Fertility and Reproductive Health: A Qualitative Study of Homeless Migrants in Delhi

Fertility, Decision-making, and Women’s Autonomy

The decision-making in the reproductive life of a couple finds its expression at several stages between pre-conception and postpartum. Generally, studies of decision-making in the space of fertility focus on the concrete logic of fertility behavior which can be studied in different socioeconomic groups and also in health-concerned situations. The studies on fertility decisions have largely focused on choices such as whether to have children or not, the number of daughters and sons a couple wants to have, etc.

Some of the extensively employed theories in analyzing fertility decisions are the economic theory and the theory of value of children, which are often found to be related to the concept of economic security and utility (Schultz, 1973). The other social theories ground these decisions with the motive to find “emotional comfort for well-being and social approval” (Leibenstein, 1981; Werding, 2014), “due to our inability to find a caregiver, other than children, to the old parents” (Tremayne, 2001), and “equating success of children to the self and raising the succeeding generation” (Tremayne, 2001), and so on.

Gender preference based on the valuation of children is also found to be an important factor in fertility decisions. Therein, the desire for a son is a widely practiced social phenomenon in patriarchal societies revolving around aspects such as “economic utility or relative advantages and expense of having son(s) and daughters,” “non-monetary assistance provide by son(s)” (Bulatao, 1981; Espenshade, 1977; Friedman et al., 1994; Vlassoff, 1990), “sons having a significant role (as males descended) in ancestor rituals and other religious practices, and being successor of family property and as one ensuring perpetuation of the lineage” (Dyson & Moore, 1983). Although scholars have found that in societies with no inheritable land or property, there is no evidential strong son preference (Kishor, 1993; Mitra, 2014).

Women’s participation and autonomy in reproductive decision-making have often been considered varying and low in highly patriarchal systems. Scholars deduced the causes of differences in autonomy exercised to the differences in the social structure, sociocultural norms, and practices between the people belonging to different states (Basu, 1992). Joshi et al. (2018) examined these differences across different caste groups and found them as manifestations of the variations in gender relations across these groups. Anderson et al. (2018, p. 357) reasoned this variation with more constraints and subordination experienced by high-status caste women in comparison to women of low-status caste groups (also see Subramaniam, 2006). They pointed out that the economic participation of women in these groups determined gender relations and behavior. The liberal gender role and norms in the latter group also encouraged a better sex ratio which is argued to have aligned with the norms of the rest of the population because of Sanskritization after independence (Anderson et al., 2018, p. 361).

Although Unnithan-Kumar (2004) focusing on the dynamism in women’s reproductive agency has underlined that they do not lack agency but rather experience and act as well to control their procreation process. She also emphasized that by focusing on their agency, one may bring to light their responses against development in reproductive planning and behavior (Unnithan-Kumar, 2004).

Migration, Place of Birth, and Social Support

The effects of migration on health outcomes are reported to be more prominent in the case of women than men. In terms of the access to reproductive services, migrant women were found to be more vulnerable due to lower usage of maternal healthcare facilities augmenting negative outcomes (Shaokang et al., 2002), especially in comparison to the nonmigrant (Stephenson & Matthews, 2004). Borhade (2011) observed more negative outcomes among migrant women as they went back to their natives to deliver their children with unqualified birth attendants or delivered their children in their slum homes due to mobility issues or gaps in outreach.

Home deliveries are less expensive than institutional deliveries but lack basic amenities to address any complications occurring during delivery and also have a risk of infections responsible for maternal mortality. The inclination towards home birth is reducing, and institutional deliveries are becoming a major trend as observed in DLHS 3(2007–2008) which reported a rise of 6.2% institutional deliveries in India between 2005 and 2007, that is, from 40.8% (2005–2006) to 47% (2007–2008) (International Institute for Population Sciences, 2007). But some of the cross-sectional studies have identified factors significantly determining or leading to the continuation of practice, which were “tradition, financial constraints, nonavailability of social support, pressure from family despite awareness, lack of awareness, no transportation and inconvenient timing of birth,” (Chhabra et al., 2017) “women’s age, education of husband, parent’s educational level, pregnancy registered, received ANC and supplementary nutrition by AWC, awareness about the pregnancy-related complications, access to maternal and child health care,” (Swain et al., 2012) and “higher birth order, religious category, SC/ST category” (Thind et al., 2008). The reported abuses during labor in institutional spaces have been reported as another important barrier to institutional births (Bhattacharya & Ravindran, 2018; Mayra et al., 2022).

