Gender, Work, and Health
Women’s Health from a Women’s Rights Perspective
Following are notes from a presentation I gave at the National Institute of Labour as part of a training program on Gender, Work, and Health. I presented on Women’s Health from a Women’s Rights Perspective, focussing on three themes, Birth, Breastfeeding and Food.
Before I continue to the three themes I presented, let me share some of my own apprehensions about speaking to both of these audiences.
My brief was to talk to the Ph D students about research methods and to the health officials about policy.
I informed the director of the training program that I did not have a PhD, nor training in research methods and would not be qualified to lecture PhD students on research methods. She said that was fine and that she felt that there should be at least one presentation from someone outside of the academy and government institutions.
She had heard my presentation on “Forgotten Foods: Nutrition, Tradition and the Price of Memory” at the World Breastfeeding Conference that took place in Delhi in 2012. In that talk I tried, as best as I could within the available time, to draw connections between the development policy of the state and the decline of agricultural and food traditions that form the cultural and dietary context of breastfeeding. I am grateful to the organizers of that conference for listing “Forgotten Foods” as one of the themes in the call for presentations. That allowed me to draw together the cultural, agricultural and nutritional dimensions of the social and political context of breastfeeding. As it turned out mine was the only presentation on that theme and so I got grouped in a sort of miscellaneous session called “Various aspects of Infant Feeding.”
When speaking to the PhD students at the National Labour Institute, I told them, after the usual introductions:
I am not going to train you in research methods but I will share my concerns and my experiences with women’s work and women’s health and ask you to develop research methods that would be able to do justice to the reality that is insufficiently reflected in the research and policy on work, health and gender.
It’s been a long time since I was in college but I can remember how I felt when I was in a seminar like this, with the rest of the students ready to hit the cutting edge of the field. We felt like we owned the place and that our ideas would shape the century. I can remember the fire I felt when reading history, social sciences and literary criticism, which I carried with me as I went to visit the tomb of Karl Marx in Highgate Cemetery and read the words engraved upon it:
“The Philosophers have only interpreted the world in various ways. The point however …“ (pause for the students to reply) ‘is to change it.”
As it happens, I left my PhD incomplete, I set out to change the world, and along the way I found how very important it is to understand it as well. How we we interpret makes a great deal of difference and today I will talk about some of the assumptions that underlie our approach to women’s bodies, women’s work, and women’s health.
[see Women’s Rights Perspective in Health – dangerous? for discussion of gender bias in medical textbook descriptions of reproductive systems]
Birth Models that Work
The first kind of work I will talk about is reproductive work, specifically, giving birth. The relevant government program is the Janani Suraksha Yojana (JSY). The government of India started this program in 2005. The goal was to reduce maternal deaths; the means to achieve that goal was to promote institutional delivery. As an incentive, women who went to an institution to deliver were entitled to receive Rs. 1400, paid through a village level health worker known as an Accredited Social Health Activist (ASHA). Such a scheme is called a “Conditional Cash Transfer” or CCT. And in fact, at the village level the program, called on a first-name basis simply as “Janani” is primarily known as a scheme for getting cash on the condition that one delivers in an institution.
What is the point, other than cash? Some women said that the purpose was to ensure safe delivery in case something went wrong, but they didn’t show much confidence in this idea. The ASHA also sees that the women get added to the rolls of the ICDS, which provides pregnant women with immunizations, vitamins and, in theory, supplemental rations. What I have heard from women, including ASHA workers, in the villages is that the typical series of events is this: The ASHA worker maintains a list of women who have missed two periods and enrolls them in the program to receive prenatal care through the Integrated Child Development Service (ICDS). One piece of information the woman receives at her first check-up is her due date. As the government of India states on its online “pregnancy calculator, “This date is a rule of thumb indicator and less than ten percent of babies abide by it.” However, in their zeal to raise the percentage of abiding babies, the doctor expects and if necessary directs the woman to deliver on her due date.
Often when we talk about right to information we focus on our right to receive information but we should not forget that it is also our right to provide information on decisions that affect us. In the case of birth, the move to an institution appears to deny women the opportunity to provide information concerning their own bodies, the progress of labour and their own feelings about how things are going. This is information that would play a role in the birth at home. Someone trained attending normal birth and home birth, such as a midwife, would rely on this information in the course of her work. However, the undue emphasis on the “due date” determined by the calendar and calculator have rendered silent the voice of the mother in the process of giving birth. Whether her contractions have begun or not, she is expected to give birth on the due date.
Since the 1970s and 1980s the government has withdrawn support for midwives and reduced the midwife component from the Auxiliary Nurse-Midwife (ANM) training program (Mavalankar, 2008). Traditional midwives are still there in rural areas and still attend births, in cases where a woman is unable or opts not to go to an institution. However after the government withdrew support for midwife training, fewer midwives are practicing and those that are cannot rely on medical back-up. Private and public health facilities have disconnected completely from midwives and promote institutional delivery as the safe option and home delivery as risky. Women who have experienced both have different stories to tell, but who listens to their stories? And who decides where they will give birth? Do they have a choice?
[An aside to the researchers: Even if I told you some of these stories, the problem would be that they are anecdotal. How can these voices be reflected in research and policy made accordingly?]
Statement of Concern about Conditional Cash Transfer
With the introduction of the Rs. 1400 cash incentive through JSY and other amounts in state level schemes such as Muthulakshmi, a greater number of women are going to an institution to give birth. (In fact, they rarely get the full Rs. 1400 and whatever they get usually goes to the men in the house, but that is a different discussion.) Has this in fact resulted in reduced maternal mortality? What other impacts has it had?
