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Thesis:KaveriMayra(2021)"’Womenaresupposedtoendurethat!’Acriticalfeministexploration

ofobstetricviolenceinwomen’sandmidwives’birthnarrativesinIndia",Universityof

Southampton,FacultyofSocialScience,PhDThesis,pp305.

UniversityofSouthampton

FacultyofSocialSciences

DepartmentofSocialStatisticsandDemography

‘Womenaresupposedtoendurethat!’Acriticalfeministexplorationofobstetric

violenceinwomen’sandmidwives’birthnarrativesinIndia

by

KaveriMayra

ORCIDID0000-0001-8395-0738

ThesisforthedegreeofDoctorofPhilosophy

November2021

UniversityofSouthampton

Abstract

FacultyofSocialSciences

ThesisforthedegreeofDoctorofPhilosophy

‘Womenaresupposedtoendurethat!’Acriticalfeministexplorationofobstetricviolencein

women’sandmidwives’birthnarrativesinIndia

by

KaveriMayra

Birthandviolenceagainstwomenaresensitiveareasofresearchsurroundedbyathickculturalsilence.

Womenaroundtheworldexperiencedifferentformsofobstetricviolenceduringchildbirthinavarietyof

settingsbyprovidersandsupportworkerswithinhealthcaresystems.Whilethereisevidenceofobstetric

violenceasaglobalissue,moresystematicexplorationisneededonitscausesfromtheperspectivesof

womenandtheircarers.Obstetricviolenceiscloselylinkedwithissuesofwomen’spositioningatthe

intersectionsofdifferentformsofoppressionandtheirexperiencesandperceptionsofobstetricviolence

canbeinfluencedbysocio-cultural,demographicandeconomiccharacteristics,theirimmediatecontexts,

theirreproductivehistoriesandgeographies.Inthisthesis,Iapplyafeministperspectivetoexplorethe

natureofobstetricviolenceandthefactorsthatmakeswomenvulnerableduringchildbirth,considering

thatwomen’sandnurse-midwives’perspectivesandexperiences.Ifirstconductaquantitativeexamination

ofthedeterminantsofobstetricviolenceinoneoftheeconomicallydeprivedstatesofBiharinIndia,and

findwomen’sexperiencesofobstetricviolenceareoftenpluralandmulti-layered.Age,parityand

educationarefoundstatisticallysignificantattributesthatincreasewomen’svulnerabilitytoobstetric

violenceinBihar.Ifollowthiswithaqualitativeexplorationthroughparticipatoryarts-basedmethodsto

cutacrossthepower-basedandlanguage-basedbarriersandlearnfromandpresentwomen’sembodied

experiencesofchildbirthandobstetricviolence.Iusedfeministmethodssuchasbirthmapping,birthing

story,poeticinquiry,feminist-relationaldiscourseanalysisandvoice-centeredrelationalanalysisfordata

collection,analysis,interpretationandpresentation,tobringforthwomen’sandnurse-midwives’voiceson

thissensitiveembodiedissue.Myresearchindicatesthatthedeterminantsdrivingobstetricviolenceare

relatedtowomenandtheirnurse-midwives,attheindividuallevel,intheirimmediatebirthing

environmentandinthelargersocialandpolicylevel.Gender,power,cultureandstructurearethekey

themesholdingtheindividualandtheinteractionsofthedeterminantsleadingtoobstetricviolence.They

needtobeaddressedateachoftheselevelsthroughmulti-sectoralapproacheswithwomenandtheir

midwivesaskeystakeholdersdrivingthechangetowardsensuringrespectfulmaternitycare.

Keywords:Obstetricviolence,Feministmethods,Respectfulmaternitycare,Bodymapping,Birth,Nurse,Midwife,Healthsystems,Bihar,India

Idedicatemydissertationtowomen

Womeninmylife,mymother,mysister,myniece,mygrandmother,myfriends,mymidwives,

mynurses,mytribe.Womenwhohaveexperiencedrespectfulcareandobstetricviolenceduring

childbirth.

Womenwhohavekindlyandbravelysharedtheirstoriesofbirthandviolence.

LineartofabirthmapbyAditiParischa

TableofContents

i

TableofContents

TableofContents............................................................................................................i

TableofTables.............................................................................................................vii

TableofFigures.............................................................................................................ix

TableofBoxes..............................................................................................................xii

Introduction........................................................................Error!Bookmarknotdefined.