Trends, Culture, and Differential Basis

The fertility trend in the population showed that half of the women had a maximum of four conceptions and less reported child mortality (see Table 1). As observed, the number of conceptions increases with the statistics of child mortality. The mechanisms through which the relationship between child mortality and fertility is explained by various scholars were biological effect, replacement effect, insurance effect, and societal response effect (see Chowdhury et al., 1976; Hossain et al., 2007; Preston, 1978; van Soest & Saha, 2018).

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Table 1.

Fertility and Child Mortality (in N).

Conceptions						Total Number of Women in the Category		Total Child Mortality	Children Alive
S. No.	Category	Basor		Pamaria
		%	N	%	N	%	N	N	N
1.	1–4	57	12	48	25	50	37	5	89
2.	5–8	38	8	44	23	42	31	31	153
3.	9–12	5	1	7	4	6	5	28	24
	Total	100	21	100	52	100	73	64	266

The Pamaria population showed preference for sons and had an anticipated number of sons for an ideal family composition, which was not reported by any of the Basor family. During conversations, Pamaria women reported that traditionally having a minimum of three sons is considered an ideal family composition which was to ensure at least one surviving. Therefore, their experience of high child mortality was observed to be crosscutting with other spheres of their life and decisions. I first met Aasma, a Pamaria woman, when she was living under the flyover with her family. When I enquired the reason of migration, she said,

In our culture, it does not work out with only one son, and in order to have more, the family enlarges. That is what happened to us also. And meeting the expenses of this enlarged family is not easy in the village. There (in the village), a person would work for a day and then would sit for two days without work. That money can ensure you the meals only. So, thinking of fulfilling the requirements of all and future expenses, we came to Delhi with a village-man who lived in this nearby slum. When we came to Delhi, the wage rate was Rs. 86/ day.… I gave birth to my children in the village only.… I gave birth to eight children in the village home out of which I lost two sons. I gave birth to one daughter and a son in years following my marriage, before migrating to Delhi. After the first two children, two sons were born but they passed away. First amongst them was two years of age, at the time of death, and the second one was one-and-a-half-year-old. They both fell sick, had fever, and could not survive it. After them I gave birth to four children, two sons and two daughters. Because of the death of children and to ensure our survival in old age, we have to have at least three sons so that at the end of the day we have at least one son surviving, who would take care of us in our old age.

After first two pregnancies, succeeding pregnancies happened in Delhi.… I used to work till I would reach near to my full term and then we used to go home (native) where with the saved money we could survive for a month or two after child birth.

In both the populations, some reported causes of child mortality were illness, a node in throat, injury and accidents, electric shocks, and “no known cause” while some reported that the child died while asleep. Among Basor, there was only one woman who reported eleven conceptions, all live births, out of which six children were surviving. Among passed away children, four had died within a month of birth and one had passed after one year of age, as experienced electric shock.

While Pamaria explained their fertility with child mortality, Basors, lacking strong son preference, explained their fertility as a result of conjugal relation or traditional pattern as used common phrases for explaining their family size, “they just happened” (Krause, 2012) or “we didn’t gave a thought to control it,” or “in past it used to be like this.” The death rate among children in Basor families was less than Pamaria who showed a general concern about death of children, regardless of their gender.

Traditionally, Pamaria practised various customs to ensure survival of children or reduce general child mortality and in turn curtailing son’s mortality as well. Munnar, a Pamaria lady, told that usually parents pierce the nose of their preceding child, in order to save the succeeding children, and the practice was called nakchiya. Although the rationale of the practice was unknown in the population and was usually explained as a traditional practice. Sebastian et al. (2013) traced the history of piercing the nose on the left side among women and explained it to be a traditional practice to make childbirth easier (p. 2). But the relevance of this, done to the preceding child, could not be found in literature.

