Balaiah Donta

Gender-based disparities in infant and child mortality based on maternal exposure to spousal violence: The heavy burden borne by Indian girls

OBJECTIVES To examine associations between intimate partner violence (IPV) against Indian women and risk of death among their infants and children, as well as related gender-based disparities. DESIGN Analyses of nationally representative data to estimate adjusted hazard ratios (aHRs) and attributable risks for infant and child mortality based on child gender and on IPV against mothers. SETTING India. PARTICIPANTS Women aged 15 to 49 years (n = 59,467) across all 29 Indian states participating in the Indian National Family Health Survey 3 provided information about 158,439 births and about infant and child mortality occurring during the 20 years before the survey. MAIN OUTCOME MEASURES Maternal IPV and infant and child (<5 years) mortality among boy vs girl children. RESULTS Infant mortality was greater among infants whose mothers experienced IPV (79.2 of 1000 births) vs those whose mothers did not experience IPV (59.1 of 1000 births) (aHR, 1.09; 95% confidence interval [CI], 1.03-1.15); this effect was significant only for girls (1.15; 1.07-1.24; for boys, 1.04; 0.97-1.11). Child mortality was also greater among children whose mothers experienced IPV (103.6 of 1000 births) vs those whose mothers did not experience IPV (74.8 per 1000 births) (aHR, 1.10; 95% CI, 1.05-1.15); again, this effect was significant only for girls (1.14; 1.07-1.21; for boys, 1.05; 0.99-1.12). An estimated 58,021 infant girl deaths and 89,264 girl child deaths were related to spousal violence against wives annually, or approximately 1.2 million female infant deaths and 1.8 million girl deaths in India between December 1985 and August 2005. CONCLUSION Intimate partner violence against women should be considered an urgent priority within programs and policies aimed at maximizing survival of children in India, particularly those attempting to increase the survival of girls 5 years and younger.

Indian Men's Use of Commercial Sex Workers: Prevalence, Condom Use, and Related Gender Attitudes

Background/Objectives:Commercial sex represents a critical context for HIV transmission within India and elsewhere. Despite research and programmatic attention to commercial sex workers (CSWs), less is known concerning the male CSW clients considered a bridge population for HIV transmission to the general population and thought to drive demand for the sex trafficking of women and girls. The current study assesses the prevalence of past year CSW contact, condom nonuse therein, and associations with demographic characteristics and gendered attitudes among a national sample of Indian men. Methods:The nationally representative Indian National Family Health Survey-3 was conducted across all Indian states in 2005-2006; the current sample was limited to 46,961 sexually active men. Analyses calculated the prevalence of past year CSW contact and inconsistent condom use; adjusted logistic regression models were used to evaluate associations of demographic characteristics, sexual entitlement and justification of wife abuse with past year CSW contact, and inconsistent condom use. Results:Approximately 1 in 100 Indian men (0.9%) reported past year CSW contact; over half of such men reported inconsistent condom use with CSWs. CSW contact was most common among men ages 15-24 (3.6%) and never married men (9.9%). Mens CSW contact related to higher levels of sexual entitlement (adjusted odds ratio = 1.64; 95% confidence interval 1.24 to 2.17) and justification of violence against wives (adjusted odds ratio = 1.41; 95% confidence interval: 1.03 to 1.93). Conclusions:Mens past year CSW contact was concentrated among young and unmarried Indian men; condom nonuse with CSWs was common. Traditional gender ideologies seemed to support mens CSW contact, bolstering consideration of this behavior as a gendered form of HIV risk. Findings provide direction for interventions to reduce mens CSW contact in the Indian context by describing high-risk subpopulations and indicating that gender ideologies should be addressed.

Violence-Related Coping, Help-Seeking and Health Care–Based Intervention Preferences Among Perinatal Women in Mumbai, India

Domestic violence is a significant public health issue. India is uniquely affected with an estimated 1 in 3 women facing abuse at the hands of a partner. The current mixed-methods study describes violence-related coping and help-seeking, and preferences for health care—based intervention, among perinatal women residing in low-income communities in Mumbai, India. In-depth interviews were conducted with women who had recently given birth and self-reported recent violence from husbands (n = 32), followed by survey data collection (n = 1,038) from mothers seeking immunization for their infants ages 6 months or younger at 3 large urban health centers in Mumbai, India. Participants described fears and other barriers to abuse disclosure, and there was a low level of awareness of formal support services related to violence. Qualitative and quantitative findings indicated that formal help-seeking is uncommon and that informal help sources are most frequently sought. Quantitative results revealed that, while few (<5%) women had been screened for violence in the health care setting, most (67%) would be willing to disclose abuse if asked. When presented with a list of possible clinic-based violence support interventions, participants endorsed crisis counseling and safety planning as most helpful (90.9%). Findings provide direction for violence-related intervention services for perinatal women. A multipronged approach that includes strengthening the informal support system, for example, neighbors and family members, as well as facilitating access to formal services building on the health care system, warrants exploration in this context.

