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Indian Journal of Community Medicine

Demography, Environmental Status and Maternal Health Care in Slums of Vellore Town, Southern India

Author(s): P.K. Mony, L. Verghese, S. Bhattacharji, A. George, P. Thoppuram, M. Mathai

Vol. 31, No. 4 (2006-10 - 2006-12)

P.K. Mony(1), L. Verghese)2), S. Bhattacharji(1), A. George(2), P. Thoppuram1, M. Mathai(2)

Abstract

Research Question: What is the status of demographic structure, domestic environment, and maternal health care in poor urban communities? Objectives: To study the demography, domestic environmental status, and maternal health care services in slums of Vellore town. Study Design: Cross-sectional study (Needs Assessment survey) Setting: Two slums in Vellore town, Tamil Nadu. Participants: All 3334 families in the two slums. Results: There were 15280 persons in the study area in the year 2000. Sex ratio was 965: 1000. About 60% of them owned houses; 56% of the houses were concrete (pucca) houses. 96% of houses had electricity connection; only 25% had household water connection and latrine. While 47% used liquefied petroleum gas as cooking fuel, 20% still used firewood. Reported rates of iron tablets consumption and tetanus toxoid acceptance were 87% and 94% among antenatal women respectively; 85% had normal vaginal deliveries. The crude birth rate was 25.7/1000. The couple protection rate was 52%. Conclusions: The two slums had comparably secure houses with reasonably good structures. Access to safe water supply, sanitation facilities, and garbage disposal was however very low. A sizeable proportion had inadequate access to high-quality antenatal and obstetric care services. Reliable, local information is essential for managing a decentralized health care system.

Key words: Demography, Environment, Maternal Health Services, Slum, India

Introduction

Paucity of data on health status is a problem of major concern in many developing countries1. While the census and national family health surveys deal with data at the national and regional levels, they compile and publish information at lengthy time intervals, and provide little by way of disaggregated information to help guide health policy and action at the local level, especially for deprived sections of society such as urban slums. The poor health status of slum and squatter dwellers usually gets obscured by the statistics comparing the relatively well-off urban population vis-a-vis the rural population. The urban population in developing countries is increasing 3 – 5 times faster than the population growth and is predicted to increase from 33.9% to 56.9% by the year 2025. Simultaneously, the slum population is also predicted to rise manifold.

Descriptive research in the form of a cross-sectional survey is an appropriate research method to tackle the problem of paucity of data on specific groups2. It could help in estimating the need for health care in a locality and can thus be quite important in community health and family welfare activities3. A demography and health survey will provide a comparable, high-quality database on a range of health indicators1,2. The advantages of such a survey are that, firstly, it will make available data on health services with regard to availability and utilization and secondly, it will provide population-based data of key health indicators.

The objectives of this study were therefore to study the sociodemographic and environmental structure, and to assess the utilization of antenatal, intranasal and postnatal care services in two urban slums of Vellore town in southern India.

Methodology

Study setting: The survey was conducted in two slums, Saidapet and Kagithapattarai, in the central and eastern parts of Vellore town. The town (estimated mid-year 2000 municipal population = 1,98,725) is the headquarters of Vellore district and is located 140 km. west of Chennai, the capital of Tamil Nadu. The population of the study area was 15,280. A slum was defined as “a contiguous settlement with households that lack one or more of the following: security of tenure, structural quality and durability of dwellings, access to safe water, access to sanitation facilities and sufficient living area” (UN-Habitat, 2002). These two areas were designated as slums by the Municipal Corporation of Vellore. The sample size was the entire population residing in Saidapet and Kagithapattarai, the field-practice areas of the Family Welfare Unit, Christian Medical College (CMC), Vellore. Health care in the town was provided mainly by CMC through its health facilities, the Government Pentland Hospital (the district hospital) and numerous private clinics.

Study design: The study instrument used was a questionnaire with two sections: Section-I (Census) obtained information on family structure, vital events, selected socio-demographic variables, housing and environment; and Section-II (Women’s Health), elicited details of utilization of antenatal, intranasal and postnatal care services among women aged 15 to 44 years of age.

This was a population-based cross-sectional study conducted during January-December 2001. The fieldwork was carried out by a team which consisted of four field workers, a field supervisor, and an editor. Interviews were conducted in each of the two areas by a pair of field workers (one male and one female, to ensure that survey respondents would feel comfortable talking about topics that they may consider sensitive). Their work was supervised by the field supervisor. The team was under the supervision of the field consultant (PM).

