Socio-cultural factors, poverty responsible for high maternal mortality, says GIDR study

A recent study “Safe Maternal Health Care in India: Can it be Made Universal?”, sponsored by the John D. and Catherine T. MacArthur Foundation for the Gujarat Institute of Development Research, Ahmedabad, has found that in rural Gujarat, while the overall proportion of home deliveries is low at 58 per cent, in tribal belt it continues to be high. The recently enacted schemes like the national Janani Suraksha Yojana and Gujarat’s Chiranjeevi scheme may have to a certain extent increased institutional deliveries and reduced home deliveries. Efforts of some of the health NGOs working in remote tribal areas have also helped increase institutional deliveries.
Yet, the study, carried out by a team led by senior academic Leela Visaria, underlines, “High pregnancy wastage and neonate mortality is a stark reality in poor tribal area even when efforts are made by committed NGOs to ensure safe assisted delivery. The important role of socio-economic and cultural factors in accessing care by women needs much deeper understanding.”
Based on data collected by a GIDR team in association with SEWA Rural, an NGO in predominantly tribal belt of South Gujarat, the study particularly focuses on 27 women who suffered maternal mortality. The study says, “In all 13 of the total 27 deceased women had been taken to at least two health facilities for pregnancy and child birth related complications. Of the 13 women, only two were more than 30 years old; all the others were less than 25. Except for two all of the others were illiterate and also belonged to poor households where husbands were also mostly illiterate and were engaged in manual work in construction or quarrying and had no regular employment.”
Profiling their death, the study says, “Five of the 13 women died in pregnancy. Of the remaining eight women, four had still births and two live born children died within few days of birth. We had collected information on the entire pregnancy history of all the women and it was very evident that those women who had experienced pregnancies earlier had very poor pregnancy outcomes. The 13 women between them had experienced a total of 30 pregnancies during their reproductive life but five women died during pregnancy. Of the 30 pregnancies, seven resulted in miscarriages, and five in still births. Only 14 pregnancies resulted in live births, but three babies died within a few hours or days of their birth.”
Pointing out that “domestic and cultural factors which play significant role in efforts to lower maternal mortality, the study says, “When women come for delivery to the parental home and need intervention in the event of an obstetric emergency, girl’s parents wait to receive her husband’s consent before agreeing in order to avoid his wrath. In the case of one woman this delay cost her life. In another case, in spite of five miscarriages and one live daughter, desire for a son put one woman’s life in danger. The repeated advice about either using a contraceptive method or seeking care early in pregnancy fell on deaf ears. Instead quacks were approached, and when the woman succumbed to profuse bleeding in the hospital, its staff was blamed for not administering oxygen to the woman and for not letting a family member in the operation theatre.”
The study underlines, “In the predominantly tribal belt even in the second decade of the 21st century, poverty and illiteracy continue to persist. Our data show that 16 out of 27 young women or three out of five were illiterate. In spite of efforts to enroll socially and economically disadvantaged students, especially girls, in schools, illiteracy continues to remain an entrenched problem. Their husbands are not much better. This limits employment in better paying economic activities and men and women in majority of the households worked as casual labourers either on farms of others, in construction or in quarrying. In all 17 of the 27 families we visited were visibly poor, lived in single room thatched roof homes with very few utensils and other amenities. Poverty coupled with illiteracy leads these tribal folks to not recognize the gravity of illness or emergency situation and the need to seek health care without any delay. They also fear the impersonal atmosphere of formal health care institutions and because of their belief in bhuva-bhagat or informal providers, who are often known to them, reach out to them first. The need to contact quacks or informal providers is even more pertinent when conception takes place outside socially sanctioned relationship. The informal providers can be trusted for maintaining secrecy and confidentiality, something that a public facility is almost unlikely to do so.”
Detailed inquiry and discussions with a range of individuals pointed to discordant inter-personal relationship between family members including between spouses at least among 14 of the 27 women who had died, the study says. “The two women who had conceived outside marriage or socially sanctioned relationship were abused and had become victim of physical violence from the members of their own natal family. At least three husbands had extra marital relations, which led to fights between spouses; men’s extra marital relations were rarely challenged by family members but for women such a situation led to harsh treatment. Young married women who become pregnant the first time also did not escape verbal abuse and physical violence. While being neglected by the family and not receiving emotional support, several of the women ended up neglecting their own health, became highly anemic and did not seek health care in spite of being visited by the health workers.13 In a few cases, there was evidence that women had willfully caused harm to their own health when husbands were suspected of having extra-marital relationship.”
Suggesting that there are enough studies on the status of women in the households and violence against them during pregnancy is also documented, the study says, “And yet, while trying to understand the determinants of maternal mortality, most of the studies focus on provision of emergency obstetric care in order to save the mother. When a young woman’s health deteriorates during pregnancy and the fear of chronic illness is on the horizon which would involve expenses over a long period, pros and cons of efforts involved in saving her are weighed by the families. We had a mother-in-law who openly informed us that instead of spending a lot of money on a chronically sick daughter-in-law, it would be more desirable to marry her son again. This reveals not only the worthlessness of a woman’s life, a woman who is in no position to fight for her right to life, but the cold calculations that are made. Such utterances also raise a question about how gender is constructed in our culture.”
Pointing out that underlying six cases in which women died even before being taken to a health facility or even before considering such a move, study stresses on “strong contributory social factors such as lack of family support available to them, and troubled or discordant relationship with husband or other family members.” It says, “This led the women to neglect their own health and that of their child’s health.” The study quotes one of the husbands, educated up to 10th as saying, “She was a sick person even before our marriage and was becoming very tired and was being treated by household remedies.”It quotes a health worker saying, “Her sickness was partly responsible for fights between her and her husband and mother-in-law. She refused to take care of herself during pregnancy.”
According to the study, “The compromised mental health or perceived mental instability, which continues to be a neglected health problem in India, adds to the misery of women. Medically, one may surmise that these women could have been saved if they had been brought to the health facility in time. However, the medical facility cannot change the social and familial situation or remove social stigma when, for example, women conceive out of wedlock. Such women become victims of violence and are abused and neglected by family members as well as by those responsible for pregnancy.”


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