In cases of infertility, Basor sought treatment from medicine men in their village while Pamaria traditionally undertook several measures. Saba, a Pamaria lady said that “when a woman experiences infertility or wants to have a son, it is suggested to take a bath in the Kamla river in Madhubani district of Bihar.” She narrated an anecdote to explain the reason. She narrated, “they were six sisters and the last one was Kamla. It was Kamla after whom one brother was born, so people usually take baths in the river when they do not have son(s) or wish to resolve their infertility issues.” She told that near their village there is a Masjid also where there is a pond (pokhar). She told, “women take bath in it too, to resolve their fertility issues, which get resolved after three seasons of the bath taken. After bathing one swears to do something good (jo bhiguch loge), and with your oath the religious leader (imam) will tie a knot in the woman’s hair, and then you are supposed to leave the premises without looking back.”

Fertility and Control: (Un)Met Desires and Stress

The prevalent child mortality in the Pamaria population was found to be influencing not only their fertility outcomes but also impacted their utility heavily, as these outcomes were often translated into social achievements or misfortunes or black magic or evil eye. In Pamaria households, having a son born was considered to be a point of satisfaction and pride for the mother. The culture of having son(s) was not only a social achievement but also a principle that governed the retention of the widows in the affinal house after the death of her husband. The unmet desire of a son, who would take care of parents in their old age or earn and resolve their poverty, deeply affected the well-being of the individuals. In Pamaria households, two women-headed households who did not have any son reported somatic symptoms of stress, and reported dissatisfaction in life.

Javeira, a Pamaria woman, was working as domestic help and had to quit work due to her ill health. During the whole research duration, she often reported persistent headaches and could be observed lying on the floor of the shelter or massaging her head with oil. She reported the reason for her persistent headaches and ill-health being “tension,” and said that “I am stressed about the future … and when I start having these unavoidable thoughts, my head starts aching.” On enquiring further, she said “I am worried about how everything will fall in place … what will happen to my girls (daughters) if I die! how they will be married. If my son would have survived, I would have been less stressed about the future. He could take care of me and his sisters nicely.” And she started crying. When I inquired about her son, she told that he passed away at the age of eight years. She narrated, “that day he came from school, and asked me to cook fish. I made some for us and in the evening when my husband returned from work, we all ate our food and slept. The next day when I went to wake him up for school, he had passed away.

Another day she reported a headache and said “I had a dream about my son today. He was telling me to take care of Muneeba (her youngest daughter). He was very fond of her … and since I have woken up I am having this headache.”

The fertility control being nontraditional was a precarious practice, also due to son preference amidst child mortality in the Pamaria population. It was practiced by a few young generation Pamaria women and men only while none of the Basor couples reported employment of any measure to control their fertility. The participants from the Basor community cited “illiteracy” and “being unthoughtful” of having control over fertility as a reason for not utilizing any measure. Most in the parental generations, in both the populations, situated it being a nontraditional and cited the historical trend of having large families. Pamaria men also consciously wanted to follow the normative composition of the family but some also pointed out that the practice to control family size can start after at least two sons are born. There were only four cases where men were observed to be having a nonnormative perspective as argued that the contribution to the life of old parents is done equally by daughters as well as sons, so, having large families in an attempt to achieve anticipated numbers of sons is unnecessary.

Some among Pamaria were observed to be controlling fertility. These were six Pamaria women among whom four relied upon Intra-Uterine Device (IUD) methods, one relied on barrier methods, and one relied on pills to control their fertility. They controlled their fertility primarily because (a) consciously wanted to have spacing between the children, irrespective of unattained anticipated family composition and (b) due to existing conflict between partners, putting the stability of the relationship at stake.

Kainat was among the few women who reported discontentment because of not having met the traditional reproductive expectations, that is, the anticipated number of sons, and had plans to meet it. She had three daughters and was with only one son. She reported that after the birth of her third child, which was a daughter, she wanted to opt for surgery, that is, tubectomy but her in-laws and her husband convinced her to give another try for another son. Kainat reported that, after two daughters when another daughter was born, the burden became unexpectedly more because of the dissatisfaction and at the same time enlarged the family where marriage of each daughter would cost them a good amount. She reported that after the birth of her third daughter, she opted for IUD and decided to cease any further attempts.

