influenced by their mother-in-laws decisions. One of them narrated that her mother-in-law objected when she heard that her husband wanted her to see a doctor. ‘pet se hai to dacter ki ka jarurat hamare na bhaye, doctoran ko to apni dukan chalani hai kahoge ki han jao khoob aram karo’ kachu na bhaya ye sab aram karne ke, sair sapata karne ke bahne hain’

Trans. If you are pregnant, why you need a doctor? As if we have not been pregnant. Doctors have to run their business. You go to them, they will say, “yes go and take all the rest”. Nothing has happened, these are all excuses to go out and have fun.

When women were asked whether they would let their daughter-in-laws avail ANC services, majority of them responded in affirmation. They agreed that things have changed and that it could not be the same, they have to change with time. Many said that

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Chapter Six: Reproductive Health of Women in Aligarh Slums they do not believe in them, but that as the times are changing, so are the practices; and they would not like to be seen as regressive.

‘je to bahu ko dikhane bhi na legayi aur bahu bhi naraj ghar men kalesh to tu ja bhaiyya, samaj men ye bhi bat hoti hai phir inka ghar bada purane vicharon wala hai’

Trans. She did not take her daughter-in-law to a doctor, and the daughter- in-law felt bad and there was discord in the house. Why would I do that, I would let her go. If I do not, then this is talked about in the community that my family is very traditional and orthodox.

Interestingly, all of them considered ANC utilization as an embodiment of modernity and their not confirming would tag them as regressive and primitive in their outlook with which they did not want to be associated. This tag would affect the future prospects of matrimonial alliances of their yet to be married sons. Thus, ANC utilization was not only seen as an important component of safe motherhood but was also a vantage point for dichotomy between modernity and tradition.

However, majority of the women who were above 40 and were already mother-in-laws thought that ANC was not required and argued that had it been so important they would not have delivered their babies successfully without its utilization.

‘je batao hamare na bhaye kachu hua, magar ab ki ladkian aisi na hain to hum kahe mana karen jo dil men aye so karo’

Trans. Tell me did we not deliver, did something happen to us but today’s girls are not like that. Then why would we say no to them, do whatever you feel like.

They believed that medical intervention in the course of their pregnancy was unwarranted. They asserted that procreation is innate to women, why then there is need for any medical supervision.

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Another interesting finding of this study was the link of pregnancy and child birth to witchcraft and black magic. For instance, many women were not supposed to go out often particularly in the initial days of their pregnancy. One of the members said:

‘us samay parchayi halki hoti hai’

Trans. During those times the shadow is dim.

Many of them were simply not allowed to go out particularly during at noon and in the evening. More on the link between witchcraft and pregnancy and child birth practices is discussed in the following section on CSN 3.

Meenu (refer to CSN 3) age 22, illiterate SC had a six month old daughter, she lives with her mother-in-law and her husband works in a nearby factory. After a year of marriage, she delivered her first born, a daughter who died after a week. She thinks that her daughter died because of black magic ‘upar ka jhatka tha’. She shared that she used to go to the hospital and often used to come in the afternoon. She also used to visit her mother, in the same city, quite often and often used to return home in the evening or after the dinner at night. Her mother-in-law and her other female relatives were of the same opinion. They believe she should not be out while being pregnant and that she had been under some spell of black magic. She also thinks that she was under the spell of black magic and witchcraft for she used to have weird dreams during her first pregnancy, she still have those dreams. She said it is believed that the first pregnancy is more vulnerable to black magic and witchcraft. Her mother-in-law has taken her to ‘kailash baba’ to get her a ‘kala ganda’ (black string) which is tied around her child’s wrist to ward off the evil spirits and the magic spell.

Similar observations were also made by Griffiths and Stephenson (2001) in their study of Mumbai slums where the authors pointed out that the constraint towards ANC; particularly during the first trimester was because of the traditional belief that the early period of pregnancy is most vulnerable to witchcraft. Women’s fertility, black magic and witchcraft are seen closely related in Indian society. Similar proscriptions and taboos in India are also observed related to menstruation.

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6.3 Child Delivery: Institutional or Home Seen from the bio-medical perspective child delivery is deemed as a complex but a physiological and biological process. However, for many child birth is not only a physical and mechanical process, but a deeply rooted cultural practice too, not to be detached from its socio-cultural context. The socio-culturally riveted nature of child birth is more than evident in the prevalence of hundreds of social practices and rituals associated with the birth of a child in a family. Thus, the construal of child birth as a mechanical event, with the policy and program linking it to the financial situation of people alone, is not only highly misleading but acts as a barrier against leveraging the state of reproductive health scenario.

Table 6.11 Prevalence of Institutional Delivery Child delivery Frequency Percent Institutional Delivery Frequency Percent Hospital 73 40.6 Government 41 22.7 Home 107 59.4 Private 32 17.7 Total 180 100.0 Nil 107 58.9 Source:Survey

Table 6.11 shows that 40.6% of women had institutional delivery as against 59.4% of women who delivered their child at home. 22% of the total institutional deliveries occurred at government health institutions while only 18% were reported at private health facilities. Institutional delivery is one of the important indicators of reproductive health and safe motherhood; and it is also one of the focal points in program and policy of the government. The government of India has introduced Janani Suraksha Yojana (JSY) under the National Rural Health Mission (NRHM). JSY is a cash incentive safe motherhood scheme which intends to reduce maternal mortality by promoting institutional delivery. It provides a cash incentive to mothers who deliver their child at government health facility at the same time it also provides cost reimbursement for transportation to the delivering mothers.

The study also observed that institutional delivery at government health facilities was higher than at the private health facilities. This trend suggests an increase in the utilization of public health facilities and perhaps is an indication of people’s faith in those

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facilities, but at the same time it raises serious concern regarding overburdening of the already overcrowded and overburdened public health system. DLHS 3 (2007-08) facility survey reported that the preparedness of public health facilities is not satisfactory. More than half of the PHCs have less than four beds and a functional operation theater (OT). Only a few PHCs (12%), including 24x7 facilities, have an electricity connection and even fewer are equipped to provide emergency obstetric care. As a result, the few facilities, including CHCs and district hospitals with appropriate infrastructure are becoming overcrowded and as a result quality of services is compromised. Similar observations regarding the state of anganwadi centers and urban primary health centers were made in this study. Majority of ANC services and urban primary health centers did not have delivery facilities. Delivering mothers had to go to the district hospital, university medical college or private health facilities. This adds up to the reasons of child delivery at home.

Table 6.12 Women’s Education and Place of Child Delivery Child Delivery Education Hospital Home Total Illiterate 9(11%) 67(88%) 76 Informal Education 11(40%) 16(59%) 27 Primary 18(50%) 18(50%) 36 Secondary 12(75%) 4(25%) 16 Senior Secondary 11(84%) 2(15%) 13 Graduation 9(100%) 0 9 Above 3(100%) 0 3 Total 73 107 180 Source: Survey

Table 6.12 presents relationship between education of women and institutional delivery. 88% of women among the illiterate category reported home deliveries. It is evident from the table that with the increase in women’s education their preference for institutional delivery increases too. The link between women’s education and institutional delivery seems to be in line with the findings of many other studies. For example, Varma, Khan

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Chapter Six: Reproductive Health of Women in Aligarh Slums and Hazra (2010) assert that the likelihood of delivery at a health institution increases sharply with the increase in women’s education. Similar findings were also seen in other studies, like, Kebede , Gebeyehu and Andargie (2013); Shiferaw , Spigt & Godefrooi. In fact, it is being claimed that when the other variables are controlled, education stands out to be the single most important determinant of maternal health care utilization in India (NFHS 2, 1997-98)

Table 6.13 Husband’s Occupation and Place of Child Delivery Child Delivery Husband’s Occupation Hospital Home Total Casual labourer 12(38%) 19(61%) 31 Regular salaried (government servant) 18(62%) 11(38%) 29 Regular salaried (Private Sector) 28(41%) 41(59%) 69 Self-employed 15(31%) 33(69%) 48 Unemployed 0 2(100%) 2 Engaged in agriculture 0 1(100%) 1 Total 73 107 180 Source: Survey

Table 6.13 shows that majority of the women whose husbands were casual labourers reported home delivery while majority of those whose husbands were salaried class and were employed in government sectors reported institutional deliveries. Majority of the women whose husbands were salaried employees in private sector reported home delivery, but in self employed category majority of the women reported institutional delivery. Similar results were also reported in a study of South India (Navaneetham & Dharmalingam, 2002) where it was found that women whose husbands were salaried were more likely to delivery at institutions or delivery attended by health professionals. However, the study had not distinguished between government and private salaried class, a distinction mad in this study. There can be many possible reasons for the choice of place of delivery. First, high institutional deliveries in the salaried class who were employed in government sector may be because many of them were employed in the city university and other government offices and know people who work at the medical

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college and district hospitals. Their acquaintance with the institutions makes the delivering experience comparatively easier than that of who are not acquainted with them. Second, and as has been discussed previously, that government sector salaried employees try to imitate the behavior of people whom they look up to, like their bosses, their superiors, and their colleagues and who also possibly suggest their colleagues for institutional delivery. Women whose husbands were self employed also had more institutional deliveries. One of the possible explanations is that many people in the self employed category were Muslims from Zakirnagar and Maulana Azadnagar, areas located in the vicinity of the university. Many who work as cooks, watchmen, drivers, clerks, etc. at the university campuses also live in these areas and people in slum look up to them. There is strong possibility that women in slums are influenced by them.

Table 6.14 Caste Category and Place of Child Delivery Child delivery Caste Category Hospital Home Total General 33(57.89%) 24(42.1%) 57 OBC 31(43.66%) 40(56.33%) 71 SC 9(17.30%) 43(82.69%) 52 Total 73 107 180 Source: Survey

Table 6.14 presents relationship between caste category and child delivery. Caste is an important feature of Indian society and it has ramifications on every aspect of people’s life in India. The table shows that with 57%, institutional delivery reported highest in the general category. On the other hand, with 82%, the SC category reported the highest home delivery. Among the OBCs the percentage figure for home and institutional delivery stands at 56.33% and 43.66% respectively. Similar results were also observed by Navaneetham and Dharmalingam (2002) in their study of four southern states of India where they observed that SC/ST women in Karnataka, Kerala and Tamil Nadu were least expected to deliver in a health institution. The study also pointed out that these marginalized groups were unable to utilize other maternal health services as compared to

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‘other’ caste. However, this study found that ANC utilization among SCs was substantially higher than the other caste category.

Matthews et.al (2005) in their study reported that women from SC caste were more likely to deliver in a health institution as compared to women from other caste categories. Kumar and Gupta (2015) in their study observed that lesser number of SC had institutional deliveries as compared to other caste categories. One of the possible reasons for this preference may also lie in the availability of dais and same caste affiliation of the delivering mother and the dais. Assistance in delivery is traditionally done by the lower caste people particularly the SC, availability of dais could be one of the reasons for high home delivery among SC concentrated slums. Saroha, Altarac and Sibley (2008), in their study of caste affiliation and the use of maternal health services, highlighted that maternal care giving involves coming in contact with health service providers who often belong to general or other higher castes. This causes lower caste women, who even now are considered as untouchables by many, to prefer home deliveries with the assistance of dais, who belong to the same caste category.

6.3.1 Reasons for Institutional Delivery It was reported that many of the women who had institutional deliveries were advised by elders or other community members. The advice of mother-in-laws, mothers, elder sister- in-laws and elder sisters were crucial as they were the ones who negotiate with husbands during the pregnancy period.

FGD 4 was organized with women of 30-50 age group at Chuharpur to study the choice of place of delivery. It consisted of nine members.

One of the members of the group said: ‘Hamare pati to apni maa pe chodh dete hain jo vo kaen vo hota hai , kahen hain ye aurton ki baten amma hi samjhoge

Trans. My husband leaves it all on my mother-in-law, whatever she says would be done; he says these all are womanly matters, let her decide.

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Many of the members also reported that they had institutional delivery because of the complications. To avoid any risk, they thought it better to deliver at the hospital under regular medical supervision. Some said institutional delivery is convenient to them, but those were the ones who relatives were employed either at the university medical college or Malkhan Singh district hospital.

But this claim was vehemently contested by another member in the group who argued saying: ‘Behen Tumahre liye howege suvidha hamen to poochta na hai vahan’

Trans. Sister, it must be convenient for you but nobody gives a damn to us.

