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An intersectional approach to understanding demand for maternal health care services in rural Gujarat, India

Dr. Parthasarathi (PARTHO) GangulyIndian Institute of Public Health Gandhinagar (Public Health Foundation of India)

Dr Kate Jehan Dr Rachel TolhurstLiverpool School of Tropical Medicine, UK

Acknowledgement: This work is a part of MATIND project, funded through an EU FP7 grant

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Most vulnerable:

those with limited access to healthcare facilities due to poverty, remote location (e.g. tribal populations)

Most deaths avoidable with adequate interventions

Access to safe childbirth and Emergency Obstetric Care (EmOC) are key

1800 maternal deaths happen in Gujarat every year (SRS, 2011)

Chiranjeevi Yojana (CY) ‘Scheme for Long Life’ 2005 – present

1. Remove the cost barrier to emergency obstetric services

2. Raise demand for hospital deliveries and improve utilisation of services by poor women

3. Ultimately decrease maternal mortality (MMR) within the state

Aims3

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Government Health System (State & District)

Contracted private obstetricians (inclusion criteria: 10 beds, able to deal with

emergency, access to blood/aneasthetist)

Grassroots level health staff (incentivised to help register, motivate, accompany women)

Below poverty line & tribal women

FundsReporting

“Chiranjeevi Yojana” (CY) – Scheme for Long Life

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Research question

How do poor rural/tribal families make decisions about where a woman gives birth and what influence the CY scheme had on their decision making

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What are intersectional approaches?

Assess how multiple systems of disenfranchisement intersect to produce health inequalities.

Ask: how do the social determinants of health (e.g. gender, class, ethnicity, education, age and geography) interact on multiple levels?

The axes don’t act independently, but they interrelate, creating a system reflecting the "intersection" of multiple forms of discrimination which may contribute to social inequalities.

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Gender

Socio- economic

status

Education

Age

Location

Caste-ethnicity

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Our study: who we interviewed, where & when• In depth interviews with 22 rural families – below poverty line/tribal

• Single, paired or triad interviews with family members

• Respondents included: mothers of the child, parents/parents-in-law, husbands, uncles/aunts, sisters/brothers-in-law, other relatives

• Families lived in catchment area of CY provider and had one childbirth in past year

• 2 districts and 6 blocks (sub-district units) in Gujarat state(province), India

• Interviews conducted in November 2013 by me and Kate Jehan

• Representation of different socio-demographic factors: - religion- caste/community- type of family (nuclear/joint) - home delivery, institutional delivery, CY or non-CY deliveries

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1. Getting married off early

• Girls from poorer socio-economic backgrounds encouraged to marry early

• More likely to have birth complications• More need for institutional care and the scheme

“In our families, marriage happens at quite an early age. I got married at 14... she at 16. It should not be before 18 years […] “Our families do not educate children much. Boys go for driving [profession]… girls get married off early.”

(Int.15 , a young mother from minority community)

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2. Lack of awareness about such schemes

• Alongside work in the home, poor women spend much of their time in labour work in the field. Women do not get the time to know/enquire about such schemes. As one of them said:

“We do not know [about the scheme]..... whole day we are doing hard labour in the field... We do not have time for this....”

(Int. 7, a middle aged mother from nuclear family - migrant agricultural labourer)

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3. Difficulty in accessing the scheme

Scheme involves complicated administrative procedures; rural poor women report finding it intimidating and their ability to engage is constrained in absence of male members in family:

“We need to get the signature of many people... The sarpanch [village headman], talati [local govt office], and had to get photocopy of election card and many other papers”

(Int. 20, a very young tribal mother from remote area)

“Who will go for arranging all those papers?....My husband works in Army…he was posted in Assam during childbirth……we did not have proper people around [male family member who could take care of the paperwork]”

(Int.17, a mother from a nuclear family)

Migrant women labourers find it difficult to get a BPL card:“We do not have ration card here, so could not do that…we have our BPL card in Chotila…we belong to Chotila…living here just for labour work….since last 5-6 yrs”

(Int.7, a middle aged mother- migrant agricultural labourer)

After marriage women lose the benefit of parent’s BPL card:“We showed the card [BPL] to the doc but he told that her name is not in this card, so can not get benefit” (Int.16, a young lady from religious minority community)

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4. Lack of empowerment • Poor women report feeling unable to question healthcare

providers• Feel afraid to use the scheme with the fear that private

doctors encourage patients to undergo unwanted C-sections and charge them extra money

• Inability to make choices or demand the care they want

"In private hospital, if they struggle to do normal delivery, [they] immediately go for C-section….”