It was observed that very few Pamaria women unwillingly took up the decisions related to fertility, resulting in an enlarged family, while most accepted and rationalized the norm of having more sons and willfully adopted it.

Their agency, as planner and also as rationalizer, situates them as agents observing, rationalizing, and taking decisions regarding their fertility. Ela, a Basor lady, had passed her first trimester but wanted to abort the fetus in her womb due to living hardship with a large family as she had four children, and upcoming additional economic burden with the fifth child. When I enquired about her awareness regarding abortion and risks, she smiled and said, “I think it (abortion) can be done till the fifth month.” I suggested her to consult a doctor to have a better understanding of it. After a few days, her husband’s younger sister informed that Ela had been consuming alcohol for the past few days regularly. Next time when I met her and explored the credibility of information, found it to be true. Ela consciously chose to go into drinking as said, “I want to let it go.” Her behavior was apparent to all which also brought her disgrace from many and consequently discontinued it after some time.

In order to understand her husband’s perspective towards having a large family I took up an informal conversation with them. On the question of the reason of having large family, Ela’s husband smiled, and said, “surely, we should control it.” I extended the context, “didn’t you think of going for any birth control measures?” He smiled and said, “Yes, something like that should be done. Actually … we are not that educated so do not think like that but, I think it is the time to get that done.”

Migration, Homelessness, Delivery, and Postpartum Care

Home, as a subjective matter, is often signified as a meaningful space with “social, personal, physical, political and cultural qualities” (see Despres, 1991; Sixsmith, 1986). The privacy served by the home is an important component for the studied homeless households. The living ways of the institutional population, that is, communal living, challenge conjugality, which on the contrary demands privacy. The inclination towards or continuation with public space of the household living in open spaces was based by them on the privacy argument.

The situation of homelessness substantially affected women of the true homeless households and women who did not want to go back to their native homes, as were in conflict with their spouse or affinal family. Homelessness left them with no place to deliver their child, when they wanted to avoid institutional delivery. Some gave birth to their children in the rarer or in the abandoned spaces of the shelters. Ela reported that, during her first pregnancy, along with other family and community women, they had called a midwife (daai) from the nearby slum who was an untrained birth attendant. Although, because of complications during delivery, Ela was immediately admitted to a hospital where a c-section was done. She also reported to have delivered her second child in one of the remote spaces inside the premise of the shelter and the third was born in the nearby abandoned transport authority. As traditionally practiced, the attendant took an award of eight hundred rupees when her first child, a daughter, was born and twelve hundred rupees for each of two sons born later.

The women of long staying migrant households generally used to go back to their native to deliver their children. Usually, these women worked till the near-end of their pregnancy to earn for the post-delivery phase where they would not be able to work and would rely on the surplus brought from the city. The women who delivered at home in their villages did not want to deliver in the city, primarily because they did not have any support in the city who could take care of them during the labor and post the delivery. For the expectant-migrant women, comfort of home and social support was significant for which they used to travel back to their home. Antenatal Care (ANC) visits to doctors were either avoided or not felt necessary by the participants, as they had planned their delivery at home (native) and could not have any at the village because they lived in the city till near the end of their pregnancy.

Childbirth has historically been an important point around which various practices and rituals revolve. Generally, it has been an all-women’s affair wherein the expectant mother is attended by other women in the family or clans, among whom an old and experienced woman would be the birth attendant. This group takes care of comfort and support by giving advice to the mother in labor which has been argued to be the prime constituent lost in the process of medicalization of childbirth. Contemporary research has proved it being an important predictor for stress physiology and its effects during the intrapartum period, such as, analgesia, lengthy labor duration, instrumental or cesarean deliveries, as well as the postpartum psychosomatic issues (Ed et al., 2011a, 2011b; Kayne et al., 2001; Lunda et al., 2018).

