Health is a major economic issue for slum residents, particularly for women. The unhealthy physical environment leads to sickness, demanding medical treatment, which results in the reduction of workdays, followed by economic loss. Economic loss leads to inability to invest in a clean environment. The vicious cycle continues. Slums have frequently been conceptualized as social clusters that produce a distinct set of health problems. The poor environmental condition coupled with high population density makes them a major reservoir for a wide spectrum of adverse health conditions such as undernutrition, delivery-related complications, postpartum morbidity, etc. In India, there have been limited efforts to study the health of individuals, especially women living in slums. Of the few studies that exist, most have reported considerable differences in the situation of reproductive and women’s health between slum and nonslum areas.
These disparities are probably the outcome of factors such as employment patterns, literacy levels, availability of health services, traditional customs, sex status, etc., which influence the use of reproductive health services. However, the major limitation of most of these studies is that they have been confined to specific cities, and therefore the findings cannot be generalized. The growth of slum areas and the concentration of poor people in the slums is a rather depressing aspect of urbanization. The majority of women slum dwellers belong to the lower socioeconomic class and have migrated to the city with the hope of better means of livelihood. Having basically low education, skill, and work experience, they have no choice in the competitive job market and pick up low-paid jobs such as construction laborer, domestic servants, casual factory workers, and petty trading business. With their meager income, they are forced to live in slum areas in the most unsanitary and unhygienic conditions, carrying out their existence with the barest necessities of life. Even if people have some money, they do not invest it in home improvement because of the temporary status of their residence or because of illegal occupation of public lands and the constant threat of eviction. Therefore, the housing of the slum dwellers is of lower quality. Poor housing conditions, overcrowded environment, poor sanitation, occupational hazards, group rivalries and clashes, stressful conditions together with lack of open space for women’s recreation, etc. are detrimental to the health of people in the slums. An overview of women’s and children’s health status presents a somber picture. Worldwide, death and illnesses are highest among poor women, particularly among women in developing countries 1. In addition to the suffering of women, yet another cause of concern is their almost apathetic attitude towards their own health and its management during illness. Women were found to seek treatment only when their health problem caused great physical discomfort or when it affected their work performance. The situation with respect to women’s and children’s health in the urban slums is not different, rather their health is neglected the most. Insecurity related to regular income, food, shelter, access to healthcare, and other essential services, along with poverty and difficult physical and social environments, such as exploitation and abuse in the treatment of women, have an adverse impact on the health of the urban poor women 2.
Low education and ignorance of women lead to continuation of wrong beliefs and unscientific attitudes toward health. The outcome is incomplete immunization, insufficient gynecological checkup during pregnancy, unsafe deliveries at home, and improper postnatal care of mothers and children, especially in terms of diet and immunization. Incomplete tuberculosis and malaria treatment leads to recurrences and relapses. The unhealthy and polluted environment, lack of immunization, malnutrition, and absence of educational exposure affect children in slums. Sadly, their physical, emotional, and intellectual growth is stunted from a very early age. Access to community facilities and health centers in these settlements is limited and not adequate. Across all surveyed slums, it was found that the health centers are not adequately equipped with medicines and that the households have to procure medicines from the open market. These health centers are also not equipped to provide antenatal and postnatal care. To overcome health problems, the corporation runs three maternity hospitals: one government hospital and several health centers located at various places in Raipur. The corporation has also started reproductive and women’s health project and it is being implemented through nongovernmental organizations. With their participation, many urban health centers have been established to provide better health services to the women and children, particularly in slums and the surrounding areas. There are also government dispensaries that are visited by the poor. There is a need to strengthen health infrastructure, ensuring food and nutritional security; however, the measures taken toward this end are not enough. There is far too much vulnerability in the lives of the poor and those just above the poverty line. Around 93% of our labor forces work in the informal sector, without any form of social protection, especially against old age 3. Moreover, vulnerability with respect to women’s health arises from the underfunding of the public health system and its inability to provide comprehensive care, which is a major concern for the majority of the population. In India, the public healthcare system has focused primarily on rural areas. With the rapid urbanization that India has witnessed over the past decades, the public health problems in the country are increasingly assuming an urban dimension. This is especially true for the estimated one-fourth of the urban population who live in slums. There are growing indications that this segment of urban India is more disadvantaged in various aspects of health and well-being 4. Low and stagnating incomes among poor women have meant that low purchasing power remains a serious constraint to household food and nutritional security, even if food production picks up as a result of interventions in the creation of urban women lives in slums.