(Int.1, an agricultural labourer mother)

“If we go to hospital [Pvt.], most likely it will be C-section and then it will be costly too”

(Int.4, young illiterate mother)

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5. Educational Status

• Poor women in rural/tribal areas less likely to be literate. • Unempowered to make informed decisions or forced to depend

on men for decision making

“I don’t know about that [CY scheme], my husband has studied up to 8th standard [8 yrs of schooling], he knows about it, so he filled up all the forms”

(Int.21, middle aged, illiterate mother from a tribal area)

“My brother in law is literate so he knows everything well….he has studied till 4th or 5th standard”

(Int.4, young illiterate mother)

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6. Lack of decision-making power

• In patriarchal systems, younger members of the family have less decision-making powers than older members, and younger women generally have less power than older women. Only in later years in the household - as their ‘reward’ for subservience in their junior years - are older women granted more decision-making power (Kandiyoti, 1988).

"In general, everyone in the family obeys the decisions of my father-in-law. [In matters of childbirth however] both my mother-in-law & father-in-law jointly decide. […] In other family matters, it’s the father-in-law who decides. I have to go where-ever my in-laws take me”

(Int.17, mother with 7 years schooling)

“[Decision is made by] Mother-in-law, whatever she says we have to do that, we have to go to the hospital of her choice….. (int.15, young mother, religious minority community, 7 yrs schooling)

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7. Avoid long absences from the home

• Poor, rural women report wanting to spend as little time as possible in hospital for childbirth as their labour work is needed in the home (preparing food, looking after other children) or in the field.

“[We] called up the ambulance only when the membrane ruptured” (Int.4, young illiterate mother)

“We are labour class people, so can not go early to hospital ...till the day of delivery we need to work [for earning money or managing the home]…we don't have peace even on those days” (Int. 7, a middle aged mother from nuclear family - migrant agricultural labourer)

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8. Dependence on immediate social network / trusted people for advice

• Mobility of poor rural women less than that of men or richer, more educated women. Rural women generally do not go far beyond own villages.

• Close social networks and trusted local health providers are more important source of information than mass media and other sources usually employed by government.

• Rural women and families report paying more importance to previous experience or immediate trusted neighbours’/relatives’ advice.

“Paruben [health worker] had given us forms to be filled up” (Int.1, a mother with some education)

“A relative works as a nurse in a hospital…she informed us….” (Int. 5, a mother with 9 years education)

“my brother took her wife there at the time of her delivery, so it was already decided that I am also going there for delivery” (Int. 8, young illiterate mother)

“Sakhi Mandal [Ladies group] ladies told us [about the scheme] (Int.11, husband)

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9. More at ease receiving care near the home and by known/trusted provider

• Poor rural/tribal women report feeling apprehensive about travelling far from home for child birth:

“It [home delivery] is good, that we don’t have to go out anywhere and all that journey, packing and all can be avoided…“ (Int 5, Mother-in-law)

“[At home] we do not get good facilities but we save transport expense...we are labourers so we can save expense. If we go to government hospital we spend money in purchasing medicines [from outside], getting tests [laboratory] from outside….we can‘t bear such expenses. A labourer can feel sir [the pinch]… so we don’t have options [apart from childbirth at home]" (Int. 7, a middle aged mother from nuclear family - migrant agricultural labourer)

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Summary

We have looked at the coexistence and interaction of a number of factors influencing the demand for maternal health services in Gujarat:

• Poverty• Gender• Age• Education• Caste-ethnicity• Geographical location

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Conclusions (I)

• An intersectional analysis of the data finds that poor, non-literate women of reproductive age in rural areas have little decision-making power over where to give birth. Decisions are mostly made by more senior women in the family, male relatives, or those perceived to be ‘more educated’

• Poor, non-literate women in rural areas struggle to access the benefits of schemes like “Chiranjeevi Yojana” which encourage hospital births, due to a number of factors, including: lack of time, mobility, awareness, intimidating documentation and inability to secure proof of eligibility from Govt. authorities

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Conclusions (II)

• Poor rural women are apprehensive of going to a city hospital for childbirth due to fear of C-sections and an inability to question health providers, lack of comfort and lack of familiarity (e.g. care received by an unknown health worker or prohibition of family members in the labour room)

• Due to these factors and families’ desire to capitalise on women’s

labour in the home and in the fields, such women often delay seeking care, often until it is too late to access a hospital.

Chiranjeevi Yojana (CY) ‘Scheme for Long Life’ 2005 – present

1. Remove the cost barrier to emergency obstetric services

2. Raise demand for hospital deliveries and improve utilisation of services by poor women

3. Ultimately decrease maternal mortality (MMR) within the state

Aims21

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Policy implications

Conclusions

• Not truly able to address the needs of the rural poor families

• Many barriers other than cost

• Apprehension about city hospitals

• Comfort in more homely atmosphere & known people

• Personal experience/ relationships influence decision making

Policy Implications

• Efforts to address the barriers other than cost

• Explore options for improving access to safe birth attendance - geographically and socially closer to women (Govt. peripheral health centers & ANM-Auxiliary Nurse Midwife)

• Develop good referral structure as a back up for emergency obstetric care in complicated cases

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Contact mail: psganguly@iiphg.org