Women ‘holding it’ in urban India: Toilet avoidance as an under-recognized health outcome of sanitation insecurity

Abstract

ABSTRACT Emerging research on sanitation challenges in the Global South increasingly uncovers health and social impacts by gender, particularly lack of sanitation safety. Women may employ strategies to avoid urination or defecation (‘holding it’) in the absence of safe sanitation, but the practice is not well understood. We quantitatively analyze survey data on women from urban slums across three cities in Maharashtra, India whose households constructed a toilet through an intervention programme. We assess relationships between household versus shared sanitation, perceptions of safety, and women’s toilet avoidance behaviours, including diet restriction. At baseline, women have more than three times the odds of reporting avoidance behaviours if they perceive a community toilet to be unsafe, even after controlling for other factors. Household water insecurity is also instrumental in the relationship between avoidance and lack of safety. Finally, avoidance exhibits a significant and major drop upon provision of a household toilet. This study provides substantial support for the prevalence of habitual toilet avoidance among vulnerable urban women without access to safe sanitation. We conclude with recommendations for policy approaches and call for more attention to the health repercussions of habitual toilet avoidance among women as a consequence of sanitation insecurity.