ResearchThesis:DeclarationofAuthorship.................................................................xix

Acknowledgements.....................................................................................................xxi

DefinitionsandAbbreviations....................................................................................xxv

Chapter1 Whystudyobstetricviolence?.....................................................................1

1.1 Introduction...............................................................................................................1

1.2 Researchobjectives...................................................................................................4

1.3 Researchquestions....................................................................................................4

1.4 Thesisorganisation....................................................................................................4

Chapter2 ObstetricViolence:Aliteraturereview&positionality................................7

2.1 Obstetricviolencefromarightsperspective.............................................................8

2.2 ‘Obstetricviolence’:Terminologies,definitions,resistance,movementsandthe

history......................................................................................................................10

2.3 Typesofobstetricviolenceduringchildbirth..........................................................17

Source:Bohrenetal.2015................................................................................................19

2.4 Globalevidenceofobstetricviolenceduringchildbirth..........................................19

2.5 Impactofobstetricviolenceduringchildbirthonhealthandwellbeing.................22

2.6 Determinantsofobstetricviolenceduringchildbirth.............................................23

2.6.1 Individualandhouseholddriversofobstetricviolence...................................24

2.6.2 Systemicdriversofobstetricviolence.............................................................25

2.7 Situating‘obstetricviolence’withingender-basedviolence...................................28

2.8 Positionality:Myassociationwith‘obstetricviolence’...........................................29

2.9 Summary.................................................................................................................32

Chapter3 BirthinginBihar:settingthecontext.........................................................33

TableofContents

ii

3.1 QualityofmaternalcareinIndia.............................................................................33

3.2 EvidenceofobstetricviolenceduringchildbirthinIndia........................................34

3.3 ThestateofmidwiferyeducationinIndia...............................................................36

3.3.1 Pre-serviceeducation......................................................................................36

3.3.2 In-serviceeducation........................................................................................37

3.4 Bihar........................................................................................................................39

3.5 MaternalhealthcareinBihar..................................................................................40

3.6 StatusofwomeninBihar........................................................................................42

3.7 Pleasure,shame,endurance:conversationsaroundbirthing.................................44

3.8 ViolenceagainstwomeninBihar............................................................................45

Chapter4 Shesmileswhenshetalksaboutviolence:Epistemologicalunderpinnings

andmethodologicalapproaches................................................................47

4.1 Epistemologicalunderpinnings...............................................................................47

4.1.1 Feministtheory................................................................................................49

4.1.2 Criticalfeministtheory....................................................................................49

4.1.3 Feministstandpointtheory.............................................................................51

4.1.4 Intersectionality...............................................................................................53

4.2 Conceptualframework............................................................................................54

4.3 Studydesignandanalysis........................................................................................56

4.4 Researchethicalapproval.......................................................................................59

Chapter5 SocialdeterminantsofobstetricviolenceinBihar:evidencefroma

householdsurvey......................................................................................61

5.1 Introduction.............................................................................................................61

5.2 Objective..................................................................................................................63

5.3 Methods..................................................................................................................63

5.3.1 Datacollection.................................................................................................64

5.3.2 Dataanalysis....................................................................................................65

5.4 Results.....................................................................................................................66

5.4.1 Participantprofile............................................................................................66

5.4.2 Experienceofobstetricviolence.....................................................................69

TableofContents

iii

5.4.3 Socialdeterminantsofobstetricviolence.......................................................77

5.5 Discussionandconclusion.......................................................................................89

Chapter6 Whatdoeswomen’sexperienceofrespect,disrespectandabuselooklike?

Breakingthesilencesurroundingobstetricviolence..................................93

6.1 Background..............................................................................................................93

6.2 Researchquestions..................................................................................................96

6.3 Objectives................................................................................................................96

6.4 Methods..................................................................................................................96

6.4.1 Bodymapping..................................................................................................98

6.4.2 Planningthedatacollectionwithbodymapping..........................................100

6.4.3 BirthmappinginBihar...................................................................................102

6.4.4 Methodologicalchallenges............................................................................104

6.4.5 Dataanalysis..................................................................................................105

6.4.6 Positionalityandreflexivity...........................................................................108

6.5 Findings..................................................................................................................109

6.5.1 ‘Good’births,‘Bad’birthsandexpectedbirths.............................................111

6.5.2 Respect,disrespectandabuseduringmedicalinterventions.......................130

6.5.2.1 Painmanagement...............................................................................133

6.5.3 Birthsetting/placerelatedrespect,disrespectandabuse............................134

6.5.4 Respect,disrespectandabuserelatedtobirthingenvironment..................138

6.5.5 Respectful,disrespectfulandabusivecommunicationaroundchildbirth....144

6.5.6 Respectful,disrespectfulandabusivepeoplearoundchildbirth..................150

6.5.7 Respect,disrespectandabuseinpersonalspaceandrelationships:household

andhusband..................................................................................................161

6.5.8 Birthinginformation,birthpreparednessandmythsaroundbirth...............167

6.6 Discussion..............................................................................................................171

6.7 Strengthsandlimitations......................................................................................176

6.8 Conclusion.............................................................................................................176

Chapter7 “Ihavetolistentothemortheymightharmme”:Whydowomenendure

obstetricviolence?..................................................................................178

TableofContents

iv

7.1 Background............................................................................................................178

7.2 Researchquestion.................................................................................................179

7.3 Objective................................................................................................................180

7.4 Findings..................................................................................................................180

