Illness and Childbearing Among Women

A woman's health is intricately linked with the social environment she lives and works in. When one studies women's health, one must, therefore, study not just her biological problems but the whole social process that gives rise to these problems. Given their subordinate position and the fact that they are being constantly discriminated against, one would expect women's health and health care utilisation to be substantially low. However, to our surprise we found that most of the national and local surveys had inadequately captured this reality. This contrasted sharply with the recent qualitative information, particularly on reproductive health. Thus, CEHAT decided to undertake a district level survey in 1998 using a methodology that incorporated certain elements of the qualitative research, for a study of women's morbidity, utilisation of health care services and expenditure. Nashik district in Maharashtra was selected for the study as it has average development index, a substantial tribal population and readiness of an NGO friendly to us working in the area to provide us support.

The study covered 3,581 women belonging to 1,193 households in rural areas of Igatpuri taluka and in the city of Nashik. The study made several innovations in the survey method:

• Women of the household were interviewed to get information on the members of the household.
• Only female investigators conducted the survey.
• The investigators were trained rigorously and sensitised on women's health issues and about the data collection technique.
• A longer process of interaction between the women in the community, the investigators and researchers was established.
• The morbidity among women was recorded first as reported by the women respondents and then by using 14 probing questions.
• We also asked questions on women's perception of, and how they relate their health problems to their bodies, household, work and environment.

The findings of the study revealed that the quantum of morbidity existing among women was higher than had been reported in any earlier household surveys. In fact, the morbidity reported among men was also higher than in any of the previous surveys. It recorded a rate of 569 morbidity episodes per month for 1000 persons. The rate for males was 330 and for females 812. Besides, 506 females per 1000 as compared to 307 males per 1000, reported sickness in the reference period of one month. Nearly 20% of morbidity reported by women was associated with their reproductive health.

• The ill health reported by women tended to be predominantly chronic and linked to the living environment (air, water, food etc), work, childbearing and contraception. There is a high correlation between morbidity and age, marital and occupational status, socio-economic class and composition of the household.
• The utilisation of health care by women was quite low, relative to the quantum of morbidity reported by them. 45 percent of the episodes reported by them were not treated. One of the major reasons cited for not seeking treatment was financial problems (40%). 23.2% reasons were attributed to the nature of the illness ("treatment was not required or would not be effective"), and 12.4% of the reasons were related to the lack of physical access to the health facilities. The use of informal care was an important part of a woman's help seeking behaviour. While the use of home remedies constituted 15 percent of the services utilised, the use of self medication accounted for 11 percent of the total services used.
• A high association between health care utilisation and the position of women in their households was found. Unmarried girls and aged women utilised more health care per episode than women who were heads of the household or wives of male heads of households. Besides, the women from deprived groups (remote villages, scheduled castes and urban minority community) received inadequate health care for a large proportion of their illnesses.
• The study found that the household health expenditure was Rs. 624 per capita per annum. The expenditure per episode, per capita and per facility in the rural areas was higher than in the urban areas. The cost of inpatient care as well as outpatient care in the rural area was lower.
• Doctor's fee, cost of medicines and injections comprised the major part of the outpatient expenditure. The cost of surgery and hospitalisation, though infrequent, was extremely high.
• The type of treatment was found to influence the expenditure. When only medicines were dispensed, the per facility expenditure was recorded at Rs. 24, but when injections were also administered, it rose to Rs 77. This explains economics of the overuse of injections in the private sector.

The ill health reported by women tended to be predominantly chronic This study has made two major contributions. Firstly it has shown that the traditional survey methodology needs to be appropriately modified in order to capture women’s health issues in the national surveys. Secondly, it provides insight and explanation on women’s morbidity, health seeking behavior and the household expenditure on women’s health.

Supported by: The John D. and Catherine T. MacArthur Foundation, New Delhi Research Team:Neha Madhiwalla, Sunil Nandraj and Roopashri Sinha