To begin, I will discuss what a maternal mortality rate is and the current rate as of 2016 in India. According to the Journal of Krishna Institute of Medical Sciences University (JKIMSU), a maternal death is the, “…death of woman while pregnant or within 42 days of termination of pregnancy…” (Shrotri, 2014). The maternal mortality rate is India responsible for 1/5 of the global burden of maternal deaths in the world. (Montgomery, et al., 2014) Although, according to Government of India, the maternal mortality ratio has been lowering since 2004. In 2004-2006, the maternal mortality ratio was 254 per 100,000 live births compared to the lowest ratio yet in 2014-2016 of 130 per 100,000 live births. (MMR) The lowering rates can be attributed to the various governmental policies that have been implemented in response to the global health problem of high mortality rates. (Shrotri, 2014) The prevalence of high maternal mortality rates can be attributed to many societal determinants that have an instrumental part and influence on the health of women in this country.
I will discuss the ways in which the social gradient within the country, stress and social factors, and transport issues are all social determinants of health within this country. To begin, a social determinant of health are the circumstances that an individual is born into that have effects on their life chances, their socioeconomic status, their environment, their health, etc. The social gradient within India looks at a person’s economic wealth and then compares that to their health. On the table in the WHO article provided during Week 6, they used life expectancy to show how a person’s occupation and wealth can be directly related to the number of years they lived. (Activity PDF 6.3) People who have the least skills and who make the least amount of money often die at an earlier age than those with professional careers. (Activity PDF 6.3) In India, it has been found that nearly a quarter of the population lives below the poverty line (Pathak et al., 2010, Pg. 2) The article has configured that more than half of the country lives in poverty, which means that in most cases, women are not seeking maternal care services necessary for a healthy and successful birth experience. (Pathak, et al., 2010, Pg. 2) In areas where income is higher and the residents all live above poverty, the maternal mortality rates were extremely low in comparison. (Pathak, et al., 2010, Pg. 2) Comparing the maternal mortality rates of those families in poverty and those who are not, it is safe to say that income is an important factor on the quality of services and care that individuals will seek during pregnancy and for delivery. Residents in rural areas of the poorer states suffered more loss in proportion to those who lived in urban areas of richer states. (Montgomery et al., 2014)
The social gradient within India can also be aligned with the feminist theoretical perspective. When analyzing the differences in socioeconomic factors and areas of poverty in relation to maternal mortality, it is important to also try to understand why these differences exist. For instance, a portion of the reason in which women do not seek efficient health services before and after they give birth is because of economic factors. Women in India suffer from poverty because of the low literacy levels and the inability to achieve financial stability or autonomy. (Pathak, et al., 2010, Pg. 2) Because India is a patriarchal society, males within society are given power and preference, while women are socialized to become good wives and mothers. The women of society are important for the upkeep within the household and is responsible for taking care of the children, but they rely heavily on the males of society for their economic needs and social status within society. (Chakraborty & Thakurata, 2013)
One of the things I found interesting about women in India is the way in which they are conditioned to keep their menstrual systems and sexuality a hidden phenomenon. For instance, when a girl reaches puberty, she likely has her menarche (first menstrual cycle) and then she is considered a woman in society. With the status of womanhood comes constraints and gender norms that are expected of her. For instance, in northern parts of India, women suffer from PCOS (Polycystic Ovary Syndrome) which has been linked to improper cleansing of the genital area. The syndrome is genetic and is often passed down through generations, but it is very rarely discussed amongst daughters and family members and is almost never taught in schools throughout society because of the taboo on menstruation and the female reproductive system. (Tabooed disease…, 2017) Women are ashamed to admit they have PCOS and hide it from others until it becomes too late. The effects of prolonging this condition without seeking proper treatment or care can inevitably lead or contribute to the maternal mortality rate. A woman may also hide this condition because money is tight and they do not want to spend their family’s money on their ‘womanly’ condition, so they hide it do to economic factors. This also contributes to the high rates.