7.4.1 Powerinfluencescareduringchildbirth........................................................180

7.4.2 Genderinfluencescareduringchildbirth......................................................185

7.4.3 Structureinfluencescarearoundchildbirth..................................................189

7.4.4 Cultureinfluencescarearoundchildbirth.....................................................194

7.5 Discussionandconclusion.....................................................................................197

Chapter8 “It’seasytoabuseobesewomen!”:Whydosomecareprovidersengagein

obstetricviolence?..................................................................................202

8.1 Background............................................................................................................202

8.2 Researchquestion.................................................................................................204

8.3 Objectives..............................................................................................................205

8.4 Methods................................................................................................................205

8.4.1 Studyinstrument...........................................................................................206

8.4.2 Datacollection...............................................................................................207

8.4.3 Dataanalysis..................................................................................................208

8.4.4 Positionalityandreflexivity...........................................................................208

8.5 Findings..................................................................................................................209

8.5.1 Reactiontothepaintingofawomangivingbirth.........................................210

8.5.2 Factorsbehinddisrespectandabuseofwomenduringchildbirth...............211

8.5.2.1 Woman-relatedfactors.......................................................................211

8.5.2.2 Nurse-midwiferelatedfactors............................................................214

8.5.3 Participant’srecommendationsforrespectfulmaternitycare.....................218

8.5.4 Respectfulmaternitycareeducationforthenextgenerationofcare

providers........................................................................................................222

8.5.5 Domidwiveshaverespectfulbirths?............................................................224

8.6 Discussion..............................................................................................................225

8.7 Limitations.............................................................................................................228

TableofContents

v

8.8 Conclusion.............................................................................................................229

Chapter9 Expectedrespectabilityfromanintersectionallens:discussionand

conclusion...............................................................................................230

9.1 Expectedrespectability.........................................................................................230

9.2 Applyinganintersectionallens..............................................................................233

Chapter10 Summary,policyrecommendationsandwayforward.............................235

10.1 Summaryofresearch............................................................................................235

10.2 Researchcontributions..........................................................................................236

10.3 Policyrecommendations.......................................................................................237

10.4 Limitations.............................................................................................................238

10.5 Futureresearch.....................................................................................................238

Postscript:Thestoryofmybirth.................................................................................241

AppendixATrahi’sbirthingexperience......................................................................245

AppendixBBodymappingaidedin-depthinterviewguide.........................................247

AppendixCNursemidwives’perspectivesonrespect,disrespect&abuseduring

childbirth.................................................................................................251

AppendixDKnowledgetranslation.............................................................................254

ListofReferences.......................................................................................................259

TableofTables

vii

TableofTables

Table2.1 Violationwomen’srightduringchildbirth........................................................9

Table2.2 Definitionsofdisrespectandabuse;andobstetricviolenceduringchildbirth13

Table2.3 Typologyofmistreatmentofwomenduringchildbirth..................................18

Table3.1 IndicatorsofviolenceagainstwomeninBiharandIndia...............................45

Table4.1 Studydesign....................................................................................................56

Table5.1 Participantprofile...........................................................................................67

Table5.2 Participant’sbirthrelatedvariables................................................................69

Table5.3 Typesofmistreatmentduringchildbirthexperiencedbywomen..................72

Table5.4 Percentageofwomenreportingobstetricviolencebywomen’sbackground74

Table5.5 Binarylogisticregression(oddsratio)(95%CI)...............................................79

Table5.6 Factoranalysis.................................................................................................83

Table5.7 Linearregressioncoefficientsofbackgroundcharacteristicsandthenew

obstetricviolencescores.................................................................................88

Table6.1 ParticipantsProfile........................................................................................110

Table6.2 Women’sunderstandingofgood,badandexpectedbirth..........................112

Table6.3 Women’sexperienceagainstBohrenet.al’sadaptedcategoriesofmistreatment

duringchildbirth............................................................................................119

Table8.1 Participantbydomainofleadership.............................................................205

Table8.2 Participantprofile.........................................................................................209

TableofFigures

ix

TableofFigures

Figure1.1 TheWHOqualityofcareframework(Source:WHO,2018,p.12)....................2

Figure2.1 Definitionofdisrespectofabuseduringchildbirth(Source:Freedmanetal.,

2014,p.916)...................................................................................................12

Figure2.2 Terminologicalterritoriesaround‘obstetricviolence’(Author’sown)...........14

Figure2.3 Evidenceofmistreatmentofwomenincountriesaroundtheworld(Author’s

own)................................................................................................................20

Figure2.4 Determinantsofdisrespectandabuseduringchildbirth................................24

Figure2.5 Personalchallengesinmidwifery(Source:Filbyetal.,2016,p.15)...............26

Figure2.6 Structuralandpolicychallengesinmidwiferycare(Source:Bradleyetal.,2019.

p.4).................................................................................................................27

Figure2.7 Meandmyclassmatesinouruniform............................................................31

