The summary of this project below was written by HSPH researcher Laura Khan, who spearheaded this study in 2010:

One of the research questions of interest to the PUKAR staff was in regards to women’s travel back to their rural villages to give birth to their children. It is often the tradition for a woman, who after marriage leaves her own family and is adopted by her husband’s family, to go back to her home village for her first delivery. But in KB there seemed to be no discernable pattern to women’s migration to and from their native village and the practice was thought to introduce maternal health risk factors such as train travel while eight months pregnant and delivery in the home. Evidence collected previously by an HSPH student seemed to indicate that children born in the village were even less likely to be immunized than children born in a government hospital in Mumbai (where most KB women who stay in the city for delivery give birth).[1]  I was asked to investigate this phenomenon via qualitative data collection during the summer of 2010, and to develop a quantitative survey to be used in the future to correlate data on women’s morbidity outcomes and their children’s morbidity and mortality outcomes to their reasons for and patterns of maternal migration. My data collection consisted primarily of questions on the following topics:

• • Where did she deliver her children and why
• • Who is she living with, what other relatives live in KB and where is her extended family
• • How did she hear about different health facilities and who told her to go there
• • How much it costs to deliver in a facility
• • Who was present for her deliveries and what were their skill levels
• • What complications arose during delivery and how were they dealt with
• • Who makes decisions in her nuclear and extended family and did they make the decision about her location of delivery
• • Where would she prefer to give birth if she had the free choice
• • Where she migrated from and how often she goes back to the village
• • How long does it take to travel back to the village, how does she get there and who goes with her
• • Who does she turn to when she is in need of support
• • Does she think it is better for a woman to give birth in the village or the city / in the hospital or the home
• • What kinds of pre- and post-natal care she received
• • Where she will deliver when she has her next baby

Since the intent was to investigate women’s maternal migration and their reasons for travelling to and from their rural villages to deliver, the research question was “how and why are women travelling back to their maternal villages to give birth, what is their level of knowledge about the importance of institutional delivery, and does that knowledge have any impact on their or their family member’s decisions regarding this travel?” A future quantitative survey will hopefully elucidate the women’s and their children’s outcomes with the intention that all the information collected will contribute to empirically informed advocacy and behavioral interventions to improve the community’s health status.

I worked with PUKAR staff member Tejal Shitole two days a week in Kaula Bandar for two months. We did six focus groups, eleven individual interviews and talked to two doctors. The women’s migration patterns, decision-making power, perceptions of health facilities and family and community support systems were surprisingly heterogeneous. But all women came from fragmented households due in part to urbanization and many often went back to their rural villages to visit or stay for extended periods of time. Many women understood the importance of giving birth in the hospital, especially in a city hospital, where birth certificates are given so their children may attend government-sponsored schools. For example, a Muslim woman who had given birth to her child in the hospital said:

“Suppose someone delivered in the home, but who would take care of the situation? In the home, no one concentrates on the cleaning part. And if they never clean you properly then there might be a chance of having an infection.”

Participants in a focus group of Muslims who gave birth to at least one of their children in a city hospital had this to say:

“Tejal: What do you think –which place is good for delivery?

H and R: In the city hospital

MB: Hospital is good.

Tejal: But why?

R: They give medicines

N: They give the birth certificate

H: Yes

R: They make proof for our child. And in future it is required.

Tejal: And what else do you think?

R: Yes, in the hospital we get a rest and they also take care of the newborn baby”

But in spite of their knowledge – which in a few cases was quite extensive – and desires, a large number of women still gave birth at home in the village. This was due to many factors not limited to need for help caring for other small children, other family members making the decision for them, not having enough money, being afraid of the hospital, functions in the village requiring their attendance, family pressures and/or simply ‘tradition’. The following is a sample of the conversation from a focus group of Hindu women who had given birth to at least one of their children in their rural village:

“Tejal: Who decided where you will deliver? You only or someone else told you?

A: My husband only.

Tejal: Aarti, but why? You’re not able to explain to your husband?

A: No.

Tejal: But suppose you want to deliver here? Then what?

A: I never thought about that. It’s not allowed to use your brain. In some homes husbands take all the decisions. In some homes the wife takes all the decisions.

KW: In my case also my husband told me that’s why I took that decision.

T: MS, you took the decision to deliver here for the second time or who told you?

MS: My husband told me.

Tejal: Where do you like?

MS: Here in the city.

Tejal: But suppose your husband says ‘go to the village for your delivery’. Then what will you do?

MS: Then I go to the village.”

Many women did not have control over their location of delivery but this seemed quite normal to them. Their husbands usually made the decision as to where they would give birth though women often went to the village of their own volition because of their need for family help and support around the time of delivery. The fragmentation of migratory families meant that mothers-in-law and other family members were often not around in KB to contribute though in a more traditional setting they would likely do so. I am in the process of incorporating the data I collected into my master’s thesis as the qualitative part of a mixed methods paper provisionally entitled “Fractured Families: The public health consequences of maternal migration and urbanization in Mumbai, India.” The findings indicate that any advocacy and intervention activities done in KB to foster a better understanding of the need for medical care before, during and after delivery MUST be directed towards or include directly the decision-maker of the family i.e. the husband in addition to educating women. It must be acknowledged that women migrate to the village before delivery (and then often deliver in the home) for a constellation of reasons but their need for family and social support around that critical time is one of their utmost concerns and motivations. Intervention (using a family-centered approach) is recommended to help and encourage women to remain in Mumbai for their deliveries.

References:

1. Shitole T & Banerjee J. 2009/2010. Child Health & Immunization Status Household Survey Exploring the Physical and Social Determinants of Urban Health. Mumbai, India.

***An abstract from this project was accepted for presentation by HSPH student Laura Khan at the 2011 International Conference on Urban Health in Belo Horizonte, Brazil: View Abstract and View Poster