Another interesting article I read on women in India has to do with women removing their wombs in the western part of India so they can continue working in the field. (Pandey, G. 2019) Since periods are considered unclean and are taboo in society, women are not allowed to work while they are on their periods. Which forces them to miss periods of work each month until they have finished their menstruation cycles. In response to this, and because of their need for money, women will get hysterectomies in order to prevent them from needing to miss work. (Pandey, G. 2019) This has to do with their low-socioeconomic status and the lack of education to what the implications of what the removal of their uterus will do to their bodies afterwards. (Pandey, G. 2019) In response to this, many women have asked for menstrual leave policies that allow them to take necessary time to take care of their menstrual cycles. One of the valid arguments in support of this states that since women make substantially less than men, a leave would not even compensate women enough to make up for the wage gap between men and women. (Prasad, 2018)
The second social determinant of health I wanted to discuss is stress. Stress is directly related with the family income and how much money the family can afford to spend on health services during pregnancy and delivery. In a family that has low income, they are likely to stress about health services and how they will afford to deliver a child if there are complications. There ma be additional physiological stress on the mother if she is also forced to work long and demanding hours in the sugarcane fields to provide for her family. In many ways, lacking income and having to stress about material needs will likely result in psychological stress which can exacerbate the rates of maternal mortality.
Through the feminist perspective, stress on women can also be attributed to their gender roles in society and how women are expected to multi-task by taking care of the household while also making a living to either gain financial stability or to provide additional income for the household. There is also stress from wanting to meet social expectations and gender norms. For instance, some of the maternal deaths occurred because of women’s preference and the social pressure behind giving birth to a son instead of a daughter. With a lack of counselling following birth and the economic factors behind a woman not being able to seek these types of services, the social pressures and stress could lead to women making harsh and impulsive decisions. (Kaur, et al., 2018) Social factors can also prevent women from discussing dangerous diseases such as PCOS, abnormal reproductive cycles, and infertility for fear of tarnishing their social image and status in society. (Tabooed disease… 2017) For instance, with infertility (which could be caused by many intersectional factors), women often feel as though they cannot fulfill their social identity until they have given birth. As discussed in the Tabooed disease article, “…a woman is considered to be complete only when she bears a child, and when she fails to do so, she is known as a ‘barren’ woman…” (Tabood disease…, 2017, Pg. 133) These social factors and stress placed on women definitely contribute to the factors in which maternal mortality rates are high.
The final social determinant of health I wanted to discuss is transportation. In India, a high proportion of the connected maternal mortality rates are tied to rural communities in India. Whether there is no form of transportation available, whether the health services were too far away given their limited amount of time, or whether the roads are in such poor conditions that travel is unsafe. Whatever the cause may be, transportation seems to play a role in the high maternal mortality rates—especially in the rural parts of the country. In an article by Kaur, et al., they analyzed different social factors on maternal mortality and 10% of the deaths that occurred during their study were the result of transportation delays. (Kaur, et al., 2018, Pg. 10) This rate shows significance in the transportation that is available to families living in areas that must travel in order to seek care.
Which brings me to the feminist perspective of this determinant which can be viewed by the way in which women have access to reliable vehicles for transport. A woman living in the poor rural communities is either working in a field or is at home taking care of the household. In either scenario, they are likely to be at the mercy of whoever is closest in transporting them to a medical facility. For this reason, women will likely choose to deliver their children at home. Which leads to a delay in getting to the hospital in time, because they wait until something serious happens before they decide to travel to the hospital for assistance. This gives them a very narrow window to leave their home and transport, let alone giving themselves enough time to find a reliable form of transportation, a decent route with good roads, or a short commute. Transportation can be seen as a barrier for many women—especially in rural parts of India. This can lead to unsafe and discouraged methods of birthing and choosing not to use medical services for assistance in delivery.