Figure3.1 MapshowingpercentagesofinstitutionalbirthsinIndiabystate(Source:IIPS,

2015)...............................................................................................................34

Figure5.1 Socialdeterminantsofmaternalhealth(Source:Khanna&Sri,2018.p.194)63

Figure5.2 Women’sexperienceofobstetricviolenceunderBohrenetal.typology(2015)

........................................................................................................................70

Figure5.3 Thenumberoftypesofobstetricviolencesufferedbywomen.....................77

Figure5.4 ScreePlot........................................................................................................81

Figure5.5 Meanscoresofobstetricviolencebyagegroup............................................84

Figure5.6 Meanscoresofobstetricviolencebyeducation............................................85

Figure5.7 Meanofobstetricviolencebysocio-economicstatus....................................86

Figure5.8 Meanscoresofobstetricviolencebycaste....................................................86

Figure5.9 Meanscoresofobstetricviolencebyparity...................................................87

TableofFigures

x

Figure6.1 Themesofexplorationforrespect,disrespectandabuseduringbirth(Author’s

own)................................................................................................................97

Figure6.2 Birthmappingpilot.......................................................................................101

Figure6.3 Birthingmappinginaction............................................................................103

Figure6.4 Feministrelationaldiscourseanalysis...........................................................107

Figure6.5 Thehybridmapoftheworstexperiencefromtheeightbodymaps...........122

Figure6.6 Birthingposturesofwomen(Author’sown).................................................127

Figure6.7 Anju’sbodymapshowingherhomebirths..................................................129

Figure6.8 Birthplaceoptionsandchanges(Author’sown)..........................................135

Figure6.9 Ria’sBodyMap..............................................................................................140

Figure6.10 Levelsofprivacytobeprotectedforthewomeninbirthingroom(Author’sown)

......................................................................................................................141

Figure6.11 Pairo’sBodyMap..........................................................................................143

Figure6.12 Pratima’sbodymap......................................................................................157

Figure6.13 Sujata’sbodymap.........................................................................................158

Figure6.14 Amrita’sbirthmap........................................................................................166

Figure6.15 Rangeofwomen’scontrapuntalvoicesaboutselfdecision-makingandsurrogate

decisionmakingduringchildbirthandinlife(Author’sown).......................172

Figure7.1 Hierarchyofpowerrelations(Author’sown)................................................180

Figure7.2 Urmila’sbirthmap........................................................................................192

Figure7.3 Impactofgender,power,culture&structureonwomen(Author’sown)...198

Figure8.1 FlashcardshowingabirthingenvironmentinIndia.....................................207

Figure8.2 RecommendationsforrespectfulmaternitycareinIndia(Author’sown)....219

Figure8.3 Midwiferyleaders’perceptionsofobstetricviolence(Author’sown)..........226

Figure9.1 ContinuumofRespectfulExperiences(CORE)model(Author’sown)..........231

xi

Figure9.2 Intersectionalitywheelofobstetricviolence(AdaptedfromSimpson,2009,p.3)

......................................................................................................................234

TableofBoxes

xii

TableofBoxes

Box6.1 Pairo’sI-poem-Thisisthefateofwomenandwomenmustendureit!.......132

Box6.2 Pratima’sI-poem-Bornathome...................................................................137

Box6.3 Sita’sIpoemonJananiSurakshaYojana(JSY)..............................................138

Box6.4 Pairo’sI-poem-Doll.......................................................................................147

Box6.5 Urmila’sI-poem-Theladydoctorwasreallynice!........................................152

Box6.6 Ria’sI-poem-Thedeadbaby.........................................................................160

Box6.7 Ria’sI-poem-Ithasstayed............................................................................163

Box6.8 Urmila’sI-poem-Inevermadeadecisionaboutmyself...............................164

Box6.9 Amrita’sIpoem-Becauseofhim,Iaminthissituation!..............................167

Box6.10 Pairo’sIpoemaboutconversationaboutbirthingandpreparedness..........169

Box7.1 Pairo’sbirthingstory.....................................................................................184

Box7.2 Amrita’sI-poem-‘I’.......................................................................................187

Box7.3 Urmila’sbirthingstory...................................................................................193

Box7.4 Ria’sIpoem-HadIbeenfairerandhadbirthedaboy..................................196

Preface

xiii

Preface

‘I’