It is to be noted that only a few women reported that their decision for institutional delivery was influenced by the doctor’s advice. No wonder in spite of high ANC prevalence, institutional delivery is very low in the studied population. The general connection between ANC and institutional delivery, found in many other research works, was not observed in this study.

One Muslim member of the group said that though earlier they had home deliveries but now they preferred institutional deliveries. Explaining she said, her children who were young then have now all grown up and comprehend and understand things. It is embarrassing to have all this at home now.

‘Bachche bade ho gaye hain, samjhte hain kya ho raha hai, achcha nahin lagta ghar pe ab’

Trans. Kids are grown up now; they understand what is going on; no longer does it look nice to happen at home.

For many Muslim members, because of their strict parda practice, institutional delivery may not be their preferred choice for child delivery. However, it is to be understood that

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‘Muslim’ is not a uniform and fixed category rather there exist within it categories of class, caste, age, individual differences informed by their particular socio-cultural context. Their needs, aspirations, motivations are diverse and different from each other.

6.3.2 Reasons for Home Delivery FGD 4 also reveals the possible reasons for the choice of home delivery over the institutional one. The members in the FGD explaining about their preferences regarding the place of child delivery said that child birth is not a morbidity which requires medical intervention and supervision. They lamented the idea of child birth being turned into a medical condition. In fact, they belief on the contrary, it is a crucial and joyous period of women’s life which should happen at home not at indifferent mechanical spaces. ‘Ja ko aisa bana do hai jaisa ki koi rog, dawai khao,sui thokwao, aram karo’ Trans. They have turned this into an illness, take medicine, injection, take rest

Many thought reproduction as innate to womanhood and does not require any medical intervention. What they wished to describe seems to resemble the idea of the pathologization of the normal by locating the child birth under the control of professional doctor. As observed above that majority of the institutional deliveries occurred in public health facilities, the state regulated health facilities acts as sites in this pathologizing process. This pathologization of the normal is an important constituent element of the whole ‘medicalization’ process. Medicalization is understood as the process through which the clinical expertise becomes the relevant basis of decision making in day to day life (Frank, 1992) and this has turned into the most important constituent element of modernization process throughout the world (Illich, 1976). The medicalization of child birth is the process through which the clinical establishment with their standardized professional guidelines and procedures incorporate birth in the category of morbidity which requires medical supervision and treatment. Scheper-Hughes and Lock (1987) opined that medicalization revolves around squandered association between individual and social bodies with leaning to turn the social into biological.

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Many women also said that the choice of place of delivery was primarily their family’s decision and they didn’t have much say in that. However, majority of the women belonged to nuclear households, then how could the choice of place of delivery was influenced by their husband’s or their own families decision. It was found out that even in the nuclear households; the husbands were in continuous consultation with their mothers or elder female acquaintances and relatives.

Another important reason for the choice of home delivery was the logistic issues required for institutional delivery. Who would take care of their other children at home, who would acquaint them at the hospital? Delivering at home, therefore, becomes a consensual choice of husband, wife and other female relatives in the family.

Many members believed that institutional delivery is an expensive affair which they could not afford. They said they don’t have enough resources even to feed their families. And with acquaintances needed to accompany the delivering women, institutional deliveries result in loss of wage and additional expenses spent on food, transportation, etc. One of the women said.

‘University men moti kamai hoti hai tumhari ham to na ja saken hain haspatal hamare liye to ghar hi badiya hai yahin ho jae sab apne bachche bhi dekhte raho ghar bhi dekhte raho’

Trans. You earn a fat salary at the university, we can’t go to hospitals, home is the best for us, and we look after our home and children here.

Another significant reason for the women not to prefer institutional delivery was the indifference and lack of empathy shown by the doctors and paramedical staff at those institutions. It is interesting to note that what the most annoyed the women were not the doctor’s indifference and their impoliteness but the apathy and disrespectful attitude of the paramedical staffs. The indifference and lack of polite behaviour shown by the doctors, the women believed, is the essence of being a doctor. In their imagination, a

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doctor cannot be a friendly individual and the one who is cannot be a true essence of a doctor. In a way they have internalized the objective and scientific paradigm of a profession. But it is the indifference of the paramedical staffs which humiliates them the most. This humiliation is aggravated because of the fact that many of the paramedical staffs are known to them and share with them the same socio-cultural, sometime the economic background, and many a time belong to the same caste category. But when the same people happen to be at medical spaces they boast of their institutional identity as a marker of power and domination. Eliot Friedson (1970) in his book Professional Dominance: The Social Structure of Medical care termed this as ‘professional dominance’. Many women members claimed that they were slapped, scolded, shouted at, name called while delivering in at health institutions. One of the members narrating her experience of institution delivery said, ‘buas’ made fun of her labour pains and she felt bad when she heard two of them saying.

“Ye us wakht bhi itna chillayi hogi” Trans. Whether she had shouted the same way at that time too.

‘Ye kallo bahut gala phad rahi rahi hai iska munh band karo koi’ Trans. This blacky is shouting her throat out, someone shut her up.

Hollen (2003) in her study also had similar observations. She elaborates that ayahs have power because of being a part of medical institutions. She further says that most of the ayahs have similar caste and class background as that of the patient’s and to maintain a social distance they exhibit such indifference and apathy to them. However, there can be another perspective to understanding the behaviour they display. In overcrowded public hospitals, buas are the ones who are positioned at the lowest rung in the hierarchy of medical profession, and they are under constant pressure to run things smoothly. If something goes wrong they are the ones to face the brunt. A lot of ayahs and buas in public health institutions are contractual employees and are under constant threat of losing their employment.

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In this study many women also expressed that home delivery provided them a comfortable and warm environment, they were surrounded by their elder female relatives, neighbours and the dais. There are studies which have shown that support and care women receive while delivering helps them to calm and reduce the pain (Kitzinger, 1994). Patel (1994) in her study of Rajasthan village also points out that female relatives and the neighbours help women release their anxiety and tension which ultimately lessen the pain of child birth. Thus, it is important to note that institution delivery is not necessarily an enriching experience for women, delivery at their homes in company of other females and friends with the help of the dais is preferred by many apparently because of the similar socio-cultural and economic background of the dais and because of the fact that they are known to the women and their husbands family for long.

CSN 4 elaborates women’s experiences of their institutional delivery. One of the members, Neetu age 31(refer to CSN 4) had three children; two daughters and a son. Her first delivery was institutional. Narrating her experiences, she said she was crying in pain but there was no help, the doctor came and asked her to calm down and stop crying. She was taken to the labour room and all she remembered was people trying hard to pull the baby out. Later she learnt due to lack of oxygen to the baby’s brain, the physical and mental development of her baby would not be normal. She decided if she ever delivers again she would go for deliver at home rather than the institutional one. In her opinion, it all happened due to the negligence of the doctors, she was crying and everyone was asking her to shut up. She said it is being said that in case of emergency during child birth women would be able to receive adequate medical attention. Now people around console her saying that it was her destiny, she refused to accept this as her fate. The next time when she got pregnant, she delivered at her home. The ‘mausi’ came to help her, and she said “look all my children are healthy, now nobody in family goes for institutional delivery.

‘Dais’ were generally addressed as mausi or khala (maternal aunt) and enjoy a celebrity status in the sampled slums. Numerous success stories were associated with dais in cases

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where even doctors and health institutions refuse to intervene. Dais help women in successful vaginal deliveries.

Many studies attest that preference for home delivery over institutional one. Ramana (2002) in her study points out the important role of traditional dais play in child delivery. Similarly, Khandelkar (1993) finds that women in slums prefer home deliveries and place immense trust on dais, who belonged to the same socio-cultural milieu. Hollen (2003) in her study of Tamil Nadu village also found that women who opt for institutional delivery do not necessarily have very enriching experience when compared to child delivery with the help of traditional dais. It is further argued that this is because they share the same social class and caste categories and have known each other for long which consoles the delivering mothers. The dais show empathy with the delivering mother. In another study it was seen that women preferred home deliveries because the dais were more readily available and accessible even at odd hours, and also help women with household chores (Sharma, Bali, & Bhargava, 1990). Helping women in household chores also ensures regular interaction between dais and the delivering mother and help them familiarize with the women’s environment. Gulati, Tyagi and Sharma (2003) in their study of Delhi slums were surprised to note that safe delivery in Delhi slums is 96% compared to only 74% in non slum population.

It seems that there is an attempt to create dichotomy of home delivery and institutional delivery. The relentless zeal to look for inherent goodness in institutional delivery is juxtaposed with dais, considered to be repository of knowledge by the birthing women. By labeling home deliveries and dais involved in it as ‘primitive’ is to assert the hegemony of the biomedical perspective of child delivery.

Complaining the discrimination they faced on account of them being from slums, many women said they face a belittling behaviour of the hospital staffs towards them as compared to women who are not from slums and who look better than them.

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‘Ham jab parcha banwate hain vo poochte hain kahan se ho to hamara pata sunke unka rawaiyya badal jata hai’

Trans. When we go to the OPD registration counter, the moment they hears of our address their attitude changes.

Such views were more frequently expressed at Zakirnagar and Chuharpur, but not across all the slums in this study uniformly. Zakirnagar is a slum in Civil Lines area inhabited by many daily wagers employed in university and domestic help. Their belonging to Zakirnagar put them on lower pedestal in power dynamics to most of the staff of medical college and hospital. In Chuharpur, Muslim women also complained how the staffs of the district hospital make fun of their fertility and reproductive practices. Many Muslim women also expressed concerns towards privacy, they say institutional delivery repudiate their privacy.

‘Be pardagi hoti hai’ Trans. It leads to compromising purda.

The breach of privacy is particularly evident in the public health institutions where labour rooms are crowded with many laboring women and with doctors, nurses, and other paramedics. And at the understaffed public hospitals, the male relatives of the delivering women also sometimes, out of anxiety and inquisitiveness, come into the labour rooms. This causes the labouring women, anxiously waiting for their turn to get attention in the overcrowded labour rooms, lose their dignity and respect.

This study also observed an increasing belief among many people that hospitals prefer C- section even when it is not required. Mahapatro (2015) in her study of Odisha also observed that women had fear of caesarean sections. The study highlighted that women perceived caesarean sections were performed unnecessarily at hospitals. This study found that the share of caesarean birth in total institutional delivery was 30%. At private hospitals this figure is more than half of the total delivery. Many women doubt the decision taken for caesarean sections. One of them said:

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‘Ye private wale to paisa banana ke liye pet kat dete hain’ Trans. These privates (hospitals) cut the belly to mint money.

The study also observed that delivery with episiotomy i.e. delivery with stitches, was found to be 12% while normal delivery was 23%. The share of normal delivery at public hospitals was found to be more than that of private hospitals.

Many members in FGD 4 also complained that, notwithstanding the purpose of their visit to health institutions, they were forced to undergo counselling for family planning. They said, even when they were there for other health issues they would be talked about the benefits of family planning. They believed that visiting medical institutions would result in their being tricked into adopting family planning, like tubectomy. Although, they were not forced into sterilization without their consent, but it was hard to resist the pressure when one is surround by so many professional paramedical and counseling staff who stare and gaze you right in your face. And one is counselled before one knows that she is persuaded, you end up being tricked only to repent it later, said the women.

6.4 Contraception Contraception is the most common method adopted by couples seeking to limit the number of their children and to space time interval between births. Contraception has been the focal point of family welfare programs right from its inception in 1951. Under the National Population Policy, 2000, the Government of India sets as its immediate objective the task of addressing unmet need for contraception to achieve the medium- range objective of bringing the total fertility rate down to replacement level by 2010. One of the socio-demographic goals identified for this purpose is to achieve universal access to information/counselling and services for fertility regulation and contraception with a wide range of choices (Ministry of Health and Family Welfare, 2000)

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Table 6.15 Contraception Utilization and its Methods

Contraception Frequency Percent Contraception Method Frequency Percent Yes 112 62 Condom 39 21.6 No 68 37 OCP 3 1.6 Total 180 100.0 Injectibles 14 7.7 IUCD 21 11.6 Sterilization 30 16.6 Any other 5 2.7

Source: Survey

Table 6.15 shows that 62% of the sample population was using contraception at the time of the interview while 37% of it was not using any contraception. AHS 2012-13 reported a 44% prevalence of family planning in Aligarh city, the slums of the city were 7 points lower than that of the city average. With 21.6% utilization, condom was the most popular method of contraception among the sampled population while, on the other hand, with 1.6% utilization, OCP was the least popular. Sterilization was used by 16.6%, IUCD by 11.6%, injectibles by 7.7% and traditional methods of contraception by 2.7%. However, many women claimed to practice traditional methods of contraception.

