Causes of neonatal and maternal deaths in Dhaka slums: Implications for service delivery

Background  

Bangladesh has about 5.7 million people living in urban slums that are characterized by adverse living conditions, poor access to healthcare services and health outcomes. In an attempt to ensure safe maternal, neonatal and child health services in the slums BRAC started a programme, MANOSHI, in 2007. This paper reports the causes of maternal and neonatal deaths in slums and discusses the implications of those deaths for Maternal Neonatal and Child Health service delivery.     

Human rights and reproductive health: political realities and pragmatic choices for married adolescent women living in urban slums,Bangladesh

Background

In Bangladesh, particularly in urban slums, married adolescent women’s human rights to life, health, and reproductive and sexual health remain adversely affected because of the structural inequalities and political economic, social and cultural conditions which shape how rights are understood, negotiated and lived.

Methods

The focus of the research and methods was anthropological. An initial survey of 153 married adolescent women was carried out and from this group, 50 in-depth interviews were conducted with selected participants and, from the in-depth interviews, a further eight case studies of women and their families were selected for in-depth repeated interviews and case histories.

Results

This paper speaks of the unanticipated complexities when writing on reproductive rights for poor adolescent women living in the slums, where the discourses on ‘universal human rights’ are often removed from the reality of adolescent women’s everyday lives. Married adolescent women and their families remain extremely vulnerable in the unpredictable, crime-prone and insecure urban slum landscape because of their age, gender and poverty. Adolescent women’s understanding of their rights such as the decision to marry early, have children, terminate pregnancies and engage in risky sexual behaviour, are different from the widely accepted discourse on rights globally, which assumes a particular kind of individual thinking and discourse on rights and a certain autonomy women have over their bodies and their lives. This does not necessarily exist in urban slum populations.

Conclusions

The lived experiences and decisions made pertaining to sexual and reproductive health and ‘rights’ exercised by married adolescent women, their families and slum communities, allow us to reflect on the disconnect between the international legal human rights frameworks as applied to sexual and reproductive health rights, and how these are played out on the ground. These notions are far more complex in environments where married adolescent women and their families live in conditions of poverty and socioeconomic deprivation.

     

Prevalence and correlates of smoking among urban adult men in Bangladesh: slum versus non-slum comparison

Background  

Smoking is one of the leading causes of premature death particularly in developing countries. The prevalence of smoking is high among the general male population in Bangladesh. Unfortunately smoking information including correlates of smoking in the cities especially in the urban slums is very scarce, although urbanization is rapid in Bangladesh and slums are growing quickly in its major cities. Therefore this study reported prevalences of cigarette and bidi smoking and their correlates separately by urban slums and non-slums in Bangladesh.     

Security lies in obedience - Voices of young women of a slum in Pakistan

Background  

Existing literature shows that young people, especially women, have poor knowledge about sexuality and reproductive health. Many of the difficulties young women experience are related to beliefs and expectations in society making them more vulnerable to reproductive ill health. The objective of this study was to explore how young women living in a slum in Islamabad are prepared for marriage and how they understand and perceive their transition to marriage and the start of sexual and childbearing activity.     