Iamarestlesssoul

Ilovedancing

IwastwoorthreewhenIfirstperformedonstage

Iamlovedfordancing

Iamstigmatisedfordancing

Ihadanomadicupbringing

ImovedtoanewstateinIndiaevery3-4years,myfatherisaretiredairman

IgetrestlesswhenIliveinastateorcountryformorethan3years

Ifeelrootsgrowingfrommywholebody

Ifindanewdestination,Imove

Iwaseducatedbymymother,shewasmymostpersistentteacher,verystricttoo

Iamadoctoralresearcher

Iamamidwiferyresearcher

Ihaveassistedchildbirths,themostlifechangingexperience

Iamanursingresearcher

Ihavefeltlifeleavingpeople’sbody

Ihavewashedthatbodyforthefamily

Preface

xiv

Igetattached

Iadvocate forgender-equality, for respectfulcare, fororgasmequality, formidwives’&

nurse’sroleinhealthpolicymakingandagainstallformsofgender-basedviolence

Iamafeminist

Iamaglobalhealthleader

Idoabitofsalsa,swing,bachata,folk,classicalandawholelotoffreestyle

Idanceintheshower

IdancewhenIcook

Ilovetravelling

Ihaveledcampaigns

Ilovecooking,Iamnotafoodie,Iamafussyeater,Ilovepostoandchingri

Ilovetherapy

Iwantedtoflyplanes

Idonotlikemaths

Ilovetalkingaboutintersectionality,positionality,inclusivityanddiversity

Ilovepeople

Ilovepeople’sstoriesofbirth

Idobirthmapping

Iampassionate,Iamkind,Iamveryweird

Ihavebeensexuallyharassed,multipletimes,atallages

Ithinkthestigmaaroundfemalemasturbationshouldend

Ithinkwomenexperiencingpleasureissexy

Iamaconfidentpublicspeaker

IamanervouswreckbeforeIfaceanaudience

Iamimpatient,Iamincapableofmeditating

Preface

xv

Iloveresearch,Ihavealwayslovedresearch

Iamawomanofscience

Ihavemadeawesomefriends,99%don’tlivearoundme

Ihaveasister,Keya,sheismylife,wehaveourparent’snamestattooedonourarms,her

tattooisnicer,it’scolourful,sheismyfavouritecompany,she’sanartist

Ifeltliberatedaftermydivorce

Ibondedthestrongestwithmyparentsaftermydivorce,Ilovethemverymuch

Ihavetwotattoos

IgotmyKalpanaSamar’stattooedonmyarminrebellionbeforemymarriage

Ialwayswantedtogetmarried,sinceIwasachild

Ithoughtthekeytofreedomfromoppressionisinfindingthemostequal-mindedhusband

Ilovemyeyes,everyonedoes,IwantedtodonatethemsinceIwasachild

Ihavetokophobia

Ilovebeinginlove

IproposewhenIfallinlove,it’sapattern

Ilikestickynotes,bignotes,whiteboards,postcards,letters,stationery

Iamscaredofpetdogs

Ithinkmusiccanhealeverything

IwriteaboutDocsplanation

IthinkonedayIwilladoptachild,Ialwayswantedto,sinceIwasachild

Ithinkfeministwritingisamazing

Ireadeverymorning

Ican’tdowithoutChikki,Chikklettismyniece,sheisChikktasticandallthingsChikk

Ilovemysurnamemorethanmyfirstname,Iwishitwasmyfirstname

IknitscarveswhenIgothroughanxietyanddepression

Preface

xvi

Ilearntknittingfrommymom

Ilearntembroideryfrommydad,no-oneembroidersbetterthanhim

Ihavetravelledtooverfourteencountries

Ithinkpeoplehaveno-ideahowtobehavearoundadivorcedwoman,theyfeelnowthatherlifeis

ruinedletthepoor-thingdowhatevermakesherhappy,itisfascinating

IamaBengali,fromIndia

Ispeakthreelanguageswell

Iunderstandmanymore

Iamaworkaholic

Ineedtolearntodrive

Ilovecolours,Iwearcolours,Idresstoresist

Iamawesomeinverbalcommunication

Iwritetoresist

Ifeelthatswitchingtoamenstrualcupwasthebestdecision

Ithinkpeoplewhoauthorgoodbooksaresuper-humans,soarevegans

Iwillwriteabooksomeday

Iknowsomereallyamazingwomen

Ipickeduphula-hoopinginthepandemic

Iamboxingthesedays,Ilovepunching

Icarryseverallayersofguilt

IhopeKeya,ChikkiandIlivetogetherfor3yearsinanothercountry,justus

Iwillhavearoomwithacupboardsomewhereintheworld,tocallmyown

Ican’tsettle,Icanneversettle

Iwillfindpatienceandcalm

Ilovewaterfalls,oceans&rivers

Preface

xvii

Iamnamedafterariver

ResearchThesis:DeclarationofAuthorship

xix

ResearchThesis:DeclarationofAuthorship

Printname:KaveriMayra

Titleofthesis:‘Womenaresupposedtoendurethat!’Acriticalfeministexplorationofobstetric

violenceinwomen’sandmidwives’birthnarrativesinIndia

Ideclarethatthisthesisandtheworkpresentedinitaremyownandhasbeengeneratedbyme

astheresultofmyownoriginalresearch.