In the sampled population, only a single male sterilization was reported as a method of contraception. A study of contraceptive use among married women in Mumbai slums found that female sterilization was the method used by majority of the women but not a single case was reported among the males in the studied population (Makade, 2012). Similarly, Reddy et al (2003), in their study found that not a single man adopted vasectomy as a method of contraception. Reddy (1984) in his study pointed out that majority had undergone sterilization and there exists huge unmet demand for contraception for spacing.

In a study of Vishakhapatnam slum (Ramana, 2002), similarly, found that around half of the women in slums use contraception and that majority of them had sterilization but male sterilization again was very low. On the issue of higher female sterilization and

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Chapter Six: Reproductive Health of Women in Aligarh Slums male aversion towards sterilization, she concluded that perhaps men prefer freedom from the burden or at least do not take the risk or bear the possible pain of the operation. She also mentioned the idea of male virility as the reason of their caution. Gulati, Tyagi, and Sharma (2003), in their study reported female sterilization as the most popular among all the methods of contraception.

NFHS-3 (2005-06) noted that contraception is 11 points higher in urban areas (64 %) than in rural areas (53 %). NFHS-3 (2005-06) also pointed out that among the slum population contraception among currently married women is lower in slum areas than in non-slum areas except in Chennai. Methods of contraception use also differ from slum and non-slum areas. In every city, the use of modern spacing methods is lower in slum areas than in non-slum areas. Another study conducted in six cities in the Northern state of UP found that unmet need for family planning among women in the urban slums is much higher than those living in non-slum areas (Speizer, Nanda, & Achyut, 2012). A study of contraception in urban slums of Poona (2000) pointed out that tubectomy was the most common method of contraception, followed by male condoms, OC pills, IUDs and vasectomy. This study also found that vasectomy is the least favoured method of contraception in the studied slums. Another study based on the analysis of NFHS-3 (2005-06) elaborated that sterilization is the most favoured method of contraception adopted by women in slums (Hazarika, 2010).

Table 6.16 Caste Category and Contraception Utilization Contraception Caste Category Yes No Total General 39 (70%) 18 57 OBC 43(60%) 28 71 SC 30 (57%) 22 52 Total 112 68 180 Source: Survey

Exploring the link between contraception and caste category, Table 6.16 shows that contraception among general caste category (70%) was substantially higher than that of

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OBC (60%) and SC (57%). Shaw (1988) in his study of Calcutta slums illustrated that caste is an important factor in contraception. The study suggested that higher castes have lower fertility than that of the lower castes. Another study on methods of family planning adoption in Varanasi district by Shweta and Singh (2010) also reported that contraception was the highest among general caste category followed by OBC and was the lowest among SC population. However, famous Indian Sociologist Yogendra Singh (1977) opined that the course of this relationship was because the upper castes in India were more educated and modernized as compared to the lower castes. To counter Singh’s argument, Shaw (1988) in his study pointed that the caste effect on fertility cannot be entirely attributed to modernization through educational upliftment. Shaw (1988) illustrated that there were certain caste specific taboos and practices related to reproduction which impinged upon contraception and fertility behavior.

Table 6.17 Caste Category and Method of Contraception Method of Contraception Caste Any Category Condom OCP Injectibles IUCD Sterilization other Nil Total General 18(31%) 0 6(10%) 6(10%) 7(12%) 1 18 57 OBC 15(21%) 2(2.8%) 3(4.2%) 10(14%) 9(12.6%) 3 28 71 SC 6(11.5%) 1(1.9%) 5(9.6%) 3(5.7%) 14(27%) 1 22 52 Total 39 3 14 21 30 5 68 180 Source: Survey

Table 6.17 shows that, with 31% prevalence, the use of condom as a method of contraception was the highest among the general caste category, while it was around 21% among the OBCs. However, with 14% prevalence, IUCD use was the highest among the OBC caste. Among the OBCs, Muslims reported sterilization least as a method of contraception. With 27%, sterilization was found to be the highest among the SC category. Similar observations were also made by Shahid (2010) in his study of Lodha block in Aligarh. The study observed that sterilization was the highest among the SC category.

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However, caste may not be the only factor affecting sterilization adoption; it depends on various other factors like achievement of desired family size, desired sex composition of children etc. It seems then, and is intriguing, that in India, unlike in other countries, women of lower age group limit their fertility through sterilization. In this study also it was observed that, among the women who were sterilized the oldest were in the age group of 29-33. The explanation of this unusual contraceptive practice possibly lies in the fact that the reproductive career of sampled population set off with their early marriage and frequent child birth. Consequently, the women achieved their desire family size at an early age which affects their fertility behaviour and contraception practices.

In CSN 6 Sunita age 33, primary educated, Brahmin women whose husband works at a lock manufacturing factory. She has 3 children (3 sons) and has undergone sterilization at Malkhan Singh district hospital two years ago, at the age of 31. But the very next year she conceived. Sharing her experience, she said, she contacted the health worker who persuaded her for sterilization. She went to the district hospital and complained, but they blamed the doctor who operated her. But the doctor was already transferred to another public hospital. Now what they could do, she was told, was abortion without any fee being charged if the child was not needed. So she aborted the child only to get pregnant afresh. But this time, she avoided going to the district hospital rather she went to a private health facility and got DMPA injection administered. This case shows the plight of sterilization failure and the apathy and lack of accountability of doctors and health professionals at public health institutions.

Table 6.18 illustrates the relationship between education of the women and contraception ustilization. It was seen in this study that the use of contraception was the least among women who are not educated. Mason (1984) elaborated in his study that with education women's knowledge, attitudes and family planning practices also increase. Chaudhury (1996) in his macro level study also asserts the positive co-relationship between female education and the adoption of family planning methods. NFHS-3 (2005-06) also pointed out significant relationship between women’s education and contraception use.

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Table 6.18 Women’s Education and Contraception Utilization Contraception Education Yes No Total Illiterate 36(47%) 40 76 Informal Education 18(66%) 9 27 Primary 23(64%) 13 36 Secondary 14(87.5%) 2 16 Senior Secondary 10(77%) 3 13 Graduation 8(88%) 1 9 Above 3 0 3 Total 112 68 180 Source: Survey

Table: 6.19 Husband’s Occupation and Contraception Utilization Contraception Husband’s Occupation Yes No Total Casual labourer 18 13 31 Regular salaried 25 4 29 (government servant) Regular salaried 43 26 69 (Private Sector) Self-employed 25 23 48 Unemployed 1 1 2 Engaged in agriculture 0 1 1 Total 112 68 180 Source: Survey

Table 6.19 shows that the husbands who were casual laborers were less likely to use contraception than those who belonged to the salaried category, especially in government jobs. But this distinction diminished between salaried category in private sector and in self employed category. The salaried ones had job security irrespective of the income and

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they had higher contraception adoption than the rest of the categories. As has been discussed previously in this chapter, Mamdani (1976) in his study discerned that the rationale for contraception use cannot be uniform in all the class situations and low contraception in any class situation cannot be attributed to their ignorance and lack of awareness. He argued that wage earners, small farmers, artisans employed in local industrial units prefer large families, and for them children are economic assets and assurance against old age. Similarly, Nankarni (1976) also reflects upon contraception elaborated that contraception among cultivators found to be lower than that of non cultivators. Their choice of having large families is based on economic rationality since large families are considered the best and only source of social security in old age (Amin, 1976)

One of the shopkeepers in the studied area, during an informal discussion, boasted that he opens his shop quite late in nights and is popular for this reason. He explained how he manages to open it quite late. He has two daughters and a son. In the morning he opens the shop and remains there till 3-4 in the afternoon then his son joins him who remains there till 11 in the night. He lamented and said:

‘agar mere ek aur ladka hota to main apni dukan rat bhar kholta’.

Trans. If I had one more son I would have opened my shop all night.

This statement exemplifies the economic rationality behind contraception use within various occupational categories. People are not some mindless invertebrates. If they do not use any contraception, they have strong reasons for their behaviour and which can be shown to have links to their unique socio-economic and cultural situations.

6.4.1 Constraints in Contraception Use A number of women among those who did not use any contraception method cited their desire for another child as the main reason for not using any contraception. Majority of those women had son preference, but there also exists desire for at least one female child.

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Women also said that they would like to use contraception but their husbands do not allow them to use any. This study also observed that majority of the women who did not use any contraception avail emergency pills quite often. Many of them also reported induced abortion and abortion through over the counter medicines which are easily available at the nearby medicine shops without prescription. Often the women seek advice from the medicine shops. Some women also reported to have used injectibles and IUCD but had stopped using them because of their side effects and started using condoms. One of the Muslim women who used to be a condom user got them from the nearby district hospital. Complaining about the behavior of the hospital staff, she said that the Madam gave me condoms initially without any hassle but after a while whenever she goes for them the lady makes faces and scolds her.

‘Abhi to ayi thi, itni jald khatm ho gaya’

Trans. You came just recently, it’s finished so soon.

The last time she visited the lady in-charge for the condom she mocked and ridiculed her by addressing her colleagues:

‘Inhen bus yahi hai aur kuch nahin hai aa jati hain roz pata nahin kitna krati hain’

Trans. They have only this and nothing else. Every day she comes, don’t know how often she does.

This exemplifies the stereotypical attitude of people towards Muslim sexual and fertility behavior. Many in India believe Muslims have sexually hyperactive who irresponsibly keep on begetting children. Lately with the change in government, the discourse on Muslim reproductive and marriage practices has reached to a level never seen before and with the local popular media fuelling the discussion these stereotypes and prejudices are cemented and reinforced.

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FGD 5 provides an insight into the use of contraception and makes us appreciate the motivations and constraints in its use. FGD 5 had eight women in the age group of 25-45, out of whom five did not use any method of contraception. The women in their 40s lamented on the issue of contraception use and said why the onus of its use is always only on women. Why only women have to use contraception, and why people keep coming to counsell them; why do not they go to their husbands, they said. Others joined in the discussion to add that for everything they ask their husbands, and if they intend to use any contraception they cannot stop them anyway, so why always they have to be counselled.

FGD 5 forces us to think how women are treated as mere reproductive beings by policy makers whose fertility needs to be curtailed. Women particularly those who do not use any contraception to control their fertility said suggestively ‘perhej se rahte hain’ referring to the periodic abstinence, to which other women cautioned:

‘Apne mard ka pet bhara rakhna chahiye, zamana bahut kharab hai kya pato vo bahar khana dhundne lage pet bharan ko ‘

Trans. Always feed your husband well, these are the bad times. You never know what if he searches food to feed himself outside home.

It is interesting to note that many Muslim women believed that it is sinful to refuse their husbands because they deem it a religious duty to make themselves available to their husbands. Many Hindu women too believed that a husband’s sexual appetite should be satisfied, the reason, however, was not religious rather they were informed by the belief that this would contribute to their husbands’ infidelity.

Referring to withdrawal as a method of contraception, another woman said:

‘Jab tak doodh men jaman nahin pade to dahi jamoge kaise’

Trans. Until the milk is not mixed with curd how will you get the curd.

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Another issue that annoys the women, particularly in the age group of 40 and above, was the repeated visits by health workers to counsell them. They believed that there are certain social do’s and don’ts regarding sexual and reproductive behavior and practices. One of them is that once their children are married off and they become grandparents, they are more cautious regarding their reproductive and sexual behavior. This is because women getting pregnant when they have their daughter-in-laws and son-in-laws would be a subject of ridicule. Attaining grand motherhood, women exhibit self control over their sexual behavior and so does their husbands.

One of the women, in her 40’s, ridiculed the futility of the continued family planning counselling to women who already have grandchildren and thus would practice abstinence.

Ab tum ja ko kaho ki tu apno bachcha band karwa le, ye dhi bahu wale ke bachche ho rau ka ki band karwa le

Trans. Now tell me, if you tell her to adopt contraception, she already has her daughters married off and have daughter-in-laws, is she in age of having children?

It has been observed that people’s reproductive and fertility behaviour and practices are inextricably linked to and are informed by their understanding of the social norms and practices of which they are part of. This link has been emphasized in various studies (Wyon & Gordon, 1971), (Kara & Sinha, 1987) & (Patel, 1994).

6.4.2 Problems with Contraceptive Use Contraception has significant bearing on the health of the user. The WHO (1989) expert group propounded two categories of the side effects. (a) Unusual and rare experiences or complications; and at times are fatal. (b) Usual minor adverse effects.