The field workers were employees of the Family Welfare Unit of CMC with 10-17 years of formal education, and 10-15 years of field experience in conducting surveys and providing antenatal and postnatal care services to the population. Training of the field staff was done over two weeks. The training course consisted of instruction in interviewing techniques, a detailed review of each item in the questionnaire, mock interviews between team members in the classroom, and practice interviews in the field. The field supervisor and editor were also updated on organization of fieldwork as also methods of detecting errors in field procedures and the completed questionnaires.

The study objectives were explained to the community representatives (formally elected leaders like municipal councilors, and local elders) and their cooperation was obtained. During the door-to-door survey, the household respondent was briefed about the purpose of the study and verbal consent obtained, and then the study questionnaire was administered. The interviews were conducted in Tamil, the local language. A pilot survey was done on 50 families and the data collected were analysed. The inputs from this exercise were used to fi ne-tune the survey.

The main duty of the editor was to examine the completed questionnaires for completeness, consistency, and legibility of the data collected, and to ensure that all necessary corrections were made. If major errors were detected, the field workers were required to revisit the houses and obtain the correct information. The fieldwork and office work were reviewed at weekly meetings of the entire team, by the study investigators.

After completion of the survey, the field supervisor, editor, statistician and the field consultant conducted a 10% sample verification of the houses to crosscheck the collected information.

Data entry and analysis: Data cleaning was completed by the field workers, and the office editing was done by the editor and field consultant. Data were entered in FoxBase and analyzed using SPSS-PC (Version 10.0).

Results

There were 3322 families in the study area. Of the 15280 individuals 7508 were females. The sex ratio was 965: 1000 (female: male). Among the population, 42% was below 15 years of age and 8.2% over 60 years of age. Eighty two percent household heads were males. Hindus comprised 80.7% of the population; the reminder comprised Muslims (15.5%), Christians (3.7%) and others (0.1%).

About 63% of the population lived in their own houses; 56% of all houses were concrete (pucca) houses (Table I). While 97% of the houses had electricity connection, only 1-in-4 had in-house water connection; and 22% of houses had in-house latrines. Almost all houses discarded garbage in street-side open dumps. While 47% used liquefied petroleum gas as cooking fuel, 20% still used firewood.

Most women received antenatal care (ANC) from easily accessible areas (within 1 km. distance) (Table II). Only one-third of women used government health care services. The largest proportion (48%) accessed CMC, while less than 10% accessed private clinics. Reported consumption of iron tablets, and tetanus toxoid acceptance rates were reasonably high (87% and 94% respectively).

Table I. Percentage of Households in Vellore Slums with Specific Facilities Compared with Indian National Urban Average (NFHS-2)

Characteristic Vellore India (Urban)
1. Housing ownership    
  Own house 63.4 78.2
  Rented/leased house 36.6 21.8
2. Type of house    
  Concrete (Pucca) 56.9 66.0
  Mixed (semi-pucca) 31.7 24.4
  Hut 11.3 9.6
3. Electricity    
  Yes 96.8 91.3
  No 3.2 8.7
4. Water supply    
  Piped water supply in house 25.2 }
  Common street tap 59.1 }74.5
  Hand pump 3.4 18.1
  Well 12.2 6.0
  Other 1.4
5. Sanitation    
  Open air/ street drain 72.0 64.0
  Public toilet 2.6 0.1
  Household latrine (without septic tank) 22.6 } 35.9
  Household latrine (with septic tank) 3.0 }
6. Garbage disposal    
  Street-side dumps 98.7 N.A.
  Dustbins 1.3 N.A.
7. Kitchen fuel    
  Liquefied Petroleum Gas (LPG) 45.4 46.9
  Kerosene 34.9 21.5
  Firewood 19.6 23.1
  Other (including cow dung) 0.9 1.4

A total of 392 births were recorded in one year in this population. The birth rate for the study area was 25.7/1000. Most women delivered vaginally: normal (85%), vaginal breech (1.8%) and instrumental deliveries (0.8) (Table III). Cesarean section accounted for 9.4% of all births. Total cesarean section rates in the public, charitable and private sectors were 7.6%, 11.1% and 13.4%, respectively. Forty five percent went to CMC for delivery. Less than one third went to government centres and less than 10% went to private clinics. Only 3.6% were delivered at home by unskilled attendants. Those from very poor families utilized the services of the municipal health centres in the town.

Table II. Antenatal care among women in Vellore slums

Characteristic No. (%)
1. Place where women receive antenatal care*  
  CMC 195(45.7%)
  CMC – Peripheral clinic 8(1.9%)
  Government Pentland hospital 63(14.8%)
  Municipal MCH centre 84(19.7%)
  Private clinics 42(9.8%)
  Others 35(8.2%)
2. Consumption of iron tablets  
  Yes 345(87.2%)
  No 50(12.8%)
3. Had completed tetanus toxoid schedule  
  Yes 369(94.1%)
  No 23(5.9%)
* total percentage is > 100% because a woman may have attended > 1 centre

Table III. Place and Type of Delivery.