Slums and Malnourishment: Evidence From Women in India

Objectives. We examined the association between slum residence and nutritional status in women in India by using competing classifications of slum type.Methods. We used nationally representative data from the 2005–2006 National Family Health Survey (NFHS-3) to create our citywide analysis sample. The data provided us with individual, household, and community information. We used the body mass index data to identify nutritional status, whereas the residential status variable provided slum details. We used a multinomial regression framework to model the 3 nutrition states—undernutrition, normal, and overnutrition.Results. After we controlled for a range of attributes, we found that living in a census slum did not affect nutritional status. By contrast, living in NFHS slums decreased the odds of being overweight by 14% (95% confidence interval [CI] = 0.79, 0.95) and increased the odds of being underweight by 10% (95% CI = 1.00, 1.22).Conclusions. The association between slum residence and nutritional outcomes is nuanced and depends on how one defines a slum. This suggests that interventions targeted at slums should look beyond official definitions and include current living conditions to effectively reach the most vulnerable.More than 50% of the world population was classified as urban for the first time in 2009 and is expected to reach around 69% in 2050.1 The proportion of the urban population in the developing world is expected to increase from 45% to 66% during the same period. One of the immediate consequences of population pressure in urban spaces is the growth of slums or urban communities that are characterized by poor access to civic services, inadequate housing, and overcrowding.2 It has been estimated that slum populations would double before 2035 in the low- and middle-income countries.3One of the main concerns regarding the growth of slum populations is that the living conditions of the slum dwellers could become a public health issue. The attention gained by the relation between poor health outcomes and living conditions is neither new nor restricted to the developing world. As early as the 19th century, the Public Health Acts of Britain aimed to improve water systems and sanitation facilities in slums.2 This was also true of other developed countries—notably, France and the United States—which attempted to regulate residential dwellings to contain the spread of disease among other things.Although the pace of urbanization in India historically has been slow, it is increasing rapidly. India’s urban population grew by about 230 million between 1971 and 2008, and it is estimated that 250 million more will swell the urban population within the next 2 decades.4 This urban growth has led to a population explosion in cities, and India boasts of 2 cities with a population of at least 10 million (Delhi and Mumbai).Literature from the developing world suggests that both communicable and noncommunicable diseases are a major concern for urban populations, particularly the slum populations. Already malnourished slum dwellers may experience additional stress because of overcrowding and poor living conditions and are more likely to have poor health outcomes. However, India-specific research findings paint a mixed picture. A study on urban slums in Maharashtra in 1999 indicated that women living in slums were more disadvantaged with respect to antenatal care than were women not living in slums.5 This was reaffirmed by another study that compared the health status of poor populations in slums and in resettlement colonies in Delhi and Chennai and found that slum dwellers had worse health outcomes than those in resettlement colonies.6 Recent research in Chandigarh that used primary data collected in 2006 showed that immunization status of children younger than 5 years was poorer in slum areas than in the rural and urban areas.7 In contrast, a 2005–2006 National Family Health Survey (NFHS-3) report suggested that slum residents were not necessarily worse off than nonslum residents on several deprivation dimensions including poor health.8 These studies have used prevalence rates of all illnesses, morbidity rates, incidence of hospitalization, and other health indicators as various proxies of health status.Our study examined the distribution of women’s malnutrition in 8 cities across slum and nonslum populations. Malnutrition is a significant problem among Indian women. According to several studies that used the NFHS-3, only 52% of the women were within the normal weight range for a given height.8,9 Following the World Health Organization, we defined malnutrition to include the dual burden of undernutrition and overnutrition. Until recently, attention has been exclusively focused on undernutrition. However, recent trends indicate that Indian women are facing a double burden of malnutrition because of the increasing prevalence of overnutrition largely caused by changing lifestyle and diet patterns.10Being underweight could affect productivity and pose health risks, particularly for women, by increasing the likelihood of negative maternal health outcomes, including low-birth-weight infants.11 However, being overweight also could lead to poor health outcomes because of the increased risk of diabetes, cardiovascular diseases, hypertension, and respiratory-related mortality.12Figures 1 and ​and22 show the prevalence of underweight and overweight women, respectively, in 8 cities in India by slum residence status. Women residing in nonslum areas were more likely to be overweight, whereas those residing in slum areas were more likely to be underweight. In cities such as Delhi, these gaps appear to be large, with 36% being overweight in nonslum areas as opposed to 26% in slum areas; in Indore, 38% were undernourished in slums, but only 28% appear to be undernourished in nonslum areas. These numbers suggest that undernutrition is a larger problem in slums, and overnutrition is mainly a nonslum problem. Therefore, slums could be used as a valid unit to study undernutrition-related policies, and nonslum areas could be used to study overweight-related problems.Open in a separate windowFIGURE 1—Distribution of underweight women in 8 cities in India by slum status: 2005–2006 National Family Health Survey (NFHS-3).Note. Prevalence was calculated with 2005–2006 NFHS-3 data that were weighted with the provided weights. The prevalence ratios were calculated as follows: the numerator is the number of people who have body mass index (BMI) < 18.5 kg/m², and the denominator is those with normal weight (BMI = 18.5–24.99 kg/m²). The slum variable includes both census-defined slums and those identified as slums by NFHS field staff.Open in a separate windowFIGURE 2—Distribution of overweight women in 8 cities in India by slum status: 2005–2006 National Family Health Survey (NFHS-3).Note. Prevalence was calculated with 2005–2006 NFHS-3 data that were weighted with the provided weights. The prevalence ratios were calculated as follows: the numerator is the number of people who have body mass index (BMI) ≥ 25 kg/m², and the denominator is those with normal weight (BMI = 18.5–24.99 kg/m²). The slum variable includes both census-defined slums and those identified as slums by NFHS field staff.However, such differences in prevalence may be attributed to differences in the configuration of infrastructure, socioeconomic and other amenities that distinguish a slum from a nonslum area, or individual characteristics between those who live in slums and those who live in nonslum areas. Individual differences tend to matter more for malnutrition outcomes than do slum characteristics.     

Using formative research to develop MNCH programme in urban slums in Bangladesh: experiences from <Emphasis Type="Italic">MANOSHI</Emphasis>, BRAC

Background  

MANOSHI, an integrated community-based package of essential Maternal, Neonatal and Child Health (MNCH) services is being implemented by BRAC in the urban slums of Bangladesh since 2007. The objective of the formative research done during the inception phase was to understand the context and existing resources available in the slums, to reduce uncertainty about anticipated effects, and develop and refine the intervention components.     

All Slums are Not Equal: Maternal Health Conditions Among Two Urban Slum Dwellers

Background:

Pregnant women inhabiting urban slums are a “high risk” group with limited access to health facilities. Hazardous maternal health practices are rampant in slum areas. Barriers to utilization of health services are well documented. Slums in the same city may differ from one another in their health indicators and service utilization rates. The study examines whether hazardous maternal care practices exist in and whether there are differences in the utilization rates of health services in two different slums.

Materials and Methods:

A cross-sectional study was carried out in two urban slums of Aligarh city (Uttar Pradesh, India). House-to-house survey was conducted and 200 mothers having live births in the study period were interviewed. The outcome measures were utilization of antenatal care, natal care, postnatal care, and early infant feeding practices. Rates of hazardous health practices and reasons for these practices were elicited.

Results:

Hazardous maternal health practices were common. At least one antenatal visit was accepted by a little more than half the mothers, but delivery was predominantly home based carried out under unsafe conditions. Important barriers to utilization included family tradition, financial constraints, and rude behavior of health personnel in hospitals. Significant differences existed between the two slums.

Conclusion:

The fact that barriers to utilization at a local level may differ significantly between slums must be recognized, identified, and addressed in the district level planning for health. Empowerment of slum communities as one of the stakeholders can lend them a stronger voice and help improve access to services.     

Prevalence,Awareness, Treatment and Control of Diabetes Among Elderly Persons in an Urban Slum of Delhi

Background:

The increasing proportion of elderly persons is contributing to an increase in the prevalence of diabetes. The residents of urban slums are more vulnerable due to poverty and lack of access to health care.

Objective:

To estimate the prevalence of diabetes in elderly persons in an urban slum and to assess their awareness, treatment and control of this condition.

Materials and Methods:

All persons aged 60 years and above, residing in an urban slum of Delhi, were included in this cross-sectional community- based study. Data were collected on sociodemographic variables. The participants’ awareness and treatment of diabetes was recorded. Their fasting blood sugar was estimated using an automated glucometer. Diabetes was diagnosed if fasting blood glucose was ≥126 mg/dL, or if the participant was taking treatment for diabetes. Impaired fasting blood glucose was diagnosed if fasting blood glucose was 110–125 mg/dL.

Results:

Among the 474 participants studied, the prevalence of diabetes was estimated to be 18.8% (95% CI 15.3–21.5). It decreased with increasing age, and was higher among women. The prevalence of impaired fasting blood glucose was 19.8% (95% CI 16.3–23.7). It was higher among women. One-third of the diabetic participants were aware of their condition; two-thirds of these were on treatment and three-fourths of those on treatment had controlled fasting blood sugar level. The awareness, treatment and control were better among women.

Conclusions:

Diabetes is common among elderly persons in urban slums. Its magnitude and low awareness warrant effective public health interventions for their treatment and control.     

The burden of disease profile of residents of Nairobi's slums: Results from a Demographic Surveillance System

Background  

With increasing urbanization in sub-Saharan Africa and poor economic performance, the growth of slums is unavoidable. About 71% of urban residents in Kenya live in slums. Slums are characteristically unplanned, underserved by social services, and their residents are largely underemployed and poor. Recent research shows that the urban poor fare worse than their rural counterparts on most health indicators, yet much about the health of the urban poor remains unknown. This study aims to quantify the burden of mortality of the residents in two Nairobi slums, using a Burden of Disease approach and data generated from a Demographic Surveillance System.     

Strategies to Reduce Exclusion among Populations Living in Urban Slum Settlements in Bangladesh

The health and rights of populations living in informal or slum settlements are key development issues of the twenty-first century. As of 2007, the majority of the world''s population lives in urban areas. More than one billion of these people, or one in three city-dwellers, live in inadequate housing with no or a few basic resources. In Bangladesh, urban slum settlements tend to be located in low-lying, flood-prone, poorly-drained areas, having limited formal garbage disposal and minimal access to safe water and sanitation. These areas are severely crowded, with 4–5 people living in houses of just over 100 sq feet. These conditions of high density of population and poor sanitation exacerbate the spread of diseases. People living in these areas experience social, economic and political exclusion, which bars them from society''s basic resources. This paper overviews policies and actions that impact the level of exclusion of people living in urban slum settlements in Bangladesh, with a focus on improving the health and rights of the urban poor. Despite some strategies adopted to ensure better access to water and health, overall, the country does not have a comprehensive policy for urban slum residents, and the situation remains bleak.Key words: Informal settlements, Social exclusion, Slums, Slum settlements, Urban health, Bangladesh     

General Morbidity Prevalence in the Delhi Slums

Research Question:

What is the sickness prevalence in the slums of a metropolitan city?

Objectives:

To estimate the morbidity prevalence with reference to a socio-economic and demographic perspective of the slum population of Delhi.

Study Design:

A cross-sectional study was conducted and data were collected by a two-stage random sampling method. In the first stage, slum locations were selected and in the second stage households were selected.

Participants:

Data were collected from 1049 households consisting of 5358 individuals'' information.

Results:

The overall morbidity prevalence is 15.4%. It is 14.7 and 16.3% for males and females, respectively but the differences are not statistically significant. The reported higher morbidity prevalence and the illiteracy status are significantly associated. Diseases of the respiratory system appear to be very high among slum dwellers.

Conclusion:

From this study, it can be concluded that the number of years of staying in the slum area, presence of a separate kitchen, type of house, it being Pucca or Kuccha, types of toilet pits or open defecation are the important environmental factors for the reports of higher morbidity patterns from the slum area.     

Pregnant women's and community health workers' perceptions of root causes of malnutrition among infants and young children in the slums of Dhaka, Bangladesh

Research in Bangladesh shows that malnutrition among infants and young children is most severe in urban slums. We examined the root causes of malnutrition as perceived by pregnant women and community health workers. We conducted 10 focus group discussions in the slums of Dhaka in 2008 and 2009. Participants accurately perceived inappropriate care, inappropriate environment, inappropriate food, and flooding to be major causes. Recurrent flooding has not traditionally been identified by experts as a cause of malnutrition. We recommend further research to address the nutritional risks flooding creates for vulnerable slum populations.     

Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in Kenya

In 2008, the global urban population surpassed the rural population and by 2050 more than 6 billion will be living in urban centres. A growing body of research has reported on poor health outcomes among the urban poor but not much is known about HIV prevalence among this group. A survey of nearly 3000 men and women was conducted in two Nairobi slums in Kenya between 2006 and 2007, where respondents were tested for HIV status. In addition, data from the 2008/2009 Kenya Demographic and Health Survey were used to compare HIV prevalence between slum residents and those living in other urban and rural areas. The results showed strong intra-urban differences. HIV was 12% among slum residents compared with 5% and 6% among non-slum urban and rural residents, respectively. Generally, men had lower HIV prevalence than women although in the slums the gap was narrower. Among women, sexual experience before the age of 15 compared with after 19 years was associated with 62% higher odds of being HIV positive. There was ethnic variation in patterns of HIV infection although the effect depended on the current place of residence.     

Women’s Reproductive Health in Slum Populations in India: Evidence From NFHS-3

The urban population in India is one of the largest in the world. Its unprecedented growth has resulted in a large section of the population living in abject poverty in overcrowded slums. There have been limited efforts to capture the health of people in urban slums. In the present study, we have used data collected during the National Family Health Survey-3 to provide a national representation of women’s reproductive health in the slum population in India. We examined a sample of 4,827 women in the age group of 15–49 years to assess the association of the variable slum with selected reproductive health services. We have also tried to identify the sociodemographic factors that influence the utilization of these services among women in the slum communities. All analyses were stratified by slum/non-slum residence, and multivariate logistic regression was used to analyze the strength of association between key reproductive health services and relevant sociodemographic factors. We found that less than half of the women from the slum areas were currently using any contraceptive methods, and discontinuation rate was higher among these women. Sterilization was the most common method of contraception (25%). Use of contraceptives depended on the age, level of education, parity, and the knowledge of contraceptive methods (p < 0.05). There were significant differences in the two populations based on the timing and frequency of antenatal visits. The probability of ANC visits depended significantly on the level of education and economic status (p < 0.05). We found that among slum women, the proportion of deliveries conducted by skilled attendants was low, and the percentage of home deliveries was high. The use of skilled delivery care was found to be significantly associated with age, level of education, economic status, parity, and prior antenatal visits (p < 0.05). We found that women from slum areas depended on the government facilities for reproductive health services. Our findings suggest that significant differences in reproductive health outcomes exist among women from slum and non-slum communities in India. Efforts to progress towards the health MDGs and other national or international health targets may not be achieved without a focus on the urban slum population.     

Childhood vaccination in informal urban settlements in Nairobi,Kenya: Who gets vaccinated?

Background  

Recent trends in global vaccination coverage have shown increases with most countries reaching 90% DTP3 coverage in 2008, although pockets of undervaccination continue to persist in parts of sub-Saharan Africa particularly in the urban slums. The objectives of this study were to determine the vaccination status of children aged between 12-23 months living in two slums of Nairobi and to identify the risk factors associated with incomplete vaccination.     

Prevalence and determinants of the cleanliness of shared toilets in Kampala slums, Uganda

Aim

Keeping shared toilets clean is a key public health challenge household users face in urban slum settlements of most developing countries. This paper provides insights on the cleanliness of households’ shared toilets and the factors that influence their cleanliness, as well as influencing the inclination of the users to keep them clean.

Subjects and methods

This analysis is part of a cross-sectional study conducted in 50 randomly selected slums in Kampala, Uganda between October and November 2010. A total of 1,500 respondents were interviewed, using a semi-structured questionnaire.

Results

Out of 1,019 respondents using shared toilets, less than 12 % reported having very clean toilets. Some of the significant factors influencing the cleanliness of shared toilets are: the ease or difficulty in keeping shared toilets clean, the number of households sharing a toilet room, effortful cleaning behaviour and cleaning intention on the part of the users.

Conclusion

The findings show that most slum dwellers use toilets that are not hygienic.     

Urban health: people living below the poverty line

Available data indicate that levels of urban poverty in India are increasing, while rural poverty is decreasing. Given the difficulty of accurately estimating the size of the poor and slum populations residing in urban areas, it is also difficult to assess the health and nutritional status of such populations. In 1991, 28% of the estimated 20 million people living in 23 major metropolitan areas lived in slums. 39-43% of India's slum population is distributed between Calcutta, Mumbai, Delhi, and Chennai. India must rise to the challenge of providing primary health care to millions of slum dwellers. Based upon the current urban growth rate, the Task Force of the National Institute of Urban Affairs has projected that by 2000, 62-78 million people will reside in India's slums, of an estimated 310 million person urban population. The health status of the urban poor is influenced by urban economies, urbanization, and urban environments. These factors are discussed, followed by consideration of the major health problems among the urban poor, the urban health care delivery system, and recommendations for a better urban health.     

Local population and regional environmental drivers of cholera in Bangladesh

Background  

Regional environmental factors have been shown to be related to cholera. Previous work in Bangladesh found that temporal patterns of cholera are positively related to satellite-derived environmental variables including ocean chlorophyll concentration (OCC).