Womens Perceptions and Experiences of Reproductive Health Care in Kerala

1
Womens Perceptions and Experiences of
Reproductive Health Care in Kerala

• Mala Ramanathan
• Achutha Menon Centre for Health Science Studies
• 7th March 2003
• New Delhi

2
Rationale for examining womens reproductive
health, PHC and PPC

• The process of decentralisation and the RCH
  programme both aim at improving access to
  marginalized groups, especially women
• However we need to examine how the
  decentralisation process that transferred PHCs to
  the PRIs served to ensure equity in access to
  health care and sexual and reproductive health
  and rights for women

3
Womens reproductive health and the PPC

• The objective that is being addressed in this
  presentation is
• To examine the dynamics of womens reproductive
  health care seeking in terms of social-economic ,
  cultural and gender factors
• What are the womens perceived reproductive
  health needs and what factors influence their
  health seeking for these needs?
• What is the potential for the PPC to address
  womens reproductive health needs?
• How does the process of political
  decentralization address womens RH needs?

4
The methods used

• In-depth interviews with 60 women in the
  communities in the two districts, 30 from each
  district.
• -Ten women from each selected Panchayat/PHC
  area
• - 6 FGDs with community level health workers
• Focus group discussions with men in the same
  communities, one each in the selected six
  communities

5
Themes for analysis

• Reproductive health problems
• Vulnerabilities
• Perceptions of reproductive health problems
• Health care utilisation
• Reasons for not seeking health care
• Participation in PRI activities

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Reproductive problems experienced
7
Womens vulnerabilities

• Womens vulnerability to reproductive morbidity
  are determined by the social milieu in which they
  live as much as biological factors.
• The autonomy to decide for themselves and the
  degree to which this is not compromised by
  domestic violence shapes their vulnerability to
  reproductive morbidity

8
Experience of domestic violence

• A third of the women report some form of domestic
  violence, and this is sometimes also linked to
  alcohol use
• Affects their mental well being
• Consequently women practice conscious deference
  to husbands and other authoritative figures such
  as mothers-in-law.

9
Male perspective

• Domestic violence impairs the ability to make
  decisions on their own
• Men see this as natural
• It is just a small slap between husband and
  wife. male participant in FGD in Palakkad
• Men more willing to recognise alcohol use as
  affecting womens well being than domestic
  violence

10
Experience of reproductive morbidity

• These conditions are not experienced singly but
  in combinations with white discharge, back ache
  and lower abdominal pain being mentioned
  simultaneously
• They are sometimes a combination of symptoms that
  are experienced progressively as the severity
  increases

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A typical case of symptom progression

• during the fifth pregnancy, I had back pain and
  bleeding and the baby was aborted. During the
  sixth pregnancy then I again had back pain and
  bleeding and I went to the hospital and was
  advised rest. All the deliveries were at home.I
  have back pain, joint pain and body pain. This
  problem has been there since the last delivery
  but for the past six months it is very bad. I am
  having periods once in 20 days. My friends told
  me many women have back pain and I did not do
  anything. When it became very severe I went to
  the PHC.. 41 year old woman who has 5 children

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Acute reproductive events Vs chronic events

• Financial resources are available from family and
  community for acute reproductive events like
  child birth, spontaneous abortions etc but not
  for everyday problems that affect a womans life,
  such resources are not available and women are
  reluctant to seek any assistance that would call
  for the spending of money

13
Contraceptive use and RH problems

• Most women had undergone tubal ligation with
  their husbands permission. Not obtaining this
  could have serious repercussions at times
• ..the back ache is severe for one year now. I
  find it difficult to do housework and with my
  husband also it is a problem. I cannot tell him
  because he will get angry and scold because I
  went and did the operation without his
  permission. So he will not give me the money to
  go to the private doctor.Woman in her 20s who
  had undergone tubal ligation and has experienced
  back pain and pain during intercourse

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Contraceptive responsibility

• Women accept contraceptive responsibility and
  face the consequences but do not have access to
  counselling and care that is needed to resolve
  these concerns
• This belief is based on their own and others
  experiences that tubal ligation causes back pain
  and also lower abdominal pain
• They prefer this permanent method as other
  methods such as oral pills or IUDs cause more
  problems

15
Perceptions of RH problems

• Women believe that current reproductive problems
  are a consequence of past reproductive events
  such as a difficult child birth or contraceptive
  use
• They also thought that white discharge was a
  problem that could not be cured
• The other belief was that treatment for white
  discharge and other RH problems was available in
  Ayurvedic system of medicine and not allopathic

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Health care utilisation

• Utilisation of services
• There is a hierarchy of care that is accessed for
  reproductive health problems starting with self
  help, indigenous treatments and lastly the
  allopathic practitioner
• Women sought health care only if the problem
  became severe
• Women deferred health care also if they provider
  in the neighbourhood was male

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Utilisation of services

• .I cannot talk about this to the doctor in the
  PHC, it is a man. How can I solve it? I need
  the money for my childrens education. I cannot
  go and see the woman doctor in town. So I have
  not done anything for the past four years.
• 42 year old widowed woman living in Palakkad

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Utilisation of services

• Women experience partial cures and move from one
  provider to the other. Even if a woman knows
  that her problems can be solved, the lack of
  resources and the absence of referral mechanisms
  within the government system may keep women
  trapped with illnesses that could be treated