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Rejecting the above listed side effects, Rao (1972) stated that in developing countries with high maternal mortality rates, side effects from the use of contraception seems very insubstantial as compared to the ‘risks associated with pregnancy or mortality and morbidity resulting from illegally induced abortions’ (Rao, 1972). Table 6.20 Types of Contraception and its Related Complications Contraception Type Yes No Total Condom 8(20%) 31 39 OCP 2(66%) 1 3 Injectibles 6(43%) 8 14 IUCD 14(66%) 7 21 Sterilization 10(33%) 20 30 Total 40 67 107

Source: Survey Source: Field Survey

The study observed that 37% of women, among those who used any kind of modern contraception, experienced problems associated with the chosen contraception. Among the OCP users except one all had experienced problems. 43% of DMPA users experienced problems with its use. Among the IUCD users 66% experienced problems as compared to 33% among those who adopted tubectomy. Those who used OCP as a method of contraception experienced problems the most as compared to the condom users, who experienced least problems. These problems varied from menstrual complications, weight gain, and vaginal discharge to pain in lower back and lower abdomen, vaginal dryness, cramps in legs to stiffness around stomach and loser abdomen. A study of slums of Baroda noted that 20% modern contraceptive users experienced some sort of side effects. Another study of urban area of Delhi reported that 11.2% among the people who ever used any contraception have contraceptive morbidity (Bhatnagar, 2013). A study of Rajasthan also noted higher prevalence of reproductive morbidity related to contraceptive use (Rathore, Swami, Gupta, Sen, & Vyas, 2003).

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FGD 6 was conducted to study and account in detail women’s experiences associated with the method of contraception use. It was done with those women who at the time of interaction were in use of any of the methods of contraception. The FGD revealed that the majority of DMPA users experienced complications. Many women complained of irregular menstrual cycles after DMPA use. Stiffness of lower abdomen and weight again around waist were also complained. A Study on the use of DMPA in Turkish society reported irregular menstrual bleeding as a major side effect women experienced with DMPA (Aktun, Moroy, Cakmak, Yalcin, & Leyla, 2005). Despite the complaints, many were still curious to know about DMPA as they inquired about ‘DIMPA’ from the researcher. DMPA, called as ‘DIMPA’ by them, is considered a magic injection and is on the list of highly desired methods for it could make them free from the fear of pregnancy for a while. DMPA, however, it is to be noted, is not part of the government family planning program in India and is not available at public hospitals. It is not accessible for women living in slum areas where women rely primarily on public health institutions for family planning.

Many women also discussed the complications and side effects of OCP. Among one of the major drawback of OCP was reported to be its strict regimen; you have to take it every day, and with numerous tasks at hand, it is difficult to maintain the tough schedule. Many alleged the unavailability of OCP at the urban primary health centers and public health facilities and claimed that they have to buy it from the market. Many said that they have used OCP in the past but discontinued its use due to its side effects. Nausea, dizziness, pain in lower back and lower abdomen were the common side effects of OCP that many in this discussion shared. Kirkconnell , Stephenson and Juvekar(2008). This study reported severe abdominal pain, nausea, vomiting and vertigo as the side effects women experienced with the use OCP. Shahid (2010) also in his study of Lodha block, Aligarh noted that the OCP users switched to other methods of contraception because of its side effects and the strict regimen one has to undergo. ‘Mera ji bahut ghabrane laga tha jab maine band kiya tab jake tabiyat sudhri meri’

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Trans. I got depressed, I felt better when I stopped taking it.

In FGD 6, talking about IUCD, one of the women complained:

‘Upar chadh jata hai’ Trans. It gets sucked up deep.

Many disclosed that how IUCD make them feel hurt in their intimate parts; they explained that it feels like there is something stuck up in their reproductive track and it’s a constant uncomfortable feeling that follows.

Rajaretnam and Deshpande (1994) in their study of rural South India also discussed that one of the constraints to the use of IUCD and pills are their side effects. It is also emphasized that in spite of the challenges and complications faced by those who undergo sterilization, they encourage others to adopt them and perceive that the ill effects of sterilization are minor than that of the IUCD and pills.

Malti, age 28 (refer to CSN 5) has three children, two daughters and a son. She adopted IUCD as a method of sterilization, but she started discharging from down under. She informed the health worker who counselled her into adopting IUCD. She visited the hospital where she got it done and informed the doctors, but only to be told that it is usual and there is nothing to worry. Later, she started bleeding profusely and was once fainted. Her husband took her to the private hospital where he worked as a clerk. The doctor removed the IUCD. She now uses condom.

NFHS-3 (2005-06) also reported high IUCD and tubectomy related morbidity. A study of Reproductive Tract Infection among rural married women in Tamil Nadu found high incidence of RTIs among the IUCD users (Mani, 2014). However, prevalence of RTIs and Pelvic Inflamatory Disease cannot be attributed alone to the use of contraception. Personal and menstrual hygiene are other significant factors leading to RTIs and PIDs.

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In FGD 6 few IUCD users reported pre-insertion screening and discussion with the doctors regarding its major side effects. Many of the women claimed that the insertion was done by the nurse and the doctor was frequently coming in and going out while the procedure was being conducted.

Table 6.21 Medical Help for Contraception related Complications Medical Help Frequency Percent Yes 13 32.5 No 27 67.5 Total 180 100.0 Source: Survey

It is evident from Table 6.21 that 32.5% among those who experienced complications with contraceptive use sought medical advice while 67.5% didn’t seek any treatment for their complications. A study in Delhi (Bhatnagar, 2013) noted that seeking medical advice for gynecological morbidity was very low as compared to the obstetric and contraceptive morbidity. The study observed that people sought treatment for contraceptive morbidity but pointed that people exhibited less compliance with the line of treatment in contraceptive morbidity comparing obstetric and gynecological morbidity.

This study also sought to find out whether the women who received medical help were satisfied with the services available. Majority of the women responded that they were not satisfied. Many of the women responded that their contraception related complications were overlooked and that their complications were diagnosed not to be linked to their contraception use. None of the women agreed with the doctor’s diagnosis as the women firmly believed that none can understand their bodies better than they themselves. And they believed it to be the ill effects of the contraception they adopted. Many women said medical help were of no use to bring any relief to their complications. They required prolonged medication which they were unable to afford. It was observed that generally women were not being counselled for the side effects of particular contraceptive method neither they were informed about alternative available methods of contraception.

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With 26.7% use, the share of condom use was the highest among the family planning methods. This was followed by sterilization. There was only one vasectomy case out of the total 30 cases of sterilization. Many women also ventilated their anger at how they were counselled to the extent of being coerced into sterilization. They also complained about health workers for asserting family planning as the only theme of their discussion.

During the researcher’s visit to one of the households, her neighbour on the terrace started shouting at the researcher.

‘Je batao hamare kitne bachche hon tumse kya hai tum do ho khane ko kyun aa jate ho vakht be vakht’

Trans. Tell me why it bothers you so much how many children we have, do you feed them?

During the field visits many women mistook the researcher as a health worker on a mission to counsell them into adopting family planning. A lot of women also confided that when people come to inquire about family planning they misreport condom as the method of family planning. Telling them any other method of contraception, evokes a lot of tricky questions which are difficult to answer; the best is to tell them condom as a method of family planning.

Narrating the incident of a team’s visit on family planning project, one of the women said the way they were inquired displayed visiting team’s insensitivity regarding the issue, as a result the residents of the area agitated and did not let them enter the area.

Wondering at this fixation with family planning, people also asked the reasons for the exceptional concern about the issue, leaving aside other issues like school education, sanitation, employment, inflation etc.

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6.5 Conclusion In this chapter it was observed that the indicators of reproductive health is affected by women’s unique socio-cultural positioning. The study has seen that there exist strong relationship between husband’s occupation and desired fertility. Women whose husbands were salaried class tend to prefer smaller families than the husbands who were self employed. The study has also observed that caste affects fertility preferences. The study has highlighted that inspite of strong son preference, almost all women prefer to have at least one girl child. The study has seen that that ANC utilization is quite high and majority of the women were seeking ANC services from the government sources, however there is low usage of IFA tablets. Another interesting point this study has raised that despite of high ANC utilization women living in slums of Aligarh still prefer to deliver their child at home with the help of dais.

The study has noticed that contraception use was substantially high in the studied population, where condom use was the most preferred method of contraception at the same the study has also thrown light on the methodological issues involved in studies on intimate behavior like fertility. The next chapter provides elaborate conclusion and suggestions.

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CHAPTER SEVEN FINDINGS AND CONCLUSION

7.0 Overview This final chapter concludes the present thesis. The aim of this chapter is to summarize this study and to offer conclusions in the form of discussions. It begins with the discussion on the key findings and their interpretation (7.1). The discussions are grounded on the analysis of the primary data collected through both quantitative and qualitative methods. This thesis is brought to an end by proposing certain suggestions (7.2) for the policy makers, health professionals, and community workers.

7.1 Findings and Interpretation In this section key findings of the study and systematic interpretation of those findings are offered. They are provided in the form of discussions on the basis of the data analysis of the indicators selected for this study.

7.1.1 Fertility It was observed in this study that majority of the sampled women i.e. 40% had more than three children at the time of interview which is higher than the replacement level of fertility i.e. 2.1 children and higher than the national average of fertility i.e. 2.4. FGD 1 and 2 provides subjective understanding of desired fertility and desired sex composition of the children. From FGD 1 and 2 it was found that there exist age wise difference in perception of desired family size and the desired sex composition of children, for older women ideal number of children is four two boys and two girls and for younger women it is three two boys and a girl. Both younger and the older women have agreement on having at least two sons in the family.

It was observed in the study that in spite of strong son preference, daughters were valued too, and at least one daughter is considered essential in family. Daughters are considered Chapter Seven: Conclusion and Suggestions

strong emotional support to old age parents. CSN 2 illustrated that how in spite of eight sons the women considered her family incomplete because she did not have a daughter. She still longs for a daughter and craves for emotional support a daughter provides to parents.

The study has also analyzed the relationship between fertility and education of women. It is seen in this study that fertility was higher among women who were uneducated than the women who were educated. The percentage of women with more than three children was found to be the same in women who were educated up to primary and secondary level and was found to be 10 points higher among the women who were educated up to senior secondary. There were only 12 women who were educated up to graduation and post graduation and none had more than three children, however with such scarce representation of women who were graduate and graduate in the sample size it is difficult to arrive at a clearly marked conclusion on relationship between fertility and women’s education.

It is seen in this study that those who were self employed their share of having more than three children was exorbitantly higher i.e. 81% than any other occupational group. Mamdani (1972) and Nankarni (1976) also have similar observations in their studies they pointed out pointed out that the wage earners, small farmers, artisans employed in local industrial units prefer large families. Mamdani (1972) in his study illustrated that for them children are economic asset and an assurance against old age. The women whose husbands were casual laborers also had higher fertility than women whose husbands were regular salaried employed either in private sector or in government sector. FGD 1 and 2 also provided qualitative description of these differentials. The women whose husbands were employed in the government sector they were found to have lowest fertility level. One possible explanation of this trend could be that people employed in the government sector no matter what education they had and on what post they were they try to imitate the behavior of their colleagues and seniors. In this way the government’s offices are the sites of ‘melting pot’ affecting each other’s behavior even the intimate behavior like

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7.1.2 ANC

It was observed in this study that ANC utilization is quite high and majority of the women were seeking ANC services from the government sources anganwadi centers, urban primary health centers and health camps organized by the district hospitals and medical college. It was observed that all those women who sought ANC, majority of them had TT injection but 75% of the participants didn’t have IFA tablets for 100 days. The findings of the study correspond with the findings of the other studies in slums of different cities (Godbole and Talwalkar, 1999). FGD 3 deliberated on consumption of IFA tablets and TT injection, it came out in the FGD 3 that government health facility are primary source of ANC services and majority however, women also complained under supply of IFA tablets for 100 days, they said they got only one strip of IFA tablets and there were advised to buy the rest of the tablets themselves which they never buy.

Women also opined that with consumption of IFA tablets they thought that it would make the baby so big that it would lead to have caesarean instead of normal delivery.

The study has observed that ANC utilization was the highest among SC and the least among OBC. This contradicts the findings of Navaneetham and Dharmalingam (2002) and Pallikadavath et al.( 2004) where they noted that schedules caste women are less likely to utilize ANC. However, this trend needs to be analyzed keeping in mind the existing facilities in the slums. In this study it was observed that the slums with SC concentration had better healthcare facilities than the slums with OBC concentration for e.g Chuharpur with 90% SC population have 4 anganwadi centers, 2 urban primary health centers and a nearby district hospital. It was also observed that the awareness among women regarding the existing facilities was also high in SC than the women from OBC. However, in Maulanaazad Nagar there are two anganwadi center and an urban primary health centre. Whereas in Zakirnagar, the anganwadi centre is not functional and

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the urban primary health centre had lack of staff, people also complained that the emphasis of the urban primary health centre was only immunization.