A meeting organized in Chennai in 2009 by the Rural Women’s Social Education Centre, Chengalpattu, CommonHealth (Coalition for Maternal-Neonatal Health and Safe Abortion) and Makkal Nalavazhvu Iyakkam issued a statement of concern about the conditional cash transfer for institutional delivery. A key point in their statement is: “It became amply clear through the various presentations from the field that “institutional delivery” did not automatically translate into “safe delivery.” They expressed concern about “near coercion to deliver in public facilities because of the link to cash incentives.” They stated that “safe delivery including overall well being of the mother and newborn should replace mere institutional delivery as an indicator of quality.”
What is the missing link that would allow us to recognize and prioritize the “overall well-being of the mother” and baby?
Impact of Janani Suraksha Yojana
Several research teams have studied the impact of the Janani Suraksha Yojana program. In three studies published in 2010, 2012, and 2013, researchers were unable to find a positive correlation between institutional birth and reduced maternal mortality. As this result surprised them, they sought to explain why. The possible reasons that the various papers considered were: cost of transportation, quality of care at the institution, quality of staff and equipment, quality of prenatal care, and whether the program reached the most vulnerable populations.
Reasons that were conspicuous by their absence were women’s voice and women’s choice. Can a woman choose where she wishes to give birth? How can having a choice play a role in improving a woman’s birth experience?
On the one hand it makes no sense to ask this question in isolation. It is meaningless to ask a woman who has not had a choice in whether she even wanted to marry or have children, or so many matters concerning her life and her body, where she wishes to give birth.
Nevertheless, women do exercise choice in the limited spaces available to them. I have an interest in stories, and birth stories in particular. Women remember so many details of their own experience in pregnancy, labour and birth – there is a wealth of information that women have about their own bodies, emotions, how their contractions are going. And they make choices about whether to share this information, when and with whom. While sharing birth stories I have, for example, heard women say, “I didn’t tell anyone when my contractions started.” Being able to decide when to share the information gives the women some control over how she will manage the initial stage of labour.
In public and private hospitals alike, women are advised by doctors to come in on their due dates whether the contractions have started or not, and once there are urged to deliver – if necessary by induction or by C-Section. Cesarean birth rates have risen dramatically and news of normal delivery is often met with awe and admiration. From the women in the villages I heard, “if you live near the road, you will have a Cesarean.”
However there are women who live near the road, had access to institutions, and in spite of the doctor’s advice to deliver on their due date, make a decision to wait for labour to progress naturally. I will share with you the stories of two such women from Srikakulam District. In their stories you will see that they had other sources of support, women who would listen to them, respect the information that came from their bodies and from their hearts regarding their own pregnancy.
[Screening of two short videos of “Birth Stories” from women living in rural Srikakulam district, AP, with brief discussion]
We need indicators beyond MMR, that treat birth not as an event to be survived so that the species continues, but as a significant life experience that can be joyful and meaningful for a woman in her own right. We should also see that women have the support they need to thrive, physically and emotionally, before, during and after giving birth. Yes, the government must provide access to institutional health facilities, but must also connect with and certainly not withdraw support from community-based and traditional health services.
Here is a book called “Birth Models that Work.” The author, Robbie Davis-Floyd, has studied birth in countries around the world and described the way birth is managed in the countries that have the highest standard of care, including but not limited to maternal and infant mortality. She described the common elements among the countries that are able to assure the best outcomes for all, regardless of income. In these countries, the health system integrates the traditional wisdom of normal birth and the modern technology required in case of complications, and uses technology rationally and not by default. Mothers, midwives and doctors work together, each respecting the role of the other. In these countries women are entitled to quality service whether they give birth at home or in an institution. Birth is considered normal, not an illness. Women trust their bodies and also trust the health system to provide care as needed.
Now comes my appeal – in India we need a Birth Model that Works. We need to bring midwives back into the health system and women should have access to institutional health services without being coerced to use them. Traditional midwives have not yet completely disappeared from India. We could design a health care model that allowed women to have access to midwife based care as well as access to institutional care and midwives could be empowered to refer cases to the institution where required. Women should receive maternity benefits regardless of whether they deliver at home or in an institution.
There are many details of how we can improve our policies to create a birth model that works, but at the heart of it is our attitude towards women and women’s bodies, which has to change at every level.
Even the selection process of the ASHA worker reflects the patriarchal assumption that a woman belongs to the village into which she marries. Therefore single women are not eligible to become ASHA workers, presumably because they will leave the village after marriage. Is it not possible that a woman may opt not to marry or may stay in her village after marriage? Why can’t she commute to work? And why can’t she cross that bridge when she comes to it? This is just one example of how assumptions about marriage and residence and belonging are written into women’s lives – to change the system we have to question these as well.
Next: Breastfeeding Models that Work.
The concerns stated at the 2009 meeting are reflected in a report issued by one of the organizations, Rural Women’s Social Education Center, Center-Staging Safe Delivery.
Studies of the Janani Suraksha Yojana:
Bharat Randive, Vishal Diwan, Ayesha De Costa, Published: June 27, 2013. DOI: 10.1371/journal.pone.0067452
Impact of Janani Suraksha Yojana on institutional delivery rate and maternal morbidity and mortality: an observational study in India.
India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation
Robbie Davis Floyd, Birth Models that Work, University of California Press, 2009.