Among participants, there were only five women who had institutional deliveries, among whom two had complications at the time of birth and only three had willfully opted for institutional delivery. The rest migrated back to their hometowns to deliver their children or delivered in shelter spaces. Institutional births were often associated with lone struggle and abuses that they heard from others or experienced in the past. It was considered unsafe for the child born also, as some cited incidences of newborn’s abduction, especially of a male child.

Mayank, Ela’s husband, and many other men in Basor population preferred noninstitutional delivery as reported that for every form filled during the formal process of admission of the expectant in the hospital, they were charged by helping personnel as they were not literate, and the cost incurred before admission goes to Rs. 500–1000, apart from other general expenses during and post the delivery. The monetary expenses, in the poverty-ridden situation, incurred before delivery acts as a barrier to the practice of institutional deliveries, functioning in combination with other barriers, such as traditional practice of home births, migration, and abuses heard or experienced, was leading to the existing gap in service accessed. In the Pamaria population, most of the women used to go to their native homes. Being migrants, they planned most of their deliveries in the native home and did not register for and receive ANC in the city. Pamaria reported lack of support in the postpartum phase as a prime reason to go to the village and deliver their children there. Most of the Basor women cited traditionally practiced home birth in the population, monetary expenses, nonavailability of support during labor and institutional abuses as the prime reasons for avoiding institutional deliveries.

In both the populations, variations in postpartum practices were also observed wherein Basor women observed taboos concerned with postpartum breastfeeding and food consumption which were absent in the Pamaria population. Pamaria do not observe any kind of restriction in food and generally breastfeed their children immediately after birth. Basor women were forbidden to breastfeed their newborn for three days and used to fast just during this period. They believed that it allows the body to expel the impurities. In the meantime, the newborn is breastfed by other women of the family. Some scholars have explored the breastfeeding practices and delay in the necessary first milk (colostrum) to the child, to understand its correlation with survival of a child and found it to be associated with child mortality (Jatrana, 2003).

Suggestions and Policy Implications

It could be observed that the provision of institutional spaces for homeless could pull them out from housing issues but some of the aspects of their life still need a deeper look and assessment. The relevance of home for development has already been highlighted by various scholars (Ghafur, 2004), which is also an important component to ensure people have their other basic rights and needs met. Generally, gender and age are argued to be important axes on which the inequality is reinforced by being ignorant towards their needs. The case of women of homeless households is reiteration of this fact. The gender and case-sensitive planning wherein women, children, drug addicts, disabled, and families are given attention, has not been able to penetrate deeper to address some of other very basic and important areas women’s needs and rights. The gaps in healthcare infrastructure and facility in institutional spaces, are found to be continuing the existing social disparities and inequalities (Baru et al., 2010).

In order to resolve this and make these spaces thoroughly gender-sensitive, as some organizations have done, Ministry of Housing and Urban Affair’s guidelines under Deendayal Antyodaya Yojana-National Urban Livelihood Mission Scheme needs to be adhered to. The need to have healthcare workers in the facility has been enforced in these guidelines, and also was realized as they could assist individuals in general as well as cases needing special care. They can also take care of reproductive health-associated needs of women, apart from general health issues. They can also counsel individuals who are opting for a large number of children (designedly or unintentionally) regarding fertility-associated behavior, mortality and associated risk and stress, and also curb noninstitutional deliveries to mitigate the child birth associated risk. These healthcare workers can also assist the needs of individuals by facilitating not just at the time of admission of expectant but also can work as birth attendants, reducing the risks during delivery. Along with it, the institution needs to assess and fulfill their postpartum needs who, as observed, either have less or no role in this sphere.

Migrants can be helped via Migrant Labour Support Programs and enrolment in the Unique Identification Authority of India (UIDAI) programs, wherein not only general wage labor support programs can be implemented but can potentially cover expecting women which can smoothen up the access to monetary and nonmonetary benefits, to be transferred in their accounts, to encourage them for institutional deliveries in hospital in cities or villages. LaQshya guidelines ³ can be made operational with the help of the local healthcare workers (of caregiving organizations) in cities and in the rural as well to cover any gaps left.