It was observed that women whose husbands were salaried class employed either in government sector or in private sector ANC utilization was substantially high in this category. The women whose husbands were employed in the government sector ANC utilization was found to be the highest among them.

It was observed in this study that with increase in education ANC utilization also increases. The women who were not educated ANC utilization is 42% while 80% women utilized ANC who were educated upto primary, 93% upto secondary and senior secondary and it became 100% in women who were graduate and above. Most of the literature available on ANC utilization pointed a strong association with women’s education. In fact, women’s education is the considered the most robust indicator associated with ANC. The more the woman is educated the more likely she is to utilize ANC services (Nielsen et al. 2001, Erci 2003). The present study also confirmed the strong association between women’s education and ANC utilization.

FGD 3 provided an insight into what women thought of ANC and it emerged that there existed age wise difference in the opinion of women regarding ANC utilization.

It came out in the FGD 3 that majority of women who were more than 40 and were already mother-in-laws thought that ANC was something unwarranted, they elaborated that had it been that important they would not have delivered their babies successfully. However, they let their daughter-in-laws to seek ANC services even though they do not believe in it. Women confided that if they do not let their daughter-in-laws visit doctor, then daughter-in-law would feel bad about her mother-in-law and also this would spread in the community that mother-in-law did not let her daughter-in-law visit doctors during her pregnancy and her family would be labeled as primitive and traditional. Interestingly women considered ANC utilization as an embodiment of modernity and if they do not confirm to this they would be tagged as primitive and they did not want to be associated

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with that tag as it would affect the future prospects of matrimonial alliance of their younger sons.

Women also thought that pregnancy and childbirth is innate to womanhood and which did not require any medical intervention. Women were also of this opinion that pregnancy is the period when women are at risk of witchcraft women should not go out. The risk of black magic and witchcraft increases if it is the first pregnancy and there is clear proscription of moving out after dark and in the afternoon time. CSN 3 illustrated also illustrated the existing belief system regarding child birth and pregnancy which is acting as a constraint towards ANC utilization.

7.1.3 Child Delivery: Institutional or Home

The study has noted that majority of the women in the studied population delivered their child at home and only 40% women had institutional delivery. Among women who had institutional delivery, majority of it occurred in public health facility. This raises two paradoxical points with more institutional delivery in government health facility than private health facility suggested increase in the utilization of public health facilities which is an optimistic indication of people’s faith in government health facility but at the same time it is equally alarming as it raises serious concern of overburdening of the already overcrowded and overburdened public health system.

The study has also observed positive relationship between women’s education and institutional delivery the more the women is educated, her chances of delivering child in an institutional also increases. With this conclusion the study also confirmed the findings of numerous studies like by Varma, Khan and Hazra (2010) where the authors have asserted that the likelihood of delivery in a health institution increases sharply with the increase in women’s education. Similar findings were also seen in other studies outside India like Kebede , Gebeyehu and Andargie (2013) and Shiferaw, Spigt, Godefrooi, et al. study of Ethiopia. In fact NFHS 3 (2005-06) concluded that when the factors are controlled, education comes out to be as the single most important determinant of maternal health care utilization in India.

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The study has observed that women whose husbands were casual labourers majority of them had home delivery, women whose husbands were salaried class and were employed in government sector, majority of them had institutional deliveries. Husbands who were salaried and employed in private sector, majority of their women had home deliveries and in self employed category majority had institutional delivery. Similar results were also reported in a study of South India () where it was found that women whose husbands were salaried were much more likely to institutional delivery or delivery attended by health professionals.

The study has seen that majority of the women from general caste category delivered in health institution while maximum women in OBC category had home deliveries and majority of the deliveries in SC they had home deliveries. Among all the caste categories the share of home delivery comparing institutional delivery is the highest among the SC in all the caste categories. One of the possible reasons for SC preference towards home delivery was the availability of ‘dais’ and the caste affiliation of these dais. It was seen in this study that assistance in delivery was provided by the dais who were also from the same caste category and same caste affiliation was also considered as one of the important reasons for SC preference for home deliveries instead of institutional delivery. Navaneetham and Dharmalingam (2002) in their study of four southern states of India they observed that SC/ST women in were least expected to deliver in a health institution. Similarly, Kumar and Gupta (2015) also observed comparable trends and claimed that lesser number of SC had institutional deliveries as compared to other caste categories.

FGD 4 provided detailed account of the motivation behind the chosen place of delivery. FGD 4 women responded that it is convenient for them to deliver in an institution, but it was seen that the women who cited that institutional delivery is convenient for them, majority of them were the women whose relatives were employed either in Medical College or Malkhan Singh. Women also pointed that they had institutional delivery because they had certain complication and they did not want to have any risk so they thought it is better to deliver in hospitals where they would be under regular medical supervision.

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On home delivery majority of the women questioned the medicalization of child birth they lamented that child birth is not a morbidity which requires medical intervention and supervision. They even reprimanded that child birth is turned into a medical condition which is in fact a crucial and joyous period of women’s life which should happen at home in company of the near and dear ones.

Women of the studied population thought reproduction is innate to womanhood and it do not require any medical intervention. What the women described here is the pathologization of the normal by locating the child birth under the control of professional doctor. As it is observed that majority of the institutional deliveries occurred in public health facilities, it is the state regulated health facilities which are the dominant actor in this pathologization process.

Substantial number of women also responded that that it was primarily their family decision and they didn’t have much say in that. Here it was observed that women who were even living in the nuclear household, the husbands were in continuous consultation with their elder female relatives on the issue of delivery. Another important aspect emerged in the FGD 4 was the logistic arrangement required in institutional delivery if they deliver in hospital who would take care of their other children at home and also they need someone in hospital as well so because of this delivering at home became common consensual choice of husband, wife and other female relatives in the family.

Women also thought that delivering in a hospital is an expensive elitist, middle class affair. They said we don’t have enough resources to feed our families and delivering in hospital is an extra liability we have to think about. They also told the researcher that suppose we deliver in hospital we need somebody to accompany us that means loss of wage plus the money spend on fooding, transportation, etc. The person who would accompany the women in hospital they would go home also, so they would need money to travel. Middle class has hefty salaries they could afford to do so not us.

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The study also observed that a significant number of women did not prefer institutional delivery because of apathetic attitude of doctors and other paramedical staff. Interestingly, what was disturbing for the women was the apathetic attitude of the paramedical staffs and not of the doctors. Women categorically pointed out that the indifference of paramedical staffs was extremely unsettling for them. They emphasized that the paramedical staffs humiliates them the most. This humiliation is aggravated because of the fact that many of the paramedical staffs are known to them and share with them the same socio-cultural, sometime the economic background, and many a time belong to the same caste category. But when the same people happen to be at medical spaces they boast of their institutional identity as a marker of power and domination. Women responded that they were slapped, scolded, shouted, called by names while delivering in an institution. Hollen (2003) in her study also had similar observation and she elaborated that ayahs have power because of being a part of the medical institution. Most of the ayah had similar caste and class background and to have a social distance from the patient they exhibit such unruly behavior.

The study has noticed that for women home delivery provided a comfortable environment where they were surrounded by their elder female relatives, neighbor and the dais. There are studies which have asserted that support and care women receive while delivering helps them to calm and also reduces the pain (Kitzinger, 1994). Patel (1994) in her study of Rajasthan village also pointed out that female relatives and the neighbors helped women to release their anxiety and tension which ultimately lessen the pain of child birth. The dais in the studied population enjoyed a celebrity status they were generally addressed by women as mausi or khala which illustrate the intimate relationship dais share with the women. The women were full of success stories of these dais in cases where even doctors and health facilities refuse to intervene, in those cases the dais help women to had successful vaginal delivery. Similarly a study of slums in Allahabad elaborated that the majority of the women favored home delivery taking the help of the untrained dais living in the same area (Khandekar, 1993). Ramana (2002) in her study pointed out the role of traditional dais behind this preference for home delivery. On this

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issue Khandelkar (1993) pointed out women living in slums preferred home deliveries and women have immense trust on dais who belonged to the same socio-cultural milieu. Women also confided in FGD 4 that they were displeased at how the lure of institutional delivery turns out to be just a hoax for family planning. At health institutions, they are bombarded with doctors and health worker’s questions who try to trick them into family planning. This could be an interesting area for further research.

7.1.4 Contraception The study has found that majority of the women were using contraception and only 37% at the time of interview were not using any type of contraception. Those who were using contraception majority of them were using condoms followed by sterilization, IUCD and injectibles and very few women were using OCP. In FGD it was revealed women generally responded that they were condom users just to evade the regular visits of the health worker this raises important methodological issues in field of family planning. Among the sterilization there was only one case of male sterilization, rest were female sterilization. Study of Vishakhapatnam slum (Ramana, 2002) also reported similar trend and found out that around half of the women in slum use contraception and there also majority of them had sterilization and negligible percent of males have gone for sterilization.

The study has observed higher contraceptive usage in general caste category than that of OBC and SC. Shaw (1988) in his study of Calcutta slums also illustrated that caste is an important factor in contraception and SC had lowest contraceptive usage than any other caste category.

The study has noticed that sterilization was maximum among SC. Similar observations were also made by Shahid (2010) in his study of Lodha block in Aligarh observed that sterilization was maximum among SC. It is intriguing that in India unlike in other nations women of lower age group limit their fertility through sterilization. This is observed in this study also, among the women who were sterilized maximum were in the age group of

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29-33. The possible explanation lies in the fact that the reproductive career of sampled population starts with an early age at marriage and early and frequent child birth, consequently the women achieve their desire family size at an early age and lead women to think about permanently limiting their fertility.

It was seen in this study that contraceptive usage was the least among women who were not educated. Mason (1984) elaborated in his study that with women education women's knowledge, attitudes and practice of family planning also increases. Chaudhury (1996) in his macro level study asserts the co-relationship between female education and the adoption of family planning. NFHS 3 also has pointed out significant relationship between women’s education and contraception.

It is found in this study that the husbands who were casual laborers were less likely to use contraception than the one who were the salaried especially in government job, though this distinction diminished in salaried in private sector and in self employed category. Mamdani (1976) in his study discerned that the rationale for contraception usage cannot be uniform in all the class situations. Mamdani (1976) pointed out that the wage earners, small farmers, artisans employed in local industrial units prefer large families, for them children are economic assets and an assurance against old age.

In FGD 5 women narrated that how quite often health workers come and inquire about their contraceptive usage. This raises an important issue how women are treated as the reproductive beings by our policy makers whose fertility needs to be curtailed and they are the one who needs to be counseled. In this whole process men are the left out category and this does not seem to be mere coincidence. Women particularly the non users lambasted that if they say that they are not using anything it does not mean that they are not controlling their fertility. Women pointed out that there are certain social dos and donts in the society related to sexual and reproductive behavior. The study has observed that people have clear understanding of social norms related to fertility and they act accordingly, as it was also pointed out in various like Wyron and Gordon in Punjab(),

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Kara and Sinha in Orissa() and Patel(1994) in Rajasthan. In this study also it was found that people conscientiously follow the social norms related to fertility. As it was pointed out that it was a social norm that after achieving the status of mother-in-law, women limit their sexual activity.

The study has observed that 37% women who are using any kind of modern contraception actually experienced problem associated with the chosen contraception. Among the OCP users except one all had experienced problems after using it and 43% of the DMPA users experienced problems after using it. Majority of the IUCD users i.e. 66% faced adversities after its usage and the women who had tubectomy 33% experienced problems after its adoption. Among all the users the problems associated with OCP users was found to be the maximum followed by IUCD users and sterilization and minimum with condom users. The problems women experienced after using contraception were menstrual problems, weight gain, white discharge, pain in lower back and lower abdominal, vaginal dryness, cramps in legs, stiffness around stomach and abdomen. In a study of slums of Baroda noted that 20% modern contraceptive users experienced some side effects related to the used contraception. Another study of urban area of Delhi noticed that higher reproductive morbidity among the contraceptive users (Bhatnagar, 2013).

FGD 6 provided women’s experiences with contraception where women raised their opinion regarding contraception. The women who were injectible users they complained of irregular menstruation after DMPA use. They also complained of stiffness of lower abdomen and weight again around their waist after DMPA use. Despite the complaints to the use of injectibles experienced by the members in the focused group women were still curious about DMPA. Interestingly, DMPA which they called ‘DIMPA’ is a considered magic injection which could make women free for 5-7 years. DMPA is not part of government family planning program in India and is not available in public hospitals. It is unreachable for women living in slum areas who majorly rely on public health institution for family planning services and its inaccessibility and to become free from fear of

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pregnancy for next few years makes it more desirable among women of the sampled population.

Many women in the focused group pointed that they used OCP in past but because of its side effects they have stopped using it. Women also expounded that the strict regimen of OCP use makes it difficult to use. Women also confided that they did not get OCP from urban primary health centers or any other public health facility and they have to buy it which again becomes a liability with their limited financial capacity.

Majority of the women complained of vaginal discharge with IUCD. It was observed in the study that very few IUCD users reported having pre-insertion screening and discussion with the doctors on its major side effects as discussed in CSN 5. Women also discussed that the insertion was actually done by the nurse and the doctor was frequently coming and going when the procedure was being conducted in the hospital. Majority of the IUCD users got it done at the district hospital who denied suffering from any complication as a result of their use of contraception. This is in stark contradiction to the findings of the FGDs and CSNs which clearly revealed many complications, majority of them face. This highlights the culture of silence related to reproductive morbidity. The complications range from menstrual problems (irregular or profuse bleeding), and white discharge to weight gain (particularly with IUCD and injectibles) and pain. Women who underwent sterilization complained of pain in lower abdomen and lower back, cramps in legs, excessive dryness around vagina etc. One of the women in CSN 6 complained of getting pregnant twice in spite of the sterilization, and at both the times, she underwent abortion. CSN 6 raises important question about how sterilization is being done in public health facilities and also the relentless zeal of the policy makers towards it. CSN 6 also reminds us of emergency period sterilization camps. Many women sought medical advice for their complications. Numerous studies on general health seeking behavior of women suggest that women seek medical advice when complications restrict their daily routine. The fact that majority of them sought medical intervention confirms that a large number of women suffer from complications. While the doctors, in majority of the cases,

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refuse to acknowledge the cause of the complication in contraception use and diagnose their problem very unlike the way that those women face them as lived experiences.

Women who underwent sterilization complained of pain in lower abdomen and lower back, cramps in legs, excessive dryness around vagina. CSN 6 complained of getting pregnant twice in spite of sterilization. CSN 6 raises important concern how sterilization is being done in public health facilities and also the relentless zeal of the policy makers towards sterilization.

Women who sought medical advice for their condition, majority of the women responded that they were not satisfied with medical help provided by the doctor. Many of the women responded that their problems were overlooked and it was actually attributed to some other condition and women said they could not agree to it because it was their body they did understand their bodies and they were kind of sure that this problem arisen because of the particular contraceptive usage but the doctors failed to buy that argument. Many women also elaborated that after the medical help there is no substantial change in their situation, it required prolonged medication which they were unable to afford. It was observed in this study that women were not being counseled for the side effects of particular contraceptive method neither they were informed about all the available method of contraception. Women were being informed only about the one which the doctor or the health worker thought suitable for the women.

The study has pointed the women’s self determination to choose the method of family planning she would like to choose for herself is seriously compromised and she is also not being informed about the side effects of the selected method on the contrary their problems associated with contraception is negated and overlooked. The concept of reproductive health which is viewed as synonymous with women’s self determination, choice and has put an end to governments target oriented and method specific family planning program but in reality the idea of freedom and choice in matters related to

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Chapter Seven: Conclusion and Suggestions contraception with which reproductive health is synonymous with is bargained with the state’s fixation to curb women’s fertility.

At this juncture it is important to ask what features of hegemony and of biomedical perspectives, if any, do we find in this reading of the negation of women’s subjective and lived experiences in the name of being objective and scientific. The findings of this study regarding the complications as a result of use of IUCD concur with numerous studies (Hoggart, 2013). What is the motivation and enthusiasm which make IUCD part of the government family planning programs in India is another valid question. Issues raised above are serious and should be topics of through future research. This study brings to the fore that women’s freedom in choosing the method of family planning and informed decision making is seriously compromised and overlooked. The concept of reproductive health is synonymous with women’s self determination and free choice and has put an end to governments target oriented and method specific family planning program. However, with the state’s fixation to curb women’s fertility, the idea of freedom and choice in matters related to contraception are compromised

7.2 Suggestions

The present study is a modest attempt to highlight the reproductive health issues of women in slums. It is evident from the study that substantial numbers of women utilize ANC services which is a positive trend towards favorable reproductive status. However, institutional delivery is still low and women prefer to deliver at home and dais are considered important in child delivery. The preference for home instead of a health facility is a serious impediment towards universal institutional delivery. A considerable number of women use contraception though only a single case of sterilization (vasectomy) was reported among males the rest were of female sterilization. This points to how women are treated as mere instruments to curb fertility. Reproductive health of women can further be improved by making concerted efforts along with the following lines:

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7.2.1 For Policy Makers

• There should be equal distribution of urban primary health centers and anganwadi centers in slums across the city. For instance it was observed that slums like Jangalgarhi with more than 5000 population there is no urban primary health center and there is only two anganwadi centers, similarly Maulanaazad Nagar with more than 8000 population too have only two anganwadi centers whereas there is provision of one anganwadi center per 1000 population. • There should be delivery facility in all the urban primary health centers. • Urban primary health centers should have facility for IUCD insertion and sterilization. • There should be proper medical screening and follow up care should be provided in matters related to contraception as it is observed that often there is no medical screening prior to adoption of IUCD, and sterilization and women face post adoption complications. • Dais should be mainstreamed into intuitional setting and trained to provide safe delivery in slum areas. Dais are considered the most trusted in matters related to child delivery. The mainstreaming of dais is pointed out by many studies like by Gulati, Tyagi, & Sharma (2003), Hollen, (2003) • It should be ensured that women are provided with 100 days of IFA tablets. • The emphasis should also be placed on safe delivery and not only on institutional delivery. Dais should be provided with training and certification to conduct safe deliveries at home.

7.2.2 For Health Professionals and Community Workers

• Women should be counseled about anemia and for 100 days IFA tablets consumption.

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• Elderly women like mother-in-laws, sister in-laws and other important filial female relatives should also be counseled about ANC, IFA tablets, safe delivery and contraception. • Women should have self determination in matters of contraception they should be informed about all the available methods of contraception and should be able to decide freely which suits them the best. • Women should be informed about all possible side effects of particular contraceptive method in order to make informed consent a reality. • The health professionals should shred away with their elitism and ‘professional dominance’ (1970) and treat people with dignity and respect. The doctors and the paramedical staffs in the health institution should be sensitive towards women’s lived experiences. Stereotyping of a particular community should be avoided, there should be a code of conduct and there should be proper monitoring of the implementation of the code of conduct. • Women should be provided with counseling on all aspect of safe motherhood not only on institutional delivery and family planning. • Men should also be counseled about matters related to reproduction and particularly on family planning. The study observed that there is dearth of male social workers in public hospitals and absence of male social workers in urban primary health centers. Male social workers should be appointed to counsel men for contraception. • Women of particular caste, class and religion should not be targeted for family planning owing to their higher fertility; this creates suspicion in the community. They should be counseled by taking the help of their informal leaders and influential community members.

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References

Adams, A., & Castle, S. (1994). Gender Relations and Household Dynamics. In G. Sen, G. Andrienne, & C. Lincoln, Population Policies Reonsidered:Health, Empowerment and Rights (pp. 161-73).

Aktun, H., Moroy, P., Cakmak, P., Yalcin, H. R., & Leyla, M. (2005). Use of a Long- acting injectible Progestin Injectable Contraceptive. Contraception , 72 (1), (pp. 24-27).

Amin, S. (1976). Population and Development. Socialist Revolution , 6 (27), (pp.77-79).

Anderson, N. (1970). Characteristics of Slums. In A. R. Desai, & S. D. Pillai, Slums and Urbanisation (pp. 44-49). Bombay: Popular Prakashan.

Balakrishnan, R. (1996). Population Policy Revisited: Examining ICPD. Health Transition Review , 6 (1), (pp.5-7).

Bandrage, A. (1997). Women Population and Global Crisis: A Political Economic Analysis. London: Zed Books.

Banerjee, D. (1976). Will Forcible Sterlisation be Effective. Economic Political Weekly , 11 (18), (pp.665-668).

Banerji, D. (1985). Health and Family Planning Services in India: An Epidemiological Socio-Cultural and Political Analysis and a Perspective. New Delhi: Lok Paksh.

Batabyal. (2004). Desirable Properties of an Unconventional Population Control Policy. Canadian Journal of Regional Science , XXVII (2), (pp.79-83).

Bergmann, B. 1986. The Economic Emergence of Women. New York: Basic Books.

Bertrand, J. T., Seiber, E., & Escudero, G. (2001). Contra ceptive dynamics in Guatemala: 1978-1998. International Family Planning Perspectives , 27 (3), (pp.112-136).

Bhagat, R. B. (2004, September 25). Census 2001 and Relegion Data:Fact and Fiction. Economic and Political Weekly , (pp.4292-4294).

Bhandarkar, P. L., & Wilkinson, T. S. (2002). Methodology and Techniques of Social Research. Bombay: Himalya Publishing House.

Bhatnagar, N., Khandekar, J., Singh, A., & Saxena, S. (2013). The Silent Epidemic of Reproductive Morbidity Among Ever Married Women (15-49 Years) in an Urban Area of Delhi. Journal of Community Health , 38, (pp. 250–256).

Bhattia, J. C., & Cleland, J. (1995). Determinant of maternal care in a region of South India. Health Transition Review , 5, (pp.127–142).

Blaikie, P. M. (1975). Family Planning in India: Diffusion and Policy. London: Edward Arnold.

Bose, A. (1988). From Population to People 2 vols. Vol. I. Delhi: B.R. Publishers.

Bose, A., & Desai, P. B. (1989). Population Planning in India: Policy Issues and Research Priorities. Delhi: B.R. Publishing Corp.

Brault, M.A, Schensul, S.L& Bankar, S (2017)).The Role of Premarital Agencyin Delaying Marriage and Reproductive Decision Making in Urban India. Global Perspectives on Women's Sexual and Reproductive Health Across the Life course. Choudhury, S., Erausquin,J.T, & Withers, M.Washington. Springer,

Caldwell, J., Caldwell, P., & Caldwell, B. (1987). Anthropology and Demography: The Mutual Reinforcement of Speculation and Research. Current Anthropology , 28 (1), (pp.25-43).

Campbell, M., Nuriye, N. S., & Potts, M. (2006). Barriers to Fertility Regulation: A Review of the Literature. Studies in Family Planning , 37 (2), (pp.87-98).

Chakarborty, M., Islam, M., Chowdhury, R., & Bari, W. (2003). Determinants of the use of maternal health services in rural Bangladesh. Health Promotion International , 18 (4), (pp.327-337).

Chaplin, S. E. (1999). Cities, sewers and poverty;India's politics of sanitation. Environment and Urbanisation , 11 (1), (pp.145-58).

Chaudhury, R. (1996). Factors Affecting Variations in Fertility by States of India: A Preliminary Investigation. Asia-Pacific Population , 12, (pp.86-92).

167

Ciceklioglu, M., Soyer, M. T., & Ocek, Z. A. (2005). Factors associated with the utilization and content of prenatal care in a western urban district of Turkey. International Journal for Quality in Health Care , 17 (6),(pp. 533-39).

Correa, S., & Petchesky, R. (1994). Reproductive and Sexual Rights:A Feminist Perspective. In G. Sen, G. Andrienne, & C. Lincoln, Population Policies Reconsidered:Health Empowerment and Rights (pp. 107-119). Cambridge: Harvard University Press.

Cottingham, J., & Mehta, S. (1993). Medical barriers to contraceptive Use. Reproductive Health Matters , (pp.97-100).

Das Gupta, M., & Narayana, D. (1997). Bangladesh's fertility decline from a regional perspective. Genus , 53 (3-4), (pp.101-128).

Das Gupta, M., Krishnan, T. N., & Lincoln, C. (1994). Women's Health in India:Risk and Vulnerable (3-29 ed.). Mumbai: Oxford University Press.

Datta, B., & Misra, G. (2000). Advocacy for Sexual and Reproductive Health: The Challenge in India. Reproductive Health Matters , 8 (16),(pp. 24-34).

Davis, M. (2006). The Planet of Slums. London: Verso.