The present study mainly focuses on the several aspects of slum development in Raipur city. The following objectives were framed for the present study:
- To examine the demographic characteristics of slum dwellers.
- To know the living conditions available for women in the slum areas.
- To study the health and nutrition level of women slum dwellers.
- To explore the use of contraceptive by women in slums.
- To see the various policy measures and programs initiated by the government for women.
Sampling of the respondents
For the present study it was decided to use the purposive sampling method to choose respondents from Raipur city slums in India. Purposive sampling may involve studying the entire population of some limited group or a subset of a population. Here the sample size was 300 women from four slums: 95 women were from Gandhinagar, 88 from Moulipara, 100 from Kushalpur, and 17 from Kota Basti, proportionately distributed. For the present study 10% of the total number of families in each selected slum area were taken. Ten percent of the total family size was 95.7 for Gandhinagar, 87.8 for Moulipara, 100.3 for Kushalpur, and 16.6 for Kota. However, the figures have been rounded off for the sake of convenience for calculation. All individuals selected in the sample were asked to provide informed voluntary consent.
Sources of data and technique
The data were collected from secondary and primary sources.
- Secondary sources: Information was collected and compiled from books, reports, published and unpublished papers, municipal records, and government circulars.
- Primary sources: The primary source of data were interviews from the field with respondents, word counselors, and slum leaders, conducted to elicit their opinions and experiences in slum life, with the help of an interview schedule. This interview schedule included all dimensions of the study and was a combination of structured and unstructured questions.
Results and discussions
Healthcare conditions of women in slums
Exclusive breastfeeding is recommended as the optimum method of feeding for the first 6 months of life to meet the physiological requirements of the infants. It has been reported from the study that the practices of early introduction of breastfeeding and late introduction of semisolids are widely prevalent, more so in slum areas 5. However, our study reveals a serious erosion of breastfeeding practices (Table 1). The use of prelacteal feeds is almost universal; the use of feeding bottles, animal milk, and commercial milk formulae is very common 6. It has also been found that the introduction of complementary foods is markedly delayed with this background. The study was conducted to assess the breastfeeding practices for children in slums and determine the factors influencing it, if any. An overall 12.67% of mothers had given colostrums within 1 h, 25.67% had breastfed their children after 1 h but before 12 h of birth, 30.33% had breastfed within the day, and 31.33% breastfed after 1 day. In Kushalpur and Gandhinagar slums, the majority of respondents admitted that they breastfed their children after a day. Mothers’ milk is very vital for the new-born baby and new-borns should be breastfed as soon as possible after birth.
Table 2 shows that men in slum areas have problems related to chest pain, headaches, abdomen pain, etc. due to smoking habits or consumption of alcohol and avail medical facilities from government as well as private hospitals for these conditions. As regards women in the slum areas, they suffered from joint pains, mental stress, white discharge, acute tiredness, etc., and most cases were dealt through self-medication. The causes of these health problems are generally overwork, inadequate food intake, overall living conditions, etc. 7. As regards girls and boys, they suffered mainly from indigestion, cough, fever, conjunctivitis, weakness, etc. and were often treated by quack or home remedies.