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The case of partial cures

• .I had complications during delivery. Now I
  have prolapsed uterus for the past one year and
  body pain and white discharge for five months I
  think. This serious problem started only five
  months ago. I went to a private hospital nearby
  and then it was still there so I went to the PHC
  but it was not enough. So I went to the PHC
  doctors house to see the doctor privately after
  my sister-in-law told me it would be better. It
  is difficult to go to hospital alone and my
  friends cannot always come with me. The cost of
  visit is also high so sometimes even if it is bad
  I cannot go tot the doctor's house. So I started
  to go to the PHC again. I have spent Rs2000 now
  on this problem alone and cannot do anything
  more. 36 year old married woman in
  Thiruvananthapuram a housewife

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Utilisation of services

• Need someone to go with them/accompany them when
  they go to hospitals
• Lack of resources to continue with treatment
  leads to recurrence
• Lack of clear understanding of the problem
• Success in seeking health care depends on
  availability of resources and supportive family
  environment

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Reasons for not seeking health care

• Women were not able to discuss reproductive
  health problems with male doctors culturally
  unacceptable
• Separated, divorced, widowed women were not able
  to seek health care
• Women thought that the problem had no cure
• Women thought that the problem was not severe
  enough to merit attention
• The burden of household work also kept women
  from seeking health care

22
Case of inability to recognize a problem as
meriting attention

• This happened very often with menstrual
  irregularity or white discharge and more often
  with young single women
• My mother said it cannot be cured and so we do
  not go to the hospital. Only once they took me to
  the private hospital nearby because I felt
  giddiness during the exams and I had exams the
  next day. I told the doctor about white discharge
  and they gave me medicines for it and I took them
  but there was no cure. 16 year old single girl
  in Thiruvanananthapuram who had white discharge

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Other reasons for not seeking health care

• Lack of financial resources
• Physical distance to the hospital
• Govt hospitals preferred for this reason as well
  as being free
• Used private sector when they had money and
  public sector when it was scarce
• Belief that allopathic has no cure for certain
  reproductive health problems and solutions
  available in Ayurvedic treatments

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The grass roots level health workers

• These workers were best able to identify womens
  reproductive health problems and the social and
  gender factors that render them vulnerable within
  their households and elsewhere
• Even though they were lowest rung of the PHC/PRI
  hierarchies, they were the ones with knowledge of
  womens RH needs
• However, they felt alienated from both systems

25
Participation in decentralisation process

• Near universal awareness of the process
• Nearly 20 per cent knew the local leadership
• They felt that the PPC had the potential to
  benefit the weaker sections and women in
  particular
• Self help groups and Kudumbashree projects
  enhanced womens earnings

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Specific benefits from PPC

• About two thirds participate in some PPC activity
• Families do not discourage participation as there
  is the scope for being selected as a beneficiary
  and 18 out of 57 women had benefited
• Women recognised that the PPC had brought them
  both tangible as well as intangible benefits

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The intangible benefits

• self help groups are useful because they give
  us an opportunity to say anything frankly and it
  gives a chance to earn
• PPC is good because there is development and
  many have benefited
• Women get freedom and energy from these
  activities
• However, sometimes women from better off
  households did not participate in many of the PPC
  activities

28
Womens awareness of the potential of PPC to
influence health

• Women did not recognize this potential and their
  suggestions to improve health in their area
  included improving the PDS and employment
  generation
• Specific suggestions for the PHC included need
  for women medical personnel at least as specific
  times and toilets for women in the PHCs

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The success stories

• Women who enjoyed some autonomy in decision
  making in the household
• Negotiate with partners
• Seek health care
• Participate in PPC processes
• Resolve reproductive morbidity experienced

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Potential of PPC

• Has the potential to influence gender power
  equations within the household
• Participation by women currently does not
  influence the planning processes for health in
  general and reproductive health in particular
• Women are not aware that they can influence the
  planning processes directly
• But PRIs can facilitate this process by
  encouraging womens well informed participation
  in the planning for health with the help of the
  health personnel

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Suggestions for policy -1

• Train all the PHC functionaries on the RH
  approach including a gender component in
  curriculum on a priority basis. This would
  facilitate the conducting of CNAs
• Train PRI and PHC functionaries to make gender
  and health concerns central to the decision
  making
• Train health care providers to recognise signs
  and symptoms of domestic violence and offer
  medical as well as non-medical counselling and
  care directly and through referrals
• Undertake gender analysis of all policies and
  programmes that are developed in future

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Suggestions for policy-2

• Use the Self-help-groups and Neighbourhood groups
  for community needs assessments for reproductive
  health needs of women
• Strengthen the role of the grass roots level
  workers to facilitate the process of bridging the
  gap between the communities and PHC
• Encourage participation of women during the
  planning process for health, facilitated by women
  leaders and health staff from the Panchayats

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Suggestions for policy - 3

• Gramasabhas need to be institutionalised
• PRIs need to play a more proactive role in the
  process of getting the health care system to be
  sensitive to peoples health
• PRIs need to identify alternative sources of
  resources for health in addition to the plan
  resources.

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Suggestions for policy - 4

• Identify those Panchayats(village, block or
  district) in the state that were very positive
  towards health sector and examine the possibility
  of replicability
• Panchayats could develop long term plan
  strategies for health in general, possibly for
  five years. It would serve the purpose of vision
  document for the health sector

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Suggestions for Policy - 5

• The Hospital Development Committees need to be
  institutionalised and act as a tool for
  strengthening PHC-PRI linkages
• Creation of a Personal Deposit account to meet
  the day to day expenses of the PHC maintenance
  and repair
• The monthly review meetings of Medical Officers
  at the District level could be used to review the
  progress of panchayats vis-à-vis health if PRI
  leaders also participate in it.

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Thank you