3.1 Demographic information
As seen in Table 2, a majority of the female participants in the study belonged to ST groups (76%), while the rest were from SC groups and Other Backward Classes (OBC). There was diversity in place of origin, with most coming from districts within Gujarat, Rajasthan and Madhya Pradesh that are close to the city of Ahmedabad, as well as from districts within states like Chhattisgarh, Bihar and West Bengal which are further away from Ahmedabad. The sample reflected very low levels of education among women, with 75% reporting that they had never been to school. Most women (69%) were unable to estimate their age bracket.
3.2 Labour characteristics and work conditions
3.2.1 Migration and mobility
We encountered two broad migration patterns among those living at construction sites. A majority of the women in the study sample (73%) were seasonal migrants (defined by NSS as households undertaking migration for one month or more up to a period of six months), from districts close to Ahmedabad. These households noted that they came to the city for shorter spells of time, returning to their villages periodically for agricultural work, weddings, festivals, and other cultural events. In this case, the migrants preferred to come to Ahmedabad, because of its proximity to their villages and also because their contractor had more established contacts in the city.
We come to the city whenever our thekedar (contractor) call us. He tells us and we go there (to the construction site) [..] We stay for a few months and then go back to the village. If he finds us more work, we come again (female participant)
The other women were semi-permanent migrants (defined as those who have been outside of their home for over six months) and had been living in the city for a longer duration - ranging from one year to five years. Several semi-permanent migrants reported that they had previously migrated to other cities as well.
I have been to many parts of the country. Delhi, Mumbai, Kerala. We will stay here as long as there is work and then move to another place (male participant)
Workers changed multiple locations within the city, as they moved from one construction site to another at the end of each project cycle, as their work at each site usually spanned between three months to over a year depending on the size of the project. We asked participants if this form of mobility affected their access to healthcare services.
I don’t know where the hospital is here. But my husband knows and the contractor will tell us if we need to find a new one (female participant)
We asked women if they altered their migration pattern because of pregnancy and child birth, a few women said no, but the question did not elicit direct responses. Instead, during our focus group discussion, one man suggested that though his family had not necessarily changed their migration routine during his spouse’s pregnancy, he took her back to the village in time for childbirth. Another male worker noted that their family’s trip to the village was delayed because of monetary constraints, and in the meanwhile his wife delivered in the city:
We had taken a loan from the contractor and we were waiting to return that. We would be in the village, if we had the money. But she had to deliver here (male participant)
A similar situation was shared by another worker. However, in his case the family could not return to the village in time, because they had not realized the woman was close to delivering the child:
She (wife) delivered at the construction site when she gave birth to our son. We thought we still had time so we were here (male participant)
3.2.2 Wage patterns
Female workers reported being paid between Rs. 250–300 (minimum wage is Rs.306 per day). At most construction sites the wages were paid to the family as a unit and was generally collected by the male head of the family. Economic decisions such as amount to be used for daily expenses or remittances were generally taken by men as reported by several women.
I get paid the same as my husband I think […] he decides what to buy and where to get it from. So, he goes. I don’t go out of here (construction site) (female participant)
He keeps the money, but we also send it home. Our entire family (in-laws) is there. They need money for food and other things (female participant)
It was common practice for households to take kharchi - a form of cash advance, to meet weekly expense of food, medical care, remittances and debt repayments. The kharchi amount was settled against the wage entitlement of the workers, either at the end of the month or when the household chose to do so, like in the case of a trip back home. A construction union leader told us that this system of kharchi also led to wage theft, wherein workers rarely received their due payment. He attributed it to the absence of labour regulation and unclear employer-employee relationship as workers were hired through a complex network of contractors and sub-contractors.
Workers don’t keep a record of the money they have borrowed or the number of days they have worked. The contractor routinely pays them lesser but they are not able to challenge it. This affects all aspects of their lives, including health expenditure.
While the system of kharchi provided workers liquid cash for regular expenses, it also increased workers’ wage insecurity and dependence on the contractor for economic support. As reported by one of the male participants there was a constant worry about mounting debts.
Last year we took Rs. 50,000 from the contractor. We are not sure how we will do it (repay it). Sometimes we don’t take money for the week […] but we have to take more (for daily expenses) and he adds it to the account (male participant).
This form of wage insecurity had implications for the kind of economic choices the family made. Importantly, as we explain in the sections ahead, it affected their decision to access maternal health care.
3.2.3 Living conditions and work environment
At the construction site workers lived in labour colonies that had separate partitioned space for each family unit, or a couple of families put together. Shelter space was not standardized across the various construction sites we visited and varied from temporary arrangements made out of tarpaulin sheets to more systematically built spaces that had tin walls. In terms of access to sanitation facilities, all construction sites that were included in the study had temporary toilet blocks within the premises of the labour colonies. However, the ratio of number of workers to the number of toilet blocks was extremely low, which made usage difficult. At two sites, women also noted that there were no toilet blocks at the place of work, which was at a distance from the labour colony. As reported by one pregnant woman this made it difficult as she felt the need to urinate more frequently.
Sometimes my stomach hurts. But we can’t go (to the toilet) very often. (pregnant woman).
Similarly, workers were concerned about the quality of water.
Last month I fell sick again. Vomiting and bad stomach pain. I couldn’t go to work for many days. They said it may be the water, it was black. It had insects and we complained to the contractor but nothing was done. (female participant)
Women worked all days of the week. Most women reported beginning their day early in the morning, around 5.00 am and going to sleep between 9–10.00 pm. Women were responsible for all household chores such as cooking, cleaning, washing as well as child care. At all construction sites we visited, the workers were allowed to take only one break, at lunch time. As we observed, women including those who were pregnant, undertook laborious tasks such as head-loading or lifting stones and bamboos, filling cement, cleaning etc. Most women reported working for 9–10 hours a day, sometimes extending up to 12 hours.
If I don’t do it (laborious work) I won’t get paid. (pregnant woman)
Sometimes if I can’t do it my husband does my share of work too. But it slows his work. I try to do whatever I can. (pregnant woman)
Women worked in the midst of heavy equipment and other construction material without any safety gear, which made them susceptible to injuries. These circumstances posed a serious threat, especially to pregnant women.
Yes, sometimes I get scared. What if I fall? But I try to be careful. (pregnant woman)
Last year I had a deep cut on my leg. It took me three months to recover. […]…] no, the contractor didn’t pay any money even though it happened here, and I could not earn any money. (female participant)
3.3 Food intake
In general, women had two meals a day: lunch and dinner. Our structured observation carried out in their homes at lunch hour suggests that lunch primarily consisted of two small wheat or corn based rotla/roti (flat bread) or a cup of white rice with dal (lentils) or a curry made of vegetables such as onions, tomatoes, and eggplants that were "inexpensive”,, "easy to clean and cook”.. None of the participants had eaten green leafy vegetables, fruits, eggs and dairy products on the day of our observation. Only four women recalled cooking meat (chicken) in the past month.
We also observed that women constantly chewed a mixture of tobacco and areca nut. Several women told us they consumed 4–6 packets a day, because as suggested by a participant, it "helped reduce hunger when at work”.. During our field work in the months of October and November, we observed several women, including pregnant women doing a ‘fast’ for a religious festival. Their lunch consisted only of puffed rice and some other snacks. Several migrant households carried maize flour, wheat flour and a few other non-perishable items that were grown in their villages. These proved to be the dietary mainstay of the family, which had to be substituted by locally available products at the end of the stock. Households that did not have this option indicated that expenditure on food items was high especially because they were forced to buy in small quantities from the local vendor due to daily budgetary constraints. Though workers said they did not have any trouble accessing food markets, several female and male workers commented that cost of food was much higher in the city.
None of the workers reported having access to the public distribution system (PDS)—a subsidized government program that provides food (rice, wheat and sugar) and non-food items (kerosene) through fair price ration shops to poor families, while in the city. This was because the PDS is tied to domicile status, and the workers did not qualify for it in their current location.
When we are in the village, we get everything. But here, we don’t get anything (female participant)
3.4 Health status and experiences
3.4.1 BMI Scores
A significant proportion of women in our study sample (47%) were underweight or suffered from low BMI (M = 18.36, SD = 1.7) (Table 3). Among the women who were underweight, 19% were severely thin, 30% moderately thin and 50% were mildly thin. Of the 11 pregnant women in the sample, four were underweight.
3.4.2 Perception and experience of morbidity
The WHO defines maternal morbidity as a “condition attributed to and/or aggravated by pregnancy and childbirth that has a negative impact on the woman’s wellbeing.” To record the incidence of maternal morbidity, we asked pregnant women, a sub-set of our sample (N = 11) to self-report all diseases, ailments, illnesses and infections they had experienced in the past two weeks. The two most commonly reported health problems that this sub sample of women associated with pregnancy were ulti (nausea) and dard/ sarirma dukhav (body pains). The other common ailments that were reported by all women, including pregnant women were sardi/zhukhaam (cold), khansi (cough), sar dard (head ache), dast (diarrhoea), thakav (tiredness), pet dard (abdominal pain), peetma dukhav (back pain).
Few days ago, I fell very sick. It happens often. The doctor gave me two injections. […] not sure what was wrong. But I couldn’t even stand. (pregnant woman)
My back always pains at night. But when I wake up in the morning it’s better. (pregnant woman)
A doctor, who conducts regular health check-up camps with construction workers considered these health ailments to be a reflection of an overall poor health status:
Many of these women are already weak when they come to the city. Here, they do hard labour work […]…] are exposed to dust and cement all day and that usually leads to respiratory issues. And then there is noise and vibration from the equipment. Imagine what these things can do to a pregnant woman.
In terms of long-term ailments, five women had been diagnosed with Tuberculosis and were receiving medical treatment in a nearby hospital for the same. Two women had been admitted in the hospital for the treatment of malaria in the past year. In the absence of medical records or diagnosis, we were unable to verify morbidity and had to rely on self-reporting of the participants.
3.5 Access to maternal health care services
3.5.1 Constraints caused by money, location and time
Severe time constraints restricted utilization of healthcare services in general. Several women noted that they couldn’t travel alone within the city and had to be accompanied by their spouse. This usually meant a loss of daily wages for two people, which the family could not afford.
The hospital is far. I don’t know how to go there alone. My husband has to come. Then our contractor will cut full day’s money. (pregnant woman)
Furthermore, as discussed in the previous section, irregular wage patterns created economic constraints because of which maternal health, which was not considered to be a serious “illness” did not take precedence in the family.
She is fine. We will go if needed (male participant)
I went to the doctor once. I don’t think (need to go again), it takes a lot of money. (female participant)
Many households found it difficult to access government run hospitals because of the distance or because they were very crowded. In one construction site that was located on the periphery of the city, people complained that they had to walk at least two kilometres to get to the main road to find transportation to reach the closest hospital. A large number of women said it was especially difficult to make this journey during pregnancy or with young children.
I can’t go alone, its far. If he (husband) comes, then there is no one to look after the children at home (female participant)
They said the hospital (government run) is very far. We will find out if we need to go. Right now, we are all okay. (female participant).
In turn, private healthcare facilities in the vicinity, which were available at a time convenient to them (post work hours in the evening) were preferred by workers. However, private healthcare services cost exponentially more, which limited their visits.
Each trip to the hospital costs Rs.250–1000. That is more than what we make as a family in a single day. We go if someone has fever, otherwise we don’t. (male participant)
We also heard from a few women that they preferred private hospitals for treatment of illnesses but for maternal health services they generally went to government hospitals. This was because maternal health costs were much higher in private set ups, which the family could not afford.
When my child had malaria, we went to private hospital but it cost us Rs. 1800 for two days […] I delivered my last child in civil (government hospital) […] private is better but someone told us that it can cost Rs. 20,000 to have a child there. (female participant)
3.5.2 Lack of follow up during antenatal care
A few women noted that they did not know about their pregnancy until the second trimester. In general, most women in the study sample (Table 4) did not receive an adequate number of antenatal care check-ups. Some did not know that more than one checkup was required, while others didn’t find it necessary to seek medical care. One woman noted that she lagged behind in seeking antenatal care because of migration.
Last time I was pregnant, I went to the doctor more often because I stayed at home. This time I had one check-up. I don’t know where the hospital is here. So, I have not gone to the doctor yet. I will go later, if I need to (pregnant woman).
When we asked women if they had received iron and folic acid (IFA) tablets and tetanus toxoid injections that are recommended by the government as part of antenatal care, numerous women replied in the affirmative. However not everyone among them could ascertain if they had completed the entire course of the medicine or had received the injection. One woman exclaimed that she had "forgotten to carry it with her”,, another remarked that the goli/davai (medicine or tablet) did not make her feel better, so she threw them away. Only a few noted that they had them every day as the doctor had emphasized its importance.
3.5.3 Challenges in institutional delivery and postpartum care
In our study sample, 58% of the women (Table 5) had institutional births. Sixteen women delivered at home (6 in the city, and 10 in the village). While two women said they had done so under the supervision of their family members in the village, three women reported doing it with the help of a local ‘dai’ (midwife), though they were unable to tell if this was a trained government employee.
Of the 11 pregnant women in the study sample, nine told us that they wanted to return to their village for child birth as they would receive support from the family. Three also noted that they were more familiar with the hospital set up back home.
I know where it (hospital) is in the village. I can always find someone to take me there. Here I don’t know. (female participant)
Though, male workers did not find the quality of care very good in the village, they felt that healthcare was more affordable in the village than in the city.
There (in the village) you take a bus or find other transport to the hospital but it is still cheaper than the doctor here (private practitioner). […] the government hospital (in the city) is a waste. (male participant)
This viewpoint was contradicted by a pregnant woman, who said she was keener on delivering in the city as the hospital in her village was far from home and inaccessible:
When I delivered my last child, we spent Rs. 10,000 to reach the town hospital. In our village the doctor said he couldn’t admit me because there was something (health complication). We had to get a private vehicle. In the city it’s much easier. You sit in the auto (autorickshaw) and you reach the government hospital
One woman reported that there was greater pressure to deliver at home when in the village:
I wanted to go to the hospital. But my husband and in-laws said when it can be done at home why go so far to the hospital.
In terms of postpartum care, among those who had delivered at home, three women reported that they had not received any postnatal care from a hospital/nurse or doctor as their family members did not find it necessary to seek care. Others mentioned that they went to the hospital much later because they had to get their child vaccinated or because they experienced a complication.
I didn’t go to the hospital at all. All my children (3) were born at home. (female participant)
I had lost a lot of blood at home. So, they called the doctor. He came after four or five days (female participant)
Two women also told us about their still born children - one woman was not sure what had caused the loss and the other noted that it may have been caused by her prolonged illness. The family back home played a greater role in helping the women recover from childbirth as articulated by one female worker:
I stayed at home. Everyone was there to look after the baby and me. (female participant)
Over half of the women in the sample claimed to have returned to work within two to three weeks of delivering a baby. One of the reasons for this was that women thought it was okay because they had seen others do so. But on prodding further, several women also acknowledged that they were compelled by monetary obligations to return to work.
Everyone works after a baby. It’s been two weeks already (since child birth) so I returned to work. (female participant)
A woman who had recently delivered a baby in the city complained that the lack of additional support made it more difficult for her as she wanted to return to work.
There is nobody to help. I have to look after the baby and go to work. It’s very difficult. But I have to earn money. (female participant)