The study shows that slum dwellers often neglect minor sicknesses and do not consult a doctor for a remedial cure unless they fall ill 8. In this situation it becomes imperative to know the medical practices of slum dwellers of Raipur city. In the surveyed population (Table 3), 57.33% of respondents said that they consult a doctor. Government hospitals provide comparatively cheaper treatment. Some of them (18.67%) consult the local doctor or quack. The most dangerous practice was self-prescription; 22.33% respondents self-prescribed medicines without proper knowledge. An overall 1.67% people have said that they do not take any medicine for minor cases. Many people in Moulipara and Gandhinagar practice this. Often, people neglect minor sicknesses in slum areas, which is evident in the data given in the table, in which Kota Basti has ranked first. In slum areas local doctors such as those having a registered medical practice, or quacks, operate. They often take advantage of the ignorance of slum dwellers, which is also evident in the Table 3. Such cases are common in Kota Basti.
Another most important factor indicates the health concern of slum dwellers, which plays a vital role in purchasing medicines 9. Large pharmacies are located in city hearts. Slums have very few shops and quacks are indirectly involved with these shops. Only a few low-cost medicines are generally available here. Medicines are sold even in grocery stores without having any valid license. Table 4 shows that 68.67% of respondents buy medicines from the medical shop; however, 31% of women depend on the local shop and 33% of women still buy medicines from the roadsides. A field study revealed that people also buy medicinal plants (Jaributi) from the local vegetable market.
Although the informal means of obtaining medicines are not genuine and safe, people spend money on such medicines 10. Local grocery stores preserve medicines for a longer time period and may have medicines that have exceeded the date of expiry. These kinds of ignorance show the worse condition of health and medical awareness among the slum dwellers, which brings far reaching consequences.
It is ironically said that good medical treatment is expensive. Indirectly it indicates to the private institutions providing medical services across the country 11. It is a fact that good health treatment is still unreachable to many poor people living in slums. So far the government hospitals are concerned they have tremendous pressure, patients come from the various places throughout the state. Here in Raipur, the number of large/good hospitals is limited. The condition of local hospitals and dispensary is miserable and are unable to handle the critical cases due to lack of infrastructure. Table 5 shows that 77% of women depend on government hospitals; however, 23% of respondents have said that they avail the facilities of private institutions for health treatment. The right to good health in many cases is unreachable to the urban poor. The data show that maximum number of people are dependent on government hospitals and a few among them can afford private treatment as and when required. All slums are projecting the same picture in this regard.
Table 6 shows that 14% of women or the partner use condoms as a contraceptive measure. An overall 32.33% of women have said that they use either cervical cap or other traditional methods for contraception. Here it is clear that the awareness level is yet to improve. Data show that many people do not bother about the doctor’s reputation. The study has shown that there are significant differences in the utilization pattern of reproductive health services among women in the slum communities. The findings of this study call for focused and sustained efforts geared toward the promotion of the use of reproductive services in the slum communities 12. A multivariate analysis was conducted to identify the factors that have an influence on the use of antenatal services among slum women. It was also found that less than half of the women from the slum areas are currently using any contraceptive methods, and discontinuation rate was higher among these women. Sterilization was the most common method of contraception (32.33%). The use of contraceptives depended on age, level of education, parity, and knowledge of the contraceptive method. In Moulipara, almost 40% of people could not answer the question and in some cases they avoided the question.
The present study Table 7 shows that in some families either boys (2%) or girls (4%) died after birth. An overall 67% of respondents have reported more than one infant death incident, whereas 93.33% of respondents have reported no such incident. The total number of infant mortality recorded was 6.67%. Infant mortality is not a single problem with a single solution. Multiple and inter-related determinants interact, demanding a chain of approaches and policies that need to be evolved to deal with and bring down the mortality rates. Mostly the health of women and children is often neglected, resulting in poor health and development. Overpopulation and poverty are pervasive and cause health hazards such as mortality. Infants are naturally innocent, vulnerable, and dependent on their parents’, mainly mother’s, nutrition status and child feeding practices, and often suffer from viral and infectious diseases. The smaller number of infant mortality cases demonstrates a greater level of awareness. It is seen that among the four slums, Moulipara has the maximum number of infant mortality cases. However, the overall scenario is encouraging in this regard.