Characteristic No. (%)
1. Type of delivery
  Normal 345(88.0%)
  Breech 7(1.8%)
  Instrumental 3(0.8%)
  Cesarean section 37(9.4%)
2. Place of delivery
  CMC 179(45.7%)
  Government Pentland hospital 79(20.1%)
  Municipal MCH centre 38(9.7%)
  Private clinics 33(8.4%)
  Home 14(3.6%)

Others (mission hospitals in other towns) 49 (12.4%) The couple protection rate in the study area was 52%. The contraceptive methods used were: tubectomy (87.6%), intrauterine device (4.0%), oral contraceptive pills (1.4%), vasectomy (0.5%) and others (4.3%).

Discussion

Improving quality of life in the slums is one of the development goals for the new millennium4. Toward this aim, this study provides a situational analysis of the demography, environment, and maternal health care status in urban slums, which are conventionally neglected, or under-represented, or ‘invisible’ because they get aggregated into the urban data of a region.

As per UN-Habitat criteria for a slum4, our study population has reasonably good housing conditions, access to electricity and cooking fuel compared to other urban areas of the country5. Environmental conditions in terms of safe water supply, sanitation and solid waste disposal are however a cause for concern5. While it may seem that most residents have access to water connection, the municipal water supply is intermittent and erratic. Low levels of water consumption along with poor sewage disposal facilities and overcrowding have been noted in other urban poor communities too6,7. Sanitation coverage of 25.5% in our study area was lower than the national average of 34%8, this could be due to lack of affordable sanitation technology and awareness or motivation. Although the sewerage system was introduced in India long ago, high installation and operational costs have prohibited it from being implemented in most towns and cities8. Similarly, the cost of a septic tank is beyond, most people, and disposal of undigested sludge from septic tanks remains a problem9. Garbage disposal is cause for current environmental concern in most cities of the developing world. In addition, there are few studies on people’s health practices in relation to solid waste disposal.

The demand for improved water supply and sanitation services in our country far outweighs the supply. Working with a resource gap, the government is left to provide environment and health services.

In our study area, only about 35% of mothers presented to a government facility for antenatal care unlike the much higher proportions seen elsewhere10 because of the presence of a not-for-profit mission hospital in the town. Iron tablets and tetanus taxied coverage rates were reasonably high. Data from the National Family Health Survey (NFHS) show that utilization of maternal health care services is comparatively high in the four southern states of the country11. But the overall quality of “essential obstetric care” at the point of service delivery is however deemed to be weak in developing countries12,13.

There were very few home deliveries in our study area compared to the 46% seen in slums of Delhi10. Cesarean section rate was comparatively lower in Vellore (9.4%) than in Chennai, India (32%)14 or parts of urban South America (16%-40%)15. Total cesarean section rates of 7.6%, 11.1% and 13.4% seen in the public, charitable and private sectors respectively were considerably lower than the 20%, 38% and 47% recorded in the neighboring city of Chennai14. Our rates were not adjusted for parity, educational status or age at delivery of mother.

Urbanization has led to increased productivity and economic diversification, but also deprivation, poverty, and marginalization. Those who suffer from the latter are disproportionately more in the slums. Current thinking on the status of slum populations is not only in terms of physical conditions like housing and environment, but also social processes like lack of social inclusion in the growth and development of towns and cities through deprivation of services such as health and education. While growth of towns and cities is indispensable to modern society, there is inequity in provision of services to its inhabitants due to imbalances in the distribution of wealth and power, usually adverse to the slums16.

The interrelations between urban planning, health, social, and environmental policies have been poorly articulated until now. Residence in urban slums deserves further consideration as a potential factor infl uencing aspects of health and well-being.

Acknowledgement

The authors are grateful to the fieldworkers: Mrs Chandra Samuel, Mrs Anjali Rajaseelan, Mr S Ramachandran and Mr M Martin for assistance in data collection; Mr B Pandiyan, for supervision of fieldworkers; and Mr. K Thinakaran for office editing. The authors would like to thank Dr L Jeyaseelan and the staff of Biostatistics department for data entry, and all the families of Saidapet and Kagithapattarai for being enthusiastic participants in the study.

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(1) Low Cost Effective-Care Unit (LCECU)
(2) Department of Obstetrics & Gynaecology, Christian Medical College, Vellore 632004, Tamil Nadu, India.
E-mail: [email protected]
Received: 11.10.04

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