The Mahila Jagat Lihaaz Samiti (Majlis) or Society for Respect for Women and the Earth, a collective of Dalit and Adivasi women organising action for the rights of women and environmental conservation, has initiated a programme of gynaecological health camps for women residing in slums in the city of Indore in Madhya Pradesh. The programme consists of a preliminary baseline survey to assess the felt needs of the women regarding their reproductive and gynaecological health and the various barriers they face to achieving a healthy status. While this survey is conducted, discussions are also held about these barriers to health and the offer is made from Majlis of holding a health camp which is to include clinical checkups by gynaecologists, laboratory tests and provision of medicine, all done free of cost to the women. After this a first health camp is held and then a follow up one fifteen days later. This whole process takes a month in one slum.
Even though all girls and women who are menstruating and those who have had menopause are provided diagnosis and treatment, for the purposes of research, only married women who are still in the menstrual age group are considered. The preliminary results of the intervention for the first 150 women to benefit from the programme are described here in brief. They show the devastating status of women's health in the slums in Indore and the cost effective way in which a well designed programme can bring about substantial improvement in the situation.
The initial part provides a comparison between the National Family Health Survey IV 2015-16 (International Institute of Population Sciences, Mumbai, 2016) data for urban areas of Madhya Pradesh and that from the Majlis sample to situate the latter in the larger context of the state.
While the sex ratio is better in the Majlis sample than in the NFHS IV sample, the literacy and education levels are much poorer for the Majlis sample and the proportion of women in the 20-24 year age group who have been married before reaching the legal age of 18 years is more than double and this affects the reproductive health of women adversely. Thus, overall the Majlis sample has a worse demographic profile than the NFHS IV.
The NFHS IV sample has a higher proportion of households with a Good Drinking water source and clean fuel while the proportion of households with good sanitation is almost the same for both samples and so in the case of these indicators also the Majlis sample overall has a worse situation than the NFHS IV sample. Especially noteworthy is the very poor situation in the slums in Indore with regard to water supply which is a major cause of ill health. The Majlis sample has much poorer values for all the indicators with the economic values of out of pocket delivery expense and cash support under JSY being particularly disadvantageous.
Anaemia due to factors like overwork and malnutrition are the bane of women in India and there is an epidemic of Vitamin B12 deficiency which directly contributes to anaemia. The Majlis sample has an alarming proportion of 76.4 % women who are anaemic much more than the NFHS IV sample. While many women suffer from gynaecological problems and especially erosion of the cervix, very few ever get themselves checked up by gynaecologists. The Majlis sample had only 4.1 % women who had had their cervix examined and these were all those who had had hysterectomies. While with regard to owning of house and having bank accounts the Majlis sample is more or less on par with the NFHS IV sample, the situation with regard to suffering spousal violence and the use of sanitary napkins is much worse for the Majlis sample.
Thus, overall the women who have been chosen for the gynaecological health programme by Majlis are in a very disadvantageous situation as compared to the NFHS IV survey results, which themselves paint a very sorry picture of the status of women's health in urban areas of Madhya Pradesh. Therefore the implementation of the current programme by Majlis is eminently justified.
During the preliminary survey the women were asked whether they were suffering from any of twenty specific women's health problems that most commonly afflict women. 92.6 per cent of the women reported reproductive health problems with an average of three different complaints per woman, with some having as many as ten complaints. 96.3 percent of the women said that this was the first time they were revealing their gynaecological problems to anyone as they did not feel that they could speak about them to anyone.
Proportion of women who complained of dizziness is very high at 64.9 percent which correlates well with the proportion of women who were tested and found to be anaemic which is 76.4 percent. A very high proportion of 71.6 percent of women complained of waist pains which generally arise from a combination of anaemia, overwork and problems of the reproductive tract. The proportion of women reporting vaginal problems which mostly arise from lack of menstrual hygiene was 44.7 percent which correlates well with the proportion of women who use cloth washed and dried in the shade during periods which is 59.5 percent. A very high proportion of 49.9 percent of the women reported having menstrual problems which too arise mostly from a combination of anaemia, overwork and lack of menstrual hygiene.
A very high proportion of 67.6 percent of the women suffered from cervical problems like erosions and cysts and as much as 30 percent had serious problems requiring cauterisation and repeated medication. This is something that the women did not know about at all as they had never had their cervix examined by a gynaecologist. Many of these women also had vaginal problems and on the whole 49.1 percent of women were suffering from these. The proportion of women with urinary tract and menstrual problems was less than what they had reported in the survey because at the time of clinical examination they were not suffering from these problems which they do from time to time only.
Clinical diagnosis and laboratory testing of blood and urine samples are quite costly if done individually but since these were done in bulk, the costs came down by as much as 60 percent. Similarly medication for cervical and vaginal problems is quite costly if branded medicines are used. However, generic medicines were used in the camps and sourced at wholesale rates through bulk purchase and so the medicine costs were only about 15 percent of the retail value of branded drugs. All the women were cured of their problems over the month's time in which they were diagnosed and treated. Some required hospital procedures such as cauterisation. There was one woman who had stitches in her vagina which had not been removed after delivery a few years ago. She was repeatedly complaining of pain in her vagina but had never visited a gynaecologist afterwards. Some women had to be given intravenous iron drips as they were highly anaemic.
Clearly, the women had poor gynaecological health mainly due to inability to articulate their problems and get access to good reproductive and sexual health services and prevalence of malnutrition and overwork, which are all due to a combination of poverty and patriarchal oppression.
We have already seen that there is a high level of gender based violence. The survey also revealed that other indicators of women's disempowered status were equally bad -
The gender division of labour is highly skewed for this sample with 81.8 percent of women doing all domestic work. The proportion of women who said that their men decided when to have sex and they had no say in the matter was very high at 90.4 percent. The proportion of women who had some knowledge of governnment schemes favouring women was only 31.8 percent. The proportion of women with knowledge of the Prevention of Domestic Violence Act was only 33.8 percent.
Meetings were held with the men also as without their cooperation, the women would fall back into ill health. In many cases the bacteria, fungi and viruses that cause vaginal infections in women are there in the penises of men also but do not affect them. Thus, it is necessary for the men also to take the medicines so that both are disinfected. These meetings with the men revealed that they too were unaware of the complexities of the reproductive tract problems of the women. In some cases the men were themselves suffering from infections of the penis but were too shy to go to a doctor for treatment. Thus, these meetings served the purpose of raising the awareness levels of the men.
The total cost of the month long intervention in one slum including the preliminary survey, the clinical diagnosis, laboratory tests, medication and documentation and analysis is Rs 50,000 catering to about 60 women. Thus, for an average cost of about Rs 800 per woman, complete diagnosis, testing and curative treatment is provided which would have cost the women at least Rs 3000 if they had tried to do it individually. Moreover, in most cases, the women do not have access to gynaecologists for their own problems even if they have the money due to lack of awareness. This programme of Majlis is consequently not only very essential but also a high impact one. The programme is financed by individual donors through crowd funding on the internet and thus provides for flexibility and innovation in its implementation.
The question naturally arises as to why the Government, which can get the clinical diagnosis, laboratory tests and the medicine at even cheaper rates than an NGO like Majlis, isn't providing this important service to the women. The survey revealed that let alone provide these gynaecological services, it is not even providing properly the safe motherhood services which are such an integral part of its family welfare agenda. Gynaecological health problems lead to both economic loss through inability to work and mental stress due to illness. An adverse gender division of labour, lack of sexual rights and domestic violence further queer the pitch for most women. Under the circumstances a more effective Government programme of reproductive health and women's empowerment would reap huge benefits in terms of economic and social progress for the society.