Sociodemographic factors for healthcare among women in the slums
In addition, poverty, lack of literacy, widespread ignorance, and the low social status of women result in malnutrition, low immunization rates, low maternal and child care, and neglect of health, thus further contributing to the ill-health of the poor 13. The problem is further aggravated by the absence of a user-friendly healthcare system. Clinics and hospitals are often far from poor settlements and entail a long and expensive trip. The hospitals are also often overcrowded and staffed by unfriendly, unsympathetic doctors. Therefore, despite good number of highly subsidized government hospitals, dispensaries, and maternal/child health centers in Raipur, the poor remain unattended and untreated. Most urban poor women, when they fall ill, prefer to consult a private practitioner, and, as these doctors charge a heavy fee, the tendency is to avoid consulting a doctor until the illness becomes very serious. Housing in slums is a major health concern because the residents of slums live in overcrowded situations. One-fourth of the households are simple one-room structures, a majority of them with dirt floors and poor ventilation. Such overcrowding can lead to a rapid spread of respiratory and skin diseases 14. It is estimated that over one-third of slum households have no access to bathroom facilities, promoting open defecation, which in turn leads to the spread of fecal-oral disease and parasitic infestation 15. Awareness regarding health requires more attention in these areas. Some major aspects are given for detailed study. It was also found there was a difference in the two populations based on the age of marriage and number of living children. Women from slum areas were more likely to marry before the legal age of marriage and also had higher number of children 16.
In the study, it was found that irrespective of the place of residence, a large proportion of our respondents had the knowledge of contraceptive methods. However, it was found that a significantly lower proportion of women from the slum areas have never used contraceptives. In fact, it was found that less than half of the women from the slum areas are currently not using any contraceptive methods.
Victimization of women is very common in slums and the usual situation is one of women enduring it. A Participatory Impact Assessment Study on the status of women was carried out in the four slums using a number of Participatory Rapid Assessment/Participatory Analysis and Learning Methods exercises such as Focus Group Discussions and Semi-Structured Interviews; before and after the exercise, social mapping, livelihood analysis, matrix scoring and cause-effect analysis were performed. The factors responsible for bringing changes to the lives of the slum women, which have also affected their status, are analyzed by the women themselves and this helped them greatly in becoming independent and further helped their development. However, according to most slum dwellers such activities take place in very small selective areas. There is a need for expanding such activities. In this context the role of NGOs is very important.
It is extremely important to invest in more services such as reorienting and sensitizing doctors/nurses, additional beds in government hospitals, well-equipped dispensaries, and maternity clinics near slums and settlements inhabited by the poorer sections. For the poor, private doctors are approachable for small ailments or coughs/cold, but free services at government hospitals are always the option in case of severe health problems. Being close to government hospitals and dispensaries is a positive factor, but more information regarding health, reproduction, availability of better government resources for illnesses for both men and women need to be appropriately addressed. Education can play a vital role in influencing women’s knowledge about nutrition, hygiene, and health. Sometimes respondents are found to be conscious about food habit but cannot afford healthy food, which is expensive for them. As most slum dwellers do not own any land and stay in public and private land, they cannot cultivate food crops and are dependent on the market price for food. Still many women (33%) breastfeed after 1 day of the birth of the child. An overall 74% of respondents do not have any complaint against the quality of the water and 57% of people consult doctor during minor sickness. Slum dwellers purchase medicines (68%) from drug stores; 77% of people depend on government hospitals for treatment. An overall 53% of slum women use condoms as contraceptive. In slum areas infant mortality is very low (6.67%). In these slums only 6% of people are found either physically or mentally challenged. The health-related problems faced by women in general comprise chest pain, headache, mental stress, joint pain, fever, cough, conjuctivitis, indigestion, etc. Sometimes they go to the government hospital and sometimes to private clinics. An important finding from the study is the dependence of slum women on the public health system for reproductive health services. This is not only encouraging but is also a concern as in Raipur, it is widely recognized that urban health facilities are marred by inadequate medical and nonmedical manpower.
Conflicts of interest
There are no conflicts of interest.