Demerath, N. J. (1976). Birth Control and Foreign Policy. New York: Harper. New York: Harper& Row.

Desai, A. R. (1980). Urban Family Planning in India. Bombay: Popular Prakashan.

Directorate of Census Operations, U.P. (2014). District Census Handbook Aligarh: Village and Townwise Primary Census Abstract of Census 2011. Lucknow: Directorate of Census Operations, U.P.

Dixon-Mueller, R. (1993). Population Policy and Women’s Rights: Transforming Reproductive Choice. Westport, CT: Praeger.

Djurfeldt, G. . (1976). Pills against Poverty. New Delhi: Oxford and IBH.

168

Donald, M., & Harvey, P. (1992). The impact of price reductions on condom sales in Haiti. Washington DC: DKT Reports Finding.

Dreze, J., & Sen, A. (1987). Hunger and Public Action. New Delhi: Oxford University Press.

D'Souza, V. (1970). Slums a Planned City: Chandigarh. In Desai,A.R and Pillai, D. Slums and Urbanisation (pp. 223-228). Bombay: Popular Prakashan.

D'Souza, V. (1979). Social Structure of a Planned City. Bombay: Orient Longman.

Erci, B. (2003). Barriers to utilization of prenatal care services in Turkey. Journal of Nursing Scholarship , 35 (3), (pp. 269–273).

Farah, M. F. (2005). Changing population paradigms post ICPD: policy and programme implications. Genus , 61 (3/4), (pp. 141-163).

Fathalla, M. (1988). Research in Human Reproduction.Biennial Report 1986-87. World Health Organisation. Geneva: World Health Organisation (WHO).

Fotso, J. C., Ezeh, A., & Oronje, R. (2008). Provision and Use of Maternal Health Services among Urban Poor Women in Kenya: What Do We Know and What Can We Do? Journal of Urban Health , 85 (3), (pp.428-442).

Frank, A. W. (1992). Twin Nighmares of the Medical Simulacrum:Jean Baurillard and David Croneberg. In W. Stearns, & W. Chaloupka, The Disappearance of Arts and Politics (pp. 82-97). New York: Saint Martin Press.

Friedson, E. (1970). Professional Dominence:The Social Structure of Medical Care.Part I& II. New York: Atherton.

Germain, A. (1997). Addressing the demographic imperative through health, empowerment, and rights: ICPD Implementation in Bangladesh. Health Transition Review , 7 (4), (pp.33-36).

169

Glei, D., Goldman, N., & Rodriguez, G. (2003). Utilization of care during pregnancy in rural Guatemala: does obstetrical need matter? Soc Sci Med , 57 (12), (pp.2447- 2463).

Godbole, V. T., & Talwalkar, M. A. (1999). Programme for Children: An Assesment of Urban areas of Maharashtra 1998. Pune: State Family Wefare Bureau.

Government of India . (1969). Fourth Five year Plan. New Delhi: GOI Press.

Government of India . (1996). Draft Statement on National Population Policy. New Delhi: Government of India Press.

Government of India. (1946). Report of the Health Survey and Development Committee, Vol-2. New Delhi: Government of India Press.

Government of India. (1961). Report of the Health Survey and Development Committee, Vol-2. New Delhi: Government of India.

Government of India. (1974). Fifth Five year Plan. New Delhi: Planning Commission, Government of India.

Government of India. (1980). Sixth Five year Plan. New Delhi: Government of India Press.

Government of India. (1985). Seventh Five year Plan. New Delhi: Government of India Press.

Government of India. (2000). National Population Policy (2000) . New Delhi: Government of India Press.

Government of India. (2013). State of Slums In India: A Statistical Compendium2013. New Delhi: Ministry of Housing and Poverty Alleviation .

Griffith, P., & Stephenson, R. (2001). Understanding users perspective of barriers to maternal health care use in Mahrashtra, India. Journal of Biosocial Science , 33 (3), (pp.339-359).

Gulati, S., Tyagi, R. P., & Sharma, S. (2003). Reproductive health in Delhi Slums. Delhi:

170

B R Publishing Corporation.

Gupta, K., Arnold, F., & Lhungdim, H. (2005-06). Health and Living Conditions in Eight Indian Cities. National Family Health Survey (NFHS-3), India. Mumbai: International Institute of Population Studies & ICF Macro.

Hartman, B. (1995). Reproductive Rights and Wrongs:The global Politics of Population Control. Boston: South End Press.

Hazarika, I. (2010). Women’s Reproductive Health in Slum Populations in India: Evidence From NFHS-3. Journal of Urban Health , 87 (2), (pp.264-277).

Hollen, C. (2003). Birth on the Threshold:Childbirth and Modernity in South India. New Delhi: Zubaan.

Hunter, D. R. (1964). The Slums : Challenge and Response. New York: The Free Press.

Illich, I. (1976). Medical Nemesis:The Exploration of Health. New York: Pantheon Books.

International Institute for Population Sciences (IIPS). (2010). District Level Household and Facility Survey(DLHS-3), 2007-08. New Delhi: Ministry of Health and Family Welfare.

International Institute for Population Sciences and Macro International. (2007). National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Mumbai: IIPS.

Islam, M., Montgomery, M., & Taneja, S. (2006). Urban Health and Care Seeking Behavior: A Case Study of Slums in India and the Philippines. Bethesda, MD: The Partners for Health Reform Project, Abt Associates.

Jefferey, P., & Jefferey, R. (2006). Confronting Saffron Demography. Gurgaon: Three Essays Collective.

Jeffery, R., & Jeffery, P. (2000, August 26-September 2). Relegion and fertility in India. Economic and Political Weekly , (pp.3252-3258).

Jejeebhoy, S. J. (1986, July 8-11). Women's status and fertility: a time-series analysis of Tamil Nadu, India, 1970-1980. Workshop on Women's Status and Fertility . Rockfeller Foundation.

171

Jejeebhoy, S. J. (1997). Addressing Women's Reproductive Health Needs: Priorities for the Family Welfare Program. Economic and Political Weekly , 32 (9&10), (pp.475-485).

Kara, P. K., & Sinha, B. N. (1987). Family Welfare Programs and Its Evaluation:Implications and Recommendations. In R. N. Pati, Population, Family and Culture (pp. 192-93).

Kebede B, G. A. (2013). Use of previous maternal health services has a limited role in re attendance for skilled institutional delivery: cross-sectional survey in Northwest Ethiopia. . 2013;5:79. Intern J Women’s Health , (pp.79-85).

Khan, M. (1979). Family Planning among Muslims in India- a Study of the Reproductive Behaviorof Muslims in an Urban Setting. New Dehi: Manohar.

Khan, M., Khalique, N., Siddiqui, A., & Amir, A. ( 2013). A.Newborn care practices among slum dwellers in Aligarh City, Uttar Pradesh. Indian Journal of Community Health, Jan-March ,(pp. 1-6).

Khandekar, J. D. (1993). Childbirth Practices among women in slum areas. The Journal of Family Welfare , (pp.13-17).

Khandekar, J., Dwivedi, S., & Bhattacharya, M. (1993). Childbirth Practices Among Women in Slum Areas. The Journal of Family Welfare ,(pp. 7-13).

Kirkconell, M. A., Stephenson, R., & Juverkar, S. (2008). Social and Logistical Barriers to the Use of Reversible Contraception among Women in a Rural Indian Village. Journal of Health and Population , 26, (pp.241-250).

Kitzinger, S. (1994). The Social context of Birth:Some Comparisons between Childbirth in Jamaica and Britain. In C. P. MacCormack, Ethnography of Fertility and Birth (pp. 171-194). Detroit: Wayne State University Press.

Kothari, C. R. (2004). Research Methodology : Methods and Techniques (2nd ed.). New Delhi: New Age International.

Kumar, P., & Gupta, A. (2015). Determinants of Inter and Intra caste Differences in Utilization of Maternal Health Care Services in India: Evidence from DLHS-3

172

Survey. International Research Journal of Social Sciences , 4 (1), (pp.27-36).

Lal Das, D. K. (2005). Designs of Social Research. Jaipur: Rawat Publication.

Lalou, R., & LeGrand., T. K. (1997). Child Mortality in the Urban and Rural Sahel. Population, An English. Population, An English Selection , 9, (pp.147-168).

Levin, A., Caldwell, B., & Khuda, B. (2000). Demand for family planning services in rural Bangladesh: Effect of cash prices and access." Paper presented at the International Union for the Scientific Study of Population Seminar on Family. Family Planning Programmes in the 21st Ceutury. Dhaka: International Union for the Scientific Study on Population.

Lubove, R. (1962). The Progressives and the Slums:Teement House Reform in Newyork city, 1890-1979. Pittsburg: University of Pittsburg.

Magadi, M., Madise, ,. N., & Rodrigues, R. (2000). Frequency and timing of antenatal care in Kenya. Social Science Medicine , 51 (4), (pp.551-561).

Mahapatro, M. (2015). Equity in utilization of health care services: Perspective of pregnant women in southern Odisha, India. Indian Journal of Medical Research , 142, (pp.183-89).

Makade, K. G. (2012). Study of Contraceptive Use Among Married Women in a Slum in Mumbai. National Journal of Community Medicine , Vol 3 (1), (pp.40-43).

Mamdani, M. (1972). The Myth of Population Control : Family, Caste, and Class in an Indian Village. New York ; London: Monthly Review Press.

Mandelbaum, D. G. (1970). Society in Indai. Bombay: Popualr Prakashn.

Mani, G. (2014). Prevalence of Reproductive Tract Infections Among Rural Married Women in Tamil Nadu, India: A Community Based Study. Pioneer Medical Science , 4 (1), (pp.14-23).

Mann, E. (1992). Boundries and Identities:Muslims, Work and Status in Aligarh. London: Sage Publications.

Mari Bhat, P. N. (2002). Levels and Differentials in Maternal Mortality in Rural India:

173

New Evidence from Sisterhood Data. Working Paper . National Council of Applied Economic Research, India.

Mason, K. O. (1984). The Status of Women: A Review of Its Relationships to Fertility and Mortality. Population Sciences Division of the Rockfeller Foundation (pp. 348-56). Rockfeller Foundation.

Mason, K. O. (1987). The impact of women's social position on fertility in developing countries. Sociological Forum , 2 (4), (pp.718-745).

Mathole, T., Lindmark, G., Majoko, F., & Ahlberg, B. M. (2004). A qualitative study of women's perspetive of antenatal care in rural area of Zimbabwe. Midwifery , 20 (2), (pp.122-132).

Mathur, K. (2008). Gender Hierarchies and Inequalities: Taking Stock of Women's Sexual and Reproductive Health. Economic and Political Weekly , 43 (49), (pp.54-61).

Matthews, Z., Mahendra, S., Kilaru, A., & Ganapathy, S. (2001). Antenatal care, care- seeking and morbidityin rural Karnataka, India: results of a prospective study. Asia-Pacific Population Journal , 16 (2), (pp.11-28).

Matthews, Z., Ramakrishna, J., Mahendra, S., Kilaru, A., & Ganpathy, S. (2005). Birth Rights and Rituals in Rural South Indai: Care Seeking in Intrapartum Period. J. Biosoc. Sci. , 37, (pp.385–411).

McKinsey Global Institute. (2011). Urban World: Mapping the Economic Power of Cities. Retrieved 10 5, 2015, from www.mckinsey.com: www.mckinsey.com/Insights/MGI/Research/Urbanization/Urban_world

Miles-Doan, R., & Brewster, K. L. (1998). The impact of type of employment on women’s use of prenatal-care services and familyplanning in urban Cebu, the Philippines. Studies in Family Planning , 29 (1), (pp.69-78).

Millennium Development Goals and Muslims in India. (2013, January). Oxfam India

174

Working Paper Series . New Delhi: Oxfam India .

Ministry of Family Welfare Statistics. (2013). Health and Family Welfare Statistics, 2013. New Delhi: Governmnet of India.

Ministry of Health and Family Welfare. (1997). New Delhi: Government of India Press.

Ministry of Health and Family Welfare. (2000). National Populational Policy;2000. New Delhi: Goverment of India.

Registrar General of India. (2013). Annual Health Survey;2012-13. New Delhi: Office of Regestrar General of India and Census Commissioner;India.

Ministry of Health Family Welfare. (1997). National Family Welfare Program. New Delhi: Government of India Press.

Ministry of Health Family Welfare. (2008). New Delhi: Government of India.

Ministry of Health Family Welfare. (2013). Health and Family Welfare Statistics in India. New Delhi: Ministry of Health and Family Welfare, Government of India Press.