Availability, accessibility and promotion of smokeless tobacco in a low-income area of Mumbai

Objective To examine the role of accessibility, product availability, promotions and social norms promotion, factors contributing to the use of smokeless tobacco (ST) products in a typical low-income community of Mumbai community using Geographic Information System (GIS), observational and interview methodologies and to assess implementation of Cigatettes and other Tobacco Products Act (COTPA) legislation. Rationale In India, the third largest producer of tobacco in the world, smokeless tobacco products are used by men, women and children. New forms of highly addictive packaged smokeless tobacco products such as gutkha are inexpensive and rates of use are higher in low-income urban communities. These products are known to increase rates of oral cancer and to affect reproductive health and fetal development. Methods The study used a mixed methods approach combining ethnographic and GIS mapping, observation and key informant interviews. Accessibility was defined as density, clustering and distance of residents and schools to tobacco outlets. Observation and interview data with shop owners and community residents produced an archive of products, information on shop histories and income and normative statements. Results Spatial analysis showed high density of outlets with variations across subcommunities. All residents can reach tobacco outlets within 30–100 feet of their homes. Normative statements from 55 respondents indicate acceptance of mens, womens and childrens use, and selling smokeless tobacco is reported to be an important form of income generation for some households. Multilevel tobacco control and prevention strategies including tobacco education, community norms change, licensing and surveillance and alternative income generation strategies are needed to reduce accessibility and availability of smokeless tobacco use.

Postpartum contraception utilization among low-income women seeking immunization for infants in Mumbai, India

OBJECTIVE The objective was to examine postpartum contraception utilization among Indian women seeking immunization for their infants in three low-income communities in Mumbai, India. STUDY DESIGN We conducted a cross-sectional questionnaire of low-income postpartum women seeking immunization for their infants at three large urban health centers in Mumbai. Contraceptive utilization data were collected as part of a larger study focused on the impact of postpartum domestic violence on maternal and infant health. Descriptive, bivariate and multivariate analyses were conducted to describe and identify predictors of postpartum contraceptive utilization. RESULTS Postpartum women aged 17-45 years (N=1049) completed the survey; 44.5% (n=467) reported resuming sexual relations with their husbands. Among these women, the majority (65.3%; n=305) reported not currently using contraception. In multivariate analyses, women who did not discuss postpartum family planning with their husbands, had not used contraception previous to the recent birth, and had experienced physical violence or forced sex were more likely to not use postpartum contraception (adjusted odds ratios=1.47-1.77). Among the 162 women using contraception, the most common time to initiation of contraception was 5 weeks postpartum, and the most common method used was condoms 77.8% (n=126). CONCLUSION Contraception nonuse was common among urban, low-income postpartum women in India. This study highlights the importance of developing interventions to increase use of highly effective contraceptive methods postpartum, and that spousal violence and lack of marital communication may present barriers to postpartum contraception utilization. Infant immunization may represent an opportunity for provision of contraceptives and contraceptive counseling. IMPLICATIONS This original research study is a unique contribution to the literature because it presents data regarding the nonuse of postpartum contraception among women seeking immunizations for their infants in urban centers in a developing country. It also reveals barriers to not using postpartum contraception and provides data for future interventions.

Socio-demographic factors associated with domestic violence in urban slums, Mumbai, Maharashtra, India.

Background & objectives: Domestic violence is identified as a public heath problem. It is associated with adverse maternal health. This study examined the prevalence and determinants of domestic violence among women in urban slums of Mumbai, India. Methods: A community based cross-sectional household survey was carried out among eligible women for the study during September 2012 to January 2013. A total of 1137 currently married women aged 18-39 yr with unmet need for family planning and having at least one child were selected using cluster systematic random sampling from two urban slums. Information on socio-demographic, reproductive and domestic violence was collected through face-to-face interview using a pretested structured questionnaire after obtaining informed written consent. Bivariate and multivariate analyses were carried out to find the socio-demographic factors associated with ever experienced domestic violence among women. Results: The prevalence of women ever experiencing domestic violence in the community was 21.2 per cent. Women whose husband consumed alcohol [RR: 2.17, (95% CI: 1.58-2.98)] were significantly at an increased risk of ever experiencing domestic violence than their counterparts. Risk of domestic violence was twice [RR: 2.00, (95% CI: 1.35-2.96)] for women who justified wife beating than women who did not justify wife beating. Interpretation & conclusions: The findings showed that domestic violence was prevalent in urban slums. Factors like early marriage, working status, justified wife beating and husbands use of alcohol were significantly associated with domestic violence.

Use of smokeless tobacco by Indian women aged 18-40 years during pregnancy and reproductive years.

Objectives This paper discusses patterns of daily smokeless tobacco (SLT) use and correlates of poly SLT use among married women aged 18–40 years in a Mumbai slum community with implications for tobacco control. Methods Using a mixed methods approach, the study included a structured survey with 409 daily SLT users and in-depth interviews with 42 women. Participants for the survey were selected using a systematic sampling procedure (one woman in every fourth eligible household). Univariate and bivariate analysis, and multiple logistic regressions were conducted to identify demographic and social factors associated with women’s use of poly SLT products. To illustrate survey results, in-depth interviews were analyzed using Atlas ti software. Results Sixty-four percent of the women surveyed used only one type of SLT; of these, 30% used mishri, 32% used pan with tobacco and the rest used chewed tobacco (11%), gul (17%) or gutkha (10%). Thirty-six percent used more than one type of SLT. Poly SLT users chewed or rubbed 50% more tobacco as compared to single users (mean consumption of tobacco per day: 9.54 vs. 6.49 grams; p<0.001). Women were more likely to be poly SLT users if they were illiterate as compared to literate (adjusted odds ratio [AOR]=1.67; 95% confidence interval [CI]=1.07-2.71), if they had lived in Mumbai for 10 years or more, versus less than ten years (AOR=1.67, 95% CI=1.03-2.71); and if their husband was a poly SLT user as compared to a non SLT user (AOR=2.78, 95% CI=1.63-4.76). No differences were noted between pregnant and non-pregnant women in SLT consumption patterns. Conclusions Tobacco control policies and programs must focus specifically on both social context and use patterns to address SLT use among women of reproductive age with special attention to poly SLT users, an understudied and vulnerable population.

Awareness of cervical cancer among couples in a slum area of Mumbai.

To assess the awareness of cervical cancer among couples, data were collected from two urban slums community in Mumbai. A total of 1958 married women aged from 18 to 49 and their husbands were selected using simple random sampling. Women (37.7%) were significantly more aware of cervical cancer than husbands (8.7%). A slight agreement (kappa statistics=0.16) was observed between husbands and wives on awareness of cervical cancer. Significantly higher percentages of wives were aware of pap smear test than husbands. Overall, awareness of cervical cancer and pap smear test among couples is low. There is need to educate and motivate both of them to participate in cervical cancer screening program.

Association of Domestic Violence From Husband and Women Empowerment in Slum Community, Mumbai

Prevalence of violence by husband against wife is an indicator of women’s status at household level. The objective of the study is to understand the relationship between domestic violence and women’s empowerment in a slum community in Mumbai, India. Data were collected from a sample of 1,136 married women aged 18 to 39 years having at least one child and reporting of unmet need for family planning. Domestic violence by husband against wife was measured in terms of either physical, sexual, or emotional violence. Three logit regression analyses were carried out using decision-making power, freedom of movement, and justified wife beating as dependent variables separately and socio-demographic and economic variables as independent variables. Furthermore, the relationship between domestic violence and women’s decision-making power, freedom of movement, and justified wife-beating index has been explored. About 21% of women had ever experienced violence, and 38% of women had decision-making power with respect to own health care, household purchase, or visiting family and relatives. A little more than one fifth of the women reported freedom of movement to market, health facilities, or places outside the community. Women who justified wife beating were 2.29 (95% CI [1.59, 3.29]) times at risk of experiencing violence than women who disagreed with the wife-beating statements. Women not empowered in decision making were 1.15 (95% CI [0.91, 1.46]) times at risk of experiencing domestic violence than women who were empowered in decision making. Women who are empowered are less likely to be at risk of domestic violence. Programs aimed at empowering women must address socio-cultural norms relating to justification of violence in marriage.

Mobilising Women from a Low Income Community to Attend Cervical Cancer Screening Camps: Insights from a Study in an Urban Slum of Mumbai

Background: To increase the cervical cancer screening rate, various strategies are being conducted in the communities. The present study uses mixed interventional approach aiming to create awareness among couples about cervical cancer and Pap smear and to increase the rate of Pap smear screening. Methods: The study was carried out in collaboration with Municipal Corporation of Greater Mumbai (MCGM). The Dr Babasaheb Ambedkar Maternity Home under MCGM situated in Vikhroli, Mumbai was selected for the study. The study followed a quasi-experimental design. Women aged between 18 to 49 years and their husbands were randomly selected for the survey. Pre and post intervention survey was conducted to see the impact of intervention on creating awareness and utilization of Pap smear services. Multilevel intervention program was adopted to achieve the objectives. Results: Significant increase in awareness about cervical cancer among couples was observed from pre (5.5%) to post (97.7%) intervention survey. About 32.2% women were found to be infected with HPV. Conclusion: Mixed interventional approach is a good strategy for early diagnosis of cervical cancer.