In conclusion, there are quite a few social determinants of health that contribute to the high maternal mortality rates in India. When analyzed through a feminist theoretical perspective, it is also shocking how much social pressure to conform to an expected identity, attempting to acquiesce to gender norms, and how socioeconomic status and economic factors can contribute to something that is often perceived as an issue that lies within the eye of the beholder. Because of India’s socialization of women to keep their reproductive system processes private and discussion of these very normal biological processes are tabooed, it has contributed to a victim-blaming issue that results in women dying due to numerous intersectional factors that should be discussed and approached institutionally. I have attempted to list all of the ways in which societal determinants of health can be viewed through a feminist theoretical approach as the causes for the high maternal mortality rates present in India. After reading all of this information, I am hopeful that the maternal mortality rates in India continue to lower and that visibility and exposure of this issue brings some resolve.
Activity PDF 6.1: Marmot (2005) – “Social determinants of Health Inequalities”
Activity PDF 6.3 WHO (2003) – “Social Determinants of Health: The Solid Facts”
Chakraborty, K., & Thakurata, R. G. (2013, January). Indian concepts on sexuality. Retrieved July 12, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705691/
Goldie, S. J., Sweet, S., Carvalho, N., Natchu, U. C., & Hu, D. (2010). Alternative Strategies to Reduce Maternal Mortality in India: A Cost-Effectiveness Analysis. PLoS Medicine, 7(4), 1-17. Retrieved July 26, 2019.
Kaur, M., Gupta, M., Pandara Purayil, V., Rana, M., & Chakrapani, V. (2018). Contribution of social factors to maternal deaths in urban India: Use of care pathway and delay models. PloS one, 13(10), e0203209. doi:10.1371/journal.pone.0203209
Maternal mortality drops to 130, Kerala top, big improvement in backward states. (2018, June 7). The Times of India. Retrieved July 26, 2019, from https://timesofindia.indiatimes.com/india/maternal-mortality-drops-to-130-kerala-top-big-improvement-in-backward-states/articleshow/64486279.cms
Maternal Mortality Ratio (MMR) (per 100000 live births). (n.d.). Retrieved from https://www.niti.gov.in/content/maternal-mortality-ratio-mmr-100000-live-births
Montgomery, A. L., Ram, U., Kumar, R., & Jha, P. (2014). Maternal Mortality in India: Causes and Healthcare Service Use Based on a Nationally Representative Survey. PLoS ONE, 9(1). doi:10.1371/journal.pone.0083331
Pathak PK, Singh A, Subramanian SV (2010) Economic Inequalities in Maternal Health Care: Prenatal Care and Skilled Birth Attendance in India, 1992–2006. PLoS ONE 5(10): e13593. doi:10.1371/journal.pone.0013593
Pandey, G. (2019, July 05). Why are menstruating women in India removing their wombs? Retrieved July 12, 2019, from https://www.bbc.com/news/world-asia-india-48836690
Prasad, U. (2018, June 07). India needs a menstrual leave policy. Retrieved July 12, 2019, from https://www.thehindubusinessline.com/opinion/india-needs-a-menstrual-leave-policy/article24105589.ece
Shrotri, A. (2014). Editorial: Towards Reducing Maternal Mortality in India. Journal of Krishna Institute of Medical Sciences University, 3(1), 1-5. Retrieved July 26, 2019.
Statistics. (2013, December 27). Retrieved from https://www.unicef.org/infobycountry/india_statistics.html#119
Tabooed disease in alienated bodies: A study of women suffering from Polycystic Ovary Syndrome (PCOS). (2017, September 08). Retrieved July 12, 2019, from https://reader.elsevier.com/reader/sd/pii/S2213398417300593?token=BC8E6CDE046E9297C930125E5E61EDC3B7CA8DA1AA19199F353F5FE8D41B6CD114A511655A48C4DD28798230D09033D9