Ministry of Home Affairs. (1978). Report of the Shah Commission of Enquiry, Volume 3. New Delhi: Government of India Press.

Ministry of Housing and Urban Poverty Alleviation(MUHPA). (2013). State of Slums in India:A Statistical Compendium. New Delhi.

Minkler, M. (1977). Thinking the Unthinkable: The prospect of compulsory sterilization in India’,. International Journal of Health Services , 7 (2), (pp.28-35).

Mishra, V. (2004). Muslim/non-Muslim Differentials in Fertility and Family Planning in India. East-West Center Working Papers: Population and Health Series, No 112 . Honolulu, Hawai: East-West Center.

Mitra, A. (1978). India's Population- Aspects of Quality and Control. New Delhi: Family Planning Foundation/ICSSR.

Montgomery, M. R., & Hewett, P. C. (2005). Urban Poverty and Health in Developing

175

Countries. Demography , 42 (3), (pp.397-425).

Nanda, N., Achyut, P., Mishra, A., & Calhoun, L. (2011). Measurement, Learning & Evaluation of the Urban Health Initiative:Uttar Pradesh, India. North Carolina: International Center for Research on Women and Carolina Population Centre.

Nankarni, M. (1976). Overpopulation and the Rural Poor. Economic and Political Weekly , 11 (31-33), (pp.1163-76).

National Sample Survey Organisation. (2002). India - Urban Slums Survey, July - December 2002, NSS 58th Round. Ministry of Statistcs and Programme Implementation(MOSPI). Government of India (GOI).

Navaneetham, K., & Dharmalingam, A. (2002). Utilization of maternal care services in southern India. Social Science and Medicine , 55 (10), (pp.1849-1869).

Nielsen, B., Hedegaard, M., Liljestrand, J., Thilsted, S. H., & Joseph, A. (2001). Characteristics of antenatal care attenders in a rural population in Tamil Nadu, South India: A community-based crosssectional. Health & Social Care in the Community , 9 (6), (pp.327-333).

Obermeyer, C. (1999). The Cultural Context of Reproductive Health: Implications for Monitoring the Cairo Agenda. International Family Planning Perspectives. International Family Planning Perspectives , 25.

O'Donnell, P. O., & Doorslaer, E. V. (2007). Are Urban Children Really Healthier? Evidence. Social Science and Medicine , 65, (pp.1986-2017).

Office of the Registrar General & Census Commissioner in India. (2011). Housing Stock, Amenities & Assets in Slums - Census 2011. New Delhi: Goverment of India.

Office of the Registrar General & Census Commissioner, India. (2011). Primary Abstract for Slum. New Delhi: Government of India.

Office of the Registrar Genral&Census Commissioner, India. (2001). Census of India 2001;Meta Data and Brief Highlights on Slum Population. New Delhi: Government of India.

176

Pachauri, S. (1995). Defining an essential package of reproductive and child health services in India's family welfare program: Towards a reproductive and child health approach. Population and Human Resources, Operations Division, The World Bank, South Asia Country Department (India, Nepal and Bhutan). Washington DC: The World Bank.

Pachauri, S. (2004). Expanding Contraceptive Choice in India:Issues and Evidence. The Journal of Family Welfare , 50 (Special), (pp.13-26).

Pallikadavath, S., Foss, M., & Stones, R. W. (2004). Antenatal care:Provision and inequality in rural North India. Social Science and Medicine , 59 (6), (pp.1147- 1158).

Patel, T. (1994). Fertility Behaviour- Population and Society in a Rajasthan Village.2nd ed. New Delhi: Oxford.

Petchesky, R. (1987). Fetal images: The Power of Visual Culture in the politics of Reproduction. Feminist Studies , 13 (2), (pp.263-292).

Planning Commission. (2013). Twelfth Five Year Plan, Vol III;Social Sectors. New Delhi: Government of India.

Poona Municipal Corporation.2000. Baseline Survey.Poona. Poona Municipal Corporation

Price, N. L., & Hawkins, K. (2007). A Conceptual Framework for the Social Analysis of Reproductive Health. Journal of Health Population and Nutrition , 25 (1), (pp.24-36).

Qadeer, I. (1998). Reproductive Health: A Public Health Perspective. Economic and Political Weekly , (pp.2675-2684).

Qadeer, I. (2011). Public Health in India: Critical Reflections. New Delhi: Danish Books.

Raina, B. L. (1988). Population Policy. Delhi: B.R. Publishing.

Rajaretnam, T., & Deshpande, R. (1994). Factors Inhibiting the use of Reversible Contraceptive Methods in Rural South India. Studies in Family Planning , 25 (2),

177

(pp.111-121).

Ramana, P. V. (2002). Women in Slums:A study of Women in Muslim Slums of Vishakhapatnam. New Delhi: Serials.

Rao, K. (1972). Health and Educational Approach to Family Planning-a Review of Studies and Implication for Social Worker's Education. In A. o. India, Social Work Education and Family Planning (pp. 14-41). Banglore: ASSWI.

Rao, K. (1974). Studies in Family Planning: India. New Delhi: Abhinav.

Rao, M. (2001). Population Policies:States Approve Coercive Measures. Economic Political Weekly , 36 (16), (pp.1299-1302).

Rao, M. (2004). From Population Control to Reproductive Health : Malthusian Arithmetic. New Delhi;London: Sage.

Rathore, M., Swami, S., Gupta, B. L., Sen, V., & Vyas, B. L. (2003). Community-Based Study of Self Reported Morbidity of Reproductive Tract Among Women of Reproductive Age in Rural Areas of Rajasthan. Indian Journal of Community Medicine , 28, (pp.117-121).

Reddy, R., Premarajan, K., Narayan, K., & Mishra, A. (2003). Rapid appraisal of knowledge, attitude and practices related to family planning methods among men within 5 years of married life. Indian J. Prev. Soc. Med , 34 (1&2), (pp.63-67).

Registrar General of India. (2012). Sample Registration System:Statistical Report. New Delhi: Office of Registrar General of India.

Registrar General of India. (2013). Annual Health Survey;2012-13. New Delhi: Office of Regestrar General of India and Census Commissioner;India.

Rondinelli, D. A., & Kasarada, J. D. (1993). Job Creation Needs in Third World Cities. In J. D. Kasarda, & A. M. Parnell, Third World Cities:Problems, Policies and Prospects (pp. 137-158). London: Sage.

Rossi-Espagnet, A. (1984). Primary Health Care in Urban Areas: Reaching the Urban Poor in Developing. Geneva: UNICEF and WHO Report No. 2499. UNICEF

178

and WHO.

Safilios-Rothschild, C. (1982). Female Power, Autonomy and Demographic Change in the third World. In R. Anker, M. Buvinic, & N. H. Youssef, Women's Roles and Population Trends in the Third World (pp. 117-32). London: Croom Helm.

Sahoo, N. (2016, May 6). India’s urbanisation is dangerously exclusionary and unequal. Retrieved July 15, 2017, from www.thewire.in

Santhya, K. G. (2003). Changing Family Planning Scenario in India: An overview of recent evidence. New Delhi: Population Council.

Saroha, E., Altarac, M., & Sibley, L. M. (2008). Caste and maternal health care service use among rural Hindu Women in Maitha, Uttar Pradesh, India. Journal of Midwifery and Women's Health , 53 (5), (pp.41-47).

Sawhney, U. (2013 ). Slum population in India: Extent and policy response. International Journal of Research in Business and Social Science , (pp. 2147-4478).

Scheper- Hughes, N., & Lock, M. (1987). The Mindful Body:A Prolegomenon to Future Work in Medical Anthropology. Medical Anthropology Quaterly , 1 (1), (pp.6-41).

Shah, N. A., Nisar, N., & Qadri, M. H. (2008). Awareness and pattern of utilizing family planning services among women attending Urban Health Care Center Azizabad Sukkur. Pakistan Journal Medical Science , 24 (4), (pp.550-555).

Shahid, M. (2010). Beyond Contraceptives:Demystifying Family Planning Dynamics in Uttar Pradesh. New Delhi: Alter Notes.

Shalev, C. (2000). Rights to Sexual and Reproductive Health: The ICPD and the Convention on the Eliminationof All Forms of Discrimination against Women. Health and Human Rights , 4 (2), (pp.38-66).

Sharma N., B. P. (1990). An indepth study of the role of Traditional Birth Attendants in providing intranatl care in an urban slum and villages of Delhi. Journal of Obstetrics and Gyneacology , (pp.85-87).

Sharma, B. (2004). Utilisation of antenatal care services in Nepal. Nepal Population Journal , 11 (10), (pp.79-07).

179

Sharma, N., Bali, P., & Bhargava, V. L. (1990). An indepth study of the role of Traditional Birth Attendants in providing intranatl care in an urban slum and villages of Delhi. Journal of Obstetrics and Gyneacology , (pp.85-87).

Shaw, A. (1988). Fertility and Child Spacing among the Urban Poor in a Third World City: The Case ofCalcutta, India. Human Ecology , 16 (3), (pp.329-342).

Shiferaw, S., Spigt, M., & Goodfrooi, M. (2013). Why do women prefer home births in Ethiopia? BMC Pregnancy Childbirth , 13 (5).(pp.189-193)

Shweta, & Singh, M. B. (2010). Knowledge and Pattern of Family Planning Adoption in Kashi Vidyapeeth Block, Varanasi District. (U.P.). Indian Journal of Preventive Medicine , 41 (1&2), (pp.19-26).

Sidhwani, P. (2015). Spatial inequalities in Big Indian Cities. Economic and Political Weekly , (pp.55-62).

Speizer, I., Nanda, P., & Achyut, P. (2012). Family planning use among urban poor women among six cities of Uttar Pradesh, India. Urban Health , (pp.639–58).

Stephenson, R., & Tsui, A. O. (2002). Contextual influences on reproductive health service use in Uttar Pradesh, India. Studies in Family , 33 (4), (pp.309-320).

The Slum Areas (Improvement and Clearance) Act, 1956

Turmen, T. (2000). Reproductive Rights:How to Move Forward? Health and Human Rights Journal , 4 (2), (pp.31-37).

UNFPA. (2005). State of World Population Report, The Promise of Equality, Gender Equity, Reproductive Health and the Millennium Development Goals, the United Nations. Geneva: United Nations Population Fund.

UN-HABITAT. (2003). The Challenge of Slums: Global Report on Human Settlements. London: UN.

Vaux's, J. H. (1812). Vocabulary of the Flash Language.

Verma, D., Khan, M. E., & Hazara, A. (2010). Increasing institutional delivery and Access to emergency obstetric care Services in rural Uttar Pradesh. The Journal of Family Welfare , 56, (pp.23–30).

180

Véron, J. (2006). Stabilizing India’s population: easier said than done’. Population and Societies , 423, (pp.39-43).

Visaria, L., Jejeebhoy, S., & Merrick. (1999). From Family Planning to Reproductive Health: Challenges Facing India. Family Planning Perspectives , 25 (Supplement).

Wang, G. Z. (2004). Reproductive Health in the Context of Economic and Democratic Development. Comparative Sociology , 3 (2), (pp.135-162).

WHO. (2006). Reproductive health indicators : guidelines for their generation, interpretation and analysis for global monitoring. Geneva: World Health Organization.

Wirth, L. (1938). Urbanism as a Way of Life. American Journal Sociology , 1-24.

Wood, K., Maforah, F., & Jewkes, R. (1998). ''He forced me to love him'':Putting violence on adolescent sexual health agendas. Soc Sci Med , 47 (2), (pp.233-42).

World Bank. (1993). World Development Report 1993: Investing in Health. London: Oxford University Press.

World Health Organisation. (1989). Measuring Reproductive morbidity. Report of technical working. Geneva: World Health Organisation.

World Health Organisation. (1996). Investing in Health Research and Development. Geneva: World Health Organisation.

Wyon, J. B., & Gordon, J. E. (1971). The Khanna Study : Population Problems in the Rural Punjab. Cambridge: Mass: Harvard University.

Y, Singh. (1977). Modernization of Indian Tradition. Faridabad, India.: Thomson Press.

Zodgekar, A. (1996). Family Welfare Programme and Population Stabilization Strategies in India. Asia-Pacific Population Journal , 11 (1), (pp.3-24).

Global Perspectives on Women's Sexual and Reproductive Health Across the Lifecourse, edited by Shonali Choudhury, Jennifer Toller Erausquin, Mellissa Withers (Springer, 2017), which has some useful references on India

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