Iconfirmthat:

1. Thisworkwasdonewhollyormainlywhileincandidatureforaresearchdegreeatthis

University;

2. Whereanypartofthisthesishaspreviouslybeensubmittedforadegreeoranyother

qualificationatthisUniversityoranyotherinstitution,thishasbeenclearlystated;

3. WhereIhaveconsultedthepublishedworkofothers,thisisalwaysclearlyattributed;

4. WhereIhavequotedfromtheworkofothers,thesourceisalwaysgiven.Withtheexception

ofsuchquotations,thisthesisisentirelymyownwork;

5. Ihaveacknowledgedallmainsourcesofhelp;

6. Wherethethesisisbasedonworkdonebymyselfjointlywithothers,Ihavemadeclear

exactlywhatwasdonebyothersandwhatIhavecontributedmyself;

7. Partsofthisworkhavebeenpublishedas:

• MayraK.,MatthewsZ.,PadmadasSS.2021.Whysosomehealthcareprovidersdisrespect

andabusewomenduringchildbirth.WomenandBirth.Inpress.Doi.

https://doi.org/10.1016/j.wombi.2021.02.003

• MayraK.,MatthewsZ.,SandallJ.Thecaseof‘surrogatedecision-making’inIndiafor

womencompetenttoconsentandchooseduringchildbirth.Agenda.Doi.

https://doi.org/10.1080/10130950.2021.1958549

• MayraK.,SandallJ.,MatthewsZ.,PadmadasSS.2021.Breakingthesilenceabout

obstetricviolence:Bodymappingwomen’snarrativesonrespect,disrespectandabuse

duringchildbirthinBihar,India.BMCPregnancyandChildbirth.Accepted.

Signature: ................................................................Date:21/07/2021

Acknowledgements

xxi

Acknowledgements

ThisthesisisbornoutofadreamthatIhavenurturedforoveradecade.Iamoneofmany

Indianwomenwhohavesuchdreams,butveryfewgetanopportunitylikeIdid.Thisthesis

andmydoctoralresearchwouldnothavebeenpossiblewithoutthesupportfrommany

peopleindifferentcountries,whohavekeptmegoing.Theyhelpedmelivemydream.

DeborahGearingwhogavemeahomeawayfromhomeandbecamemyfamilyawayfrom

family,andsupportedmethroughthetoughestoftimesbeitapandemic,ornumerous

personalcrisis.Shehasalsoentertainedmyseveral‘English’relatedquestions,withimmense

knowledge,supportedbymanydictionariesandlanguagestyleguides.

TomNewton-Lewissawnotjustpotential,buta‘rockstar’inmeandhelpedmeinevery

possibleway,tomakethisPhDhappen.RodantevanderWaal,myphilosophyguruand

EuniceMueni,mystatisticscoach,havebothseenthefearsandtearsupclose.Eunicehas

entertainedmylatenightvideoscreensharingcallswheneverIneededher,whichwastoo

manytimes.SudiptaBosesavedmefrompurchasingseveralpanic-laptopsandishelping

withtechnologyevenasIwritetheacknowledgements,thatisrightnow!Thesefriends,

family,havehelpedmethroughwaytoomanyanxieties,tocount.

SmritikanaMani,mymidwiferyprofessorandM.Prakasamma,mymentor,havebeenrole

modelsandhavebroadenedmyunderstandingofthechallengesinmidwifery,nursingand

maternalhealthathomeandIcontinuetobeinspiredbythem.Allmymidwifery,nursing

andglobalhealthfriendsandcolleaguesinIndiaandeverywhereintheworldwhohave

masteredinsocial-mediasupportandmotivation,andhavebeenabigwarmvirtualfamily.

SandyAvrutin,PabloTrucco,BenRoss,Christian,AparnaJohn,JurajMihalik,VictoriaHobbs,

CamillaPickles,RituKumari,SoumiKarmakar,SubarnaGhosh,SudeshnaDey,ManasMurmu,

KarimaKhalilandVanesaRomero-Kutznerhavebeenimportantcheerleadersandhavebeen

essentialformymentalhealth.

Mysupervisors,ZoëMatthewsandSabuPadmadas,withwhommypassionformaternal

healthresearchalignedfromthemomentwemetandIwantedtodomyPhDwithonly

them.IneverappliedforastudentshipanywhereelsebutUniversityofSouthampton,

becauseitisfortunatetohavethemasprofessors.Iamtheluckiesttohavethembothasmy

supervisors.IhaveproudlyshowedoffasthehappiestPhDstudentanditwasallbecauseof

them.IamtemptedtodoasecondPhDrightawayifthey’llhavemeasastudentagain.My

externalsupervisor,JaneSandall,atKingsCollegeLondon,tookmeupasaPhDstudentand

Acknowledgements

xxii

guidedmethroughuniquefeministresearchmethods.Iamverygratefultoherforher

generositywithhertime,effortsandguidance.

FranMcConville,BrigidMcConville,BashiKumar-HazardandmanyotherfriendsattheWHO

HQ,WhiteRibbonAllianceUKandIndia,WHOIndia,OxfordPolicyManagementLtd.,

WomeninGlobalHealthIndia,AcademyforNursingStudiesandWomen’sEmpowerment

ResearchStudies,HumanRightsinChildbirth,InternationalConfederationofMidwives,

All4BirthandSocietyofMidwivesIndiahavesupportedmethroughthickandthinandhave

enrichedmewiththeirwisdom.

IamgratefulforthefundingsupportfromtheViceChancellor’sScholarshipattheUniversity

ofSouthampton;BurdettTrustforNursing,UK;ParkesFoundation,UKandtheRoyal

NorwegianEmbassy,India.

IwillforeverbegratefulforhavingVarunKakdeinmylife,assomeonewhohasbeena

sourceofconstantsupport,loveandhappinesssincebeforeIstartedmyPhDandtheperson

IcausedthemostpainsoIcouldaccomplishmybiggestdream.

Keya,Chikki,Baba(SamarendraNathMayra)andMa(KalpanaMayra),Icanfinallybook

ticketstoseemyfamilybackinIndia.Iamlookingforwardtothebiggestreunionever!Ithas

beenalmosttwoyearsIhavenotseenthemandIfeelthepandemichasbroughtuscloser.

ThisPhDwouldnotbewrittenwithouttheirsupportandsacrificeandthegenesIrecently

foundoutaboutthatturnsallthewomeninourfamilyintobookworms.Iamtoldmy

grandmother,marriedofbeforeshehitpubertylearnttoreadfromherchildren’sschool

booksandthennoonecouldseparateherbooks,newspapers,advertisements,everything,

withatinylampshewouldhidefromeveryone.Iftherewerewordsanywhere,shewould

readthem.Hertwolibrarycardswerehergreatestpossessionandcouldnotsatisfyher

hungertoread.Thispassionforeducationwassharedbymymotherwhopasseditontome

andmysisterandIseeitinmyniecewhoisneverwithoutabook.Weareallvoracious

readers.

PS:Nowthatyouhaveseenyournamesintheacknowledgement,doreadthethesis.J

Acknowledgements

xxiii

DefinitionsandAbbreviations

xxv


ANC......................................AntenatalCare

ANM....................................AuxiliaryNurseMidwives

AMANAT..............................ApaatkalinMatritvaevamNavjaatTatparta

ASHA....................................AccreditedSocialHealthActivist

BPHC....................................BlockPrimaryHealthCentre

BEmONC..............................BasicEmergencyObstetricandNeonatalCare

CHC......................................CommunityHealthCentre

CEMONC..............................ComprehensiveEmergencyObstetricandNeonatalCare

CEDAW................................ConventionontheEliminationofDiscriminationAgainstWomen

CS.........................................CesareanSection

CME.....................................ContinuedMedicalEducation

CMS.....................................CentreforMediaStudies

CAMT...................................CentreforAdvancedMedicalTraining

CORE....................................ContinuumofRespectfulExperiences

EAG......................................EmpoweredActionGroup

ERCC....................................EssentialRespectfulCareCourse

FRDA....................................FeministRelationalDiscourseAnalysis

GE........................................GeneralExamination

GOI......................................GovernmentofIndia

GNM....................................GeneralNurseandMidwife

HH........................................Household

IDI........................................In-depthInterview

IUCD....................................IntrapartumUterineContraceptiveDevice

IMR......................................InfantMortalityRate

INC.......................................IndianNursingCouncil

ICM......................................InternationalConfederationofMidwives


xxvi

ICN.......................................InternationalCouncilofNurses

IPV.......................................IntimatePartnerViolence

IV.........................................IntraVenous

JSY.......................................JananiSurakshaYojana

NFHS....................................NationalFamilyHealthSurvey

NHM....................................NationalHealthMission

NPM.....................................NursePractitionerinMidwifery

NRHM..................................NationalRuralHealthMission

MDG....................................MillenniumDevelopmentGoals

MMR....................................MaternalMortalityRatio

MNMT.................................MobileNurseMentoringTraining

LMIC....................................LowerMiddleIncomeCountries

OT........................................OperationTheatre

PSE.......................................Pre-ServiceEducation

PTSD....................................PostTraumaticStressDisorder

PMNCH................................<KaveriMayratofill>

QoC......................................QualityofCare

SDG......................................SustainableDevelopmentGoals

SES.......................................Socio-EconomicStatus

SOMI....................................SocietyofMidwivesIndia

SIDA.....................................SwedishInternationalDevelopmentAgency

SNC......................................StateNursingCouncil

SPSS.....................................StatisticalPackageforSocialSciences

SRS.......................................SampleRegistrationSystem

SBA......................................SkilledBirthAttendants

UNFPA.................................UnitedNationsFundsforPopulationActivities

UNHCR.................................UnitedNationsHighCommissionforRefugees

UN.......................................UnitedNational


xxvii

VE........................................VaginalExaminations

WHO....................................WorldHealthOrganisation

WRA.....................................WhiteRibbonAlliance

Chapter1

1

Chapter1 Whystudyobstetricviolence?

1.1 Introduction

“DoNoHarm”isthekeyethicalprincipleforhealthcareproviders,yetevidenceismounting

showingwomen’sexperiencesofobstetricviolenceduringchildbirth–arguablythemost

vulnerablephaseoftheirlife(Vogeletal.,2015;Khoslaetal.,2016;Pateletal.,2015).Childbirth

isanaturalprocessandthoughtheeventismarkedbyritedepassageandcelebrations(Nayak&

Nath,2018),evidencefromoverhalfoftheworld’snationsindicatethatobstetricviolenceisa

globalissue.Thisthesismakesanoriginalcontributiontounderstandingtheextentofobstetric

violenceinresourceconstrainedsettingsinIndiawithafocusonexperiencesandperceptionsof

bothwomenandnurse-midwives,astheirprimarycareproviders.

Irefertotheproblemas‘obstetricviolence’throughoutthisthesiswithreasonsexplained

throughmypositionalityinthenextchapter,althoughthereareseveralterminologiesusedby

researchersthatIrefertowhenIquotestudies.Mistreatmentofwomeninlabourisrecognised

asadeterrenttofacility-basedbirthwhichalsothreatensprogresstowardsreductionsin

maternalmortality(Bohrenteal.,2015).Itisaviolationofwomen’srighttothehighestattainable

standardsofhealth(WHO,2015)thatincludesrespectfulanddignifiedcareduringchildbirth.Itis

importanttounderstandwhatitmeanstoreceivequalityofcareandhowrespectfulcareis

situatedinitsrealmwhilebeingmindfulthateverywoman’sexperience,needsandexpectations

ofrespectfulcarecanbeuniqueandneedstobeunderstoodtoprovideperson-centeredcare

(Downe,2019).

TheWorldHealthOrganization(WHO)definesqualityofcareas‘theextenttowhichhealthcare

servicesprovidedtoindividualsandpatientpopulationsimprovedesiredhealthoutcomes’and

furthersays,‘toachievethis,healthcareneedstobesafe,effective,timely,efficient,equitable

andpeoplecentred’(WHO,2016,p.14).Inrecognitionofthis,WHOhasincludedexperienceof

careasamainaspectintheprocess,whichisfurtherdividedinto:1)effectivecommunication;2)

respectandpreservationofdignityand3)emotionalsupportasthethreecomponentsinthe

WHOframeworkforQualityofCare(Figure1.1)(Hulton,Matthews&Stones,2000).The

frameworkisinlinewithDonabedian’sModelofQualityofCare(Donabedian,1988),butthesub-

componentsonrespectanddignityforwomenseekingcaremakesitmoreresponsivetowomen

centredcareandoutcomes.

Chapter1

2

Figure1.1 TheWHOqualityofcareframework(Source:WHO,2018,p.12)

Respectfulnesshasbeenidentifiedasanessentialactionpointwhenitcomestoperson-centred

careprovision(WHO,2015).WHO’sguidelinesforintrapartumcareconsistsoffournew

recommendationsspecificallyon:1)respectfulmaternitycare;2)effectivecommunication;3)

companionshipduringlabourandchildbirthand4)continuityofcare.Otherrecommendations

alsoaimtoensurerespectfulnessanddignityofwomenduringchildbirthbyensuringherchoice

ofpositionandadequatemobility,byavoidingunnecessaryinterventions,andensuringadequate

painrelief.Theserecommendationsintendtomakechildbirthapositiveexperienceandcareto

bewomencentred(WHO,2018).

Thereisagrowingevidencerelatedtoobstetricviolencefromaroundtheworldbuttherehave

beenlimitedeffortstounderstandwhatdrivesthisissueandthedeterminantsofobstetric

violenceduringchildbirth(Bhattacharyaetal.,2013;Murray,2008;Jefferyetal.,2010;Hunter,

2009).Itisalsoimportanttonotethatoftenwhatdrivestheproblemisnotlearntfromthose

whoexperienceitandthoseatthefrontlineofcareprovision,suchasthenurse-midwives.There

isalackofstudiesexploringwomen’sunderstandingoftheissueofobstetricviolencewherethe

issueexists,giventhecultureandcontextdrivensubjectivenatureofperceptionsofrespect,

dignity,disrespect,abuseandviolence.Thisgapneedstobeaddressedtocallforanendto

obstetricviolencebylearningthewaystoaddressthisissuefromwomenandcareproviders(such

asnurse-midwivesinIndia),asthekeystakeholdersinvolvedinthisprocessofexperiencingcare

andprovidingcare.Thedeterminantsofobstetricviolencelieatdifferentlevelssuchasthe

individual,structuralandpolicylevels(Freedmanetal.,2014).Theythereforeneedtobeexplored

atthesethreelevelstobeaddressedintheserespectivelevels.Whilewomencansharetