UTILIZATION OF MATERNAL HEALTH SERVICES AMONG INTERNAL MIGRANTS IN MUMBAI, INDIA

Temporary childbirth migration and maternal health care in India

BACKGROUND

Women in South Asia often return to their natal home during pregnancy, for childbirth, and stay through the postpartum period-potentially impacting access to health care and health outcomes in this important period. However, this phenomenon is understudied (and not even named) in the demographic or health literature, nor do we know how it impacts health.

OBJECTIVE

The aim of this study is to measure the magnitude, timing, duration, risk factors and impact on care of this phenomenon, which we name Temporary Childbirth Migration.

METHODS

Using data from 9,033 pregnant and postpartum women collected in 2019 in two large states of India (Madhya Pradesh and Bihar) we achieve these aims using descriptive statistics and logistic regression models, combined with qualitative data from community health workers about this practice.

RESULTS

We find that about one third of women return to their natal home at some point in pregnancy or postpartum, mostly clustered close to the time of delivery. Younger, primiparous, and non-Hindu women were more likely to return to their natal home. Women reported that they went to their natal home because they believed that they would receive better care; this was born out by our analysis in Bihar, but not Madhya Pradesh, for prenatal care.

CONCLUSIONS

Temporary childbirth migration is common, and, contrary to expectations, did not lead to disruptions in care, but rather led to more access to care.

CONTRIBUTION

We describe a hitherto un-named, underexplored yet common phenomenon that has implications for health care use and potentially health outcomes.

Health care access and migration experiences among Venezuelan female sex workers living in the Dominican Republic

Objective

To identify sexual risk behaviors and barriers to sexual and reproductive health care (SRH) among Venezuelan female sex workers living in the Dominican Republic.

Methods

This was a mixed-methods study using four focus group discussions (FGDs) and a cross-sectional quantitative survey with Venezuelan migrant female sex workers. The study was conducted from September through October 2021 in two urban areas (Santo Domingo and Puerto Plata) in the Dominican Republic. Information collected from the FGDs was analyzed using thematic content analysis, and quantitative data were analyzed using univariate descriptive statistics. Data analysis was conducted from 30 November 2021 to 20 February 2022.

Results

In all, 40 Venezuelan migrant female sex workers with a median (range) age of 33 (19-49) years participated in the FGDs and survey. The FDGs identified barriers to SRH services, including immigration status and its implications for formal employment and health access, mental wellbeing, quality-of-life in the Dominican Republic, navigating sex work, perceptions of sex work, SRH knowledge, and limited social support. Findings of the quantitative analysis indicated that most participants reported feeling depressed (78%), lonely/isolated (75%), and having difficulty sleeping (88%). Participants reported an average of 10 sexual partners in the past 30 days; 55% had engaged in sexual practices while under the influence of alcohol; and only 39% had used a condom when performing oral sex in the past 30 days. Regarding AIDS/HIV, 79% had taken an HIV test in the past 6 months, and 74% knew where to seek HIV services.

Conclusions

This mixed-methods study found that nationality and social exclusion have a multilayered influence on migrant female sex workers, sexual risk behaviors, and access to health care. Recommendations for effective evidence-based interventions to address sexual health knowledge need to be implemented to address risky sexual behaviors, improve access to SRH, and reduce affordability barriers.

Health service behaviors of migrants: A conceptual framework

Universal health coverage is vital to the World Health Organization's (WHO's) efforts to ensure access to health as a human right. However, it has been reported that migrants, including both international immigrants and internal migrants, underuse health services. Establishing a conceptual framework to facilitate research on the health service behaviors (HSB) of migrants is particularly important. Many theoretical frameworks explaining the general population's HSB have been published; however, most theoretical frameworks on migrants' HSB only focus on international immigrants without the inclusion of internal migrants. Of note, internal migrants are much more abundant than immigrants, and this group faces similar barriers to HSB as immigrants do. Based on theoretical frameworks of immigrants' HSB and Anderson's behavior model, the author proposes a new conceptual framework of migrants' HSB that includes both immigrants and internal migrants. The new conceptual framework divides the determinants into macro-structural or contextual factors, health delivery system characteristics, and characteristics of the population at risk and describes subgroup-specific factors. The author added some variables and reclassified variables in some dimensions, including characteristics of health delivery systems and access to healthcare. The characteristics of health delivery systems comprise the volume, organization, quality, and cost of the health delivery system, while the characteristics of access to healthcare include time accessibility, geographic accessibility, and information accessibility. The outcomes of HSB have been expanded, and relationships between them have been reported. The mediating effects of some variables have also been described. This conceptual framework can facilitate a deep and comprehensive understanding of the HSB determination process for migrants, including internal migrants.

Health Workers’ Perceptions about Maternal and Adolescent Health among Marginalized Populations in India: A Multi-Centric Qualitative Study

Frontline workers are instrumental in bridging the gap in the utilization of maternal health services. We performed a qualitative cross-sectional study with medical officers, accredited social health activists (ASHA), and auxiliary nurse midwifes (ANM), across 13 districts of India, in order to understand the barriers and enablers, at the system and population levels, for improving access of adolescents and mothers to services. The data were collected by means of in-depth interviews (IDI) with medical officers and focus group discussions (FGD) with ASHA and ANM in 2016. The interview guide was based on the conceptual framework of WHO health interventions to decrease maternal morbidity. Content analysis was performed. In total, 532 frontline workers participated in 52 FGD and 52 medical officers in IDI. Adolescent clinics seemed nonexistent in most places; however, services were provided, such as counselling, iron tablets, or sanitary pads. Frontline workers perceived limited awareness and access to facilities among women for antenatal care. There were challenges in receiving the cash under maternity benefit schemes. Mothers-in-law and husbands were major influencers in women’s access to health services. Adolescent clinics and antenatal or postnatal care visits should be seen as windows of opportunities for approaching adolescents and women with good quality services.

Assessment of Squalor in Migrant Colonies of Thiruvalla Province of Kerala, India using Rapid Survey Technique

Background:

Domestic squalor refers to households that are extremely cluttered, in a filthy condition, and where the accumulation of items such as personal possessions, rubbish, excrement and decomposing food creates an environment that jeopardizes the health and wellbeing of the occupant(s). In India, an estimated 258 million are migrants. They are more likely to live in squalor due to inferior socio-economic status and no permanent residence. This poses a threat to the health of the migrants and the neighbors.

Objective:

To assess the squalor and morbidity pattern among the migrants of Migrant colonies in Thiruvalla using Rapid survey technique.

Methodology:

The state of squalor in migrant colonies was assessed by Lot Quality Assurance Sampling Methodology using the Environment Cleanliness and Clutter Scale (ECCS). The sample size for each lot/colony was '14' dwellings according to LQAS table. The details were collected from 14 inhabitants of different dwellings of the same colony. The inhabitants were selected randomly and were excluded if he belonged to the same dwelling. Fifteen colonies were randomly selected to achieve the sample size of 210 (15*14). The study was done in Tiruvalla municipality.

Results and Conclusion:

Only two colonies (n = 15) were squalor free. Majority of the dwellings (n = 210) were having an ECCS score between 13 and 15. Common ailments affecting migrants include Common cold, Skin disorders, and dental caries and gastritis. Squalor was found in most of the migrant colonies as they are living in inhuman conditions.

The Association between Social Integration and Utilization of Essential Public Health Services among Internal Migrants in China: A Multilevel Logistic Analysis

This study investigated the association between social integration and utilization of essential public health services among internal migrants. Data were from the 2017 China Migrants Dynamic Survey. Social integration was measured through four dimensions: economic integration, structural integration, sociocultural adaptation, and self-identity. Multilevel logistic regressions were used taking into account heterogeneity in the level of regional development. The utilization of health records and health education was less than 40% and varied widely across regions. Social integration was related to a higher likelihood of utilization of health records and health education. Moreover, sociocultural adaptation had a stronger effect on the utilization of health records in developed regions than in developing regions, and structural integration was strongly and positively related to the utilization of health education in developed regions. Hence, it appears that the relationship of some dimensions of social integration and utilization of essential public health services is moderated by the level of economic development. Promoting structural integration and sociocultural adaptation could strongly improve utilization of essential public health services in developed regions.

Association of Time since Migration from Rural to Urban Slums and Maternal and Child Outcomes: Dhaka (North and South) and Gazipur City Corporations

This study analyzes data from a new Urban Health and Demographic Surveillance (UHDSS) in five slums in Dhaka (North and South) and Gazipur City Corporations to examine the relationship between migration status and maternal and child health service utilization. Migration status was determined by duration in urban slums (<= 9.99 years, 10-19.99 years, 20+ years, and urban-born). Compared to those born in the city, migrants were characterized by significant disadvantages in every maternal, neonatal, and child health (MNCH) indicator under study, including antenatal care, facility-based delivery, doctor-assisted delivery, child immunization, caesarean-section delivery, and use of modern contraceptives. We found that the level of service coverage among migrants gradually converged-but did not fully converge-to that of the urban-born with increasing duration in the city. We observed a strong positive association between wealth and total MNCH coverage, with a more modest association with higher levels of schooling attainment. Women who were engaged in market employment were less likely to receive adequate coverage, suggesting a tradeoff between livelihood attainment and mother-and-child health. After controlling for these socioeconomic and neighborhood variations in coverage, the duration gradient was diminished but still significant. In line with existing studies of healthcare access, this study highlights the persistent and widespread burden of unequal access to maternal and child health care facing migrants to slum areas, even relative to the overall disadvantages experienced in informal settlements.

Quality of life among migrant construction workers in Bangalore city: A cross-sectional study

Context

The construction industry is one of the oldest industries in India, which employs a large number of workers of poor socioeconomic status. Bangalore has seen significant rise in the number of migrants from various parts of the country to work in construction industry. These workers suffer from lack of good accommodation, basic sanitation, health facilities, stressful working conditions, and poor social life. Quality of life (QoL) among a population is an essential step to understand and improve health status, well-being, and mental health of the population.

Materials and Methods

A cross-sectional study was done to assess QoL among migrant construction workers in Bangalore. We interviewed 400 workers using questionnaire containing sociodemographic profile and WHOQOLBREF scale. Factors associated with QoL were tested using independent "t" test and Chi-square test and P < 0.05 was considered as statistically significant.

Results

The mean age of the workers was 26.38 + /4.3 years and majority of them were men (95.2%). The smokers had higher mean score in psychological domain with a significant P value. Those who lived in huts had higher mean score (60.4+/9.71) in the social domain as compared with those who lived in pucca houses (59.7 + /12.5). Those who were married, worked as nonlaborers, lived in pucca houses, earned higher income had higher mean scores in the environmental domain compared with those who were unmarried, laborers, lived in huts, and earned lower income.

Conclusion

Migrant construction workers had poor physical, social, and psychological QoL, whereas QoL in environmental domain is better compared with studies done across the country and it was significantly associated with higher income, education, better accommodation, and type of work. We recommend strategies to improve their physical, social and psychological well-being of this vulnerable population through strict legislations.

Migration and young women's access to maternal healthcare in sub-Saharan Africa

Pregnant young women have increased risk of poor maternal health outcomes and frequently have low rates of skilled maternal healthcare utilization. Migrant youth may suffer even poorer use of maternal health services given the disruption of migration, changes in social support, and potential difficulties in obtaining care in a new community. Using a sample of 46,905 women aged 15-24 from 27 Demographic and Health Surveys collected across sub-Saharan Africa from 2003 to 2009, I examine variation in use of skilled maternal healthcare, looking at three aspects of migration: place, disruption, and adaptation. I find evidence of a significant advantage in migrating to urban versus rural areas, suggesting that there is an urban advantage in maternal healthcare regardless of migrant stream. I find no evidence of positive adaptation on maternal healthcare use, but show that rural-rural migrants experience negative adaptation after longer duration of residence. There are lingering positive effects of this urban advantage for urban-rural migrants, who, despite a dearth of healthcare facilities in rural areas, maintain high use of maternal healthcare well after migration.

Migration and health: A systematic review on health and health care of internal migrants in India

The objective of this paper is to review published studies on various health conditions and health care access of internal migrants in India. The guidelines under PRISMA Statement for Reporting Systematic Reviews and Meta-Analysis were followed. We searched 3 databases-Web of Science, Medline (PubMed), and Google Scholar. By applying selection criteria, we identified a total of 42 papers to include in the review. These studies reported various health problems/morbid conditions, and some studies reported health care access. Major health issues of poor migrants included work-related injuries, noncommunicable diseases like diabetes and hypertension, and communicable diseases like malaria and HIV. In addition, behavioural risks such as the use of tobacco and alcohol are reported. Information on health care seeking and poor access to government health care system are available. This review demonstrates the need to improve the health status and health care access of poor migrants. As health systems-related factors also influence the health care seeking behaviour, they are to be considered along with improving the living conditions of this population. Thus, a comprehensive migrant-sensitive health care should be the part of the urban health care system.

Mobility patterns and associated factors among pregnant internal migrant women in China: a cross-sectional study from a National Monitoring Survey

Background

Residential instability during pregnancy has been linked to poor health outcomes. As a first step toward providing better health care to pregnant migrant women, the size and characteristics of this population and factors associated with mobility during pregnancy should be studied.

Methods

Using the “Monitoring Data of Chinese Migrants” for 2012, from the Chinese National Population and Family Planning Commission, this study explored mobility patterns during pregnancy and associated factors among migrants within China. From a library of 158,556 participants, two subsamples were selected. Percentages, with chi-squared tests, and means and standard deviations, with ANOVAs, were adopted to describe mobility patterns during pregnancy (always staying in sending area, mainly staying in sending area, mainly staying in receiving area, and always staying in receiving area) and delivery location choice. Logistic regression analysis was used to explore the associated factors.

Results

We found that the percentage of migrants always or mainly staying in receiving areas during pregnancy rose from nearly 40% in 1985 to more than 80% in 2012, while the percentage of migrants who were mobile between receiving and sending areas during pregnancy fluctuated between 30 and 40% before 1995, and between 40 and 45% after 1995, decreasing to around 40% after 2008. The percentage of respondents who chose to deliver in receiving areas fluctuated but increased from 10% in 1985 to more than 50% in 2011. Among respondents who had delivered during the last year of the survey period, families with older pregnant women (OR = 1.09, 95% CI 1.05–1.13), their own housing (OR = 5.66, 95% CI 2.45–13.05), longer time in the receiving area (OR = 1.14, 95% CI 1.09–1.20), and strong will to integrate (OR = 1.32, 95% CI 1.15–1.51) always stayed in the receiving area during pregnancy, rather than the sending area, and families with broadly similar characteristics were inclined to choose the receiving area for their delivery.

Conclusions

The mobility patterns of pregnant migrant women in China have been changing in recent years, with the percentage of them staying in receiving areas during pregnancy and delivering there increasing. Individual and family characteristics were also associated with mobility patterns and delivery location choice.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1813-2) contains supplementary material, which is available to authorized users.

Internal migrants' experiences with and perceptions of frontline health workers: A nationwide study in 13 Indian cities

The role of frontline health workers is crucial in strengthening primary health care in India. This paper reports on the extent of services provided by frontline health workers in migrants' experiences and perceptions of these services in 13 Indian cities. Cluster random sampling was used to sample 51 055 households for a quantitative survey through interviewer-administered questionnaires. Information was sought on the receipt of health workers' services for general health care overall (from the head/other adult member of the household) and maternal and immunization services in particular (from mothers of children <2 years old). Purposively, 240 key informants and 290 recently delivered mothers were selected for qualitative interviews. Only 31% of the total respondents were aware of the visits of frontline health workers, and 20% of households reported visits to their locality during past month. In 4 cities, approximately 90% of households never saw health workers in their locality. Only 20% of women and 22% of children received antenatal care and vaccination cards from frontline health workers. Qualitative data confirm that the frontline health workers' visits were not regular and that health workers limited their services to antenatal care and childhood immunization. It was further noted that health workers saw the migrants as"outsiders." These findings warrant developing migrant-specific health-care services that consider their vulnerability and living conditions. The present study has implications for India's National Urban Health Mission, which envisions addressing the health care needs of the urban population with a focus on the urban poor.

Birth preparedness and determinants of birth place among migrants living in slums and slum-like pockets in Delhi, India

OBJECTIVE

The objective of this paper is to report birth preparedness and place of birth and its determinants among recent- and settled- migrant households living in slums of Delhi.

METHODS

In a cross-sectional survey, 458 migrant mothers with a child aged below one year of age were identified. Socio-demographic details, data on the place of childbirth, antenatal care (ANC) and birth preparedness in terms of planning for home birth or hospital birth, transport, saving money, knowledge of danger signs were collected through interviewer-administered pretested questionnaire. Logistic regression was carried out for the determinants of hospital birth.

RESULTS

The present study migrants are characterised by younger ages, low educational attainment, low incomes and represented by socioeconomically disadvantaged communities. They mainly relied on government healthcare services for maternal care. ANC seeking was not satisfactory with 16% of women with no ANC; 46% receiving 1-3 visits; and only 23% of women reported health worker visited them at home. 59% of the births took place at hospitals. Having ANC visits (Adjusted Odds Ratio (AOR) for having 4 or more ANC visits = 5.252), planning for hospital birth (AOR = 6.114), plan for transport (AOR = 1.989), mass media exposure (listening to radio; AOR = 2.871) and knowledge of danger signs (AOR = 3.872) resulted in significant chances of hospital birth.

CONCLUSION

Migrant women are at the risk of utilizing the services to a less extent. The health systems need to take measures to mitigate the disadvantage due to migration through specific strategies to make them inclusive and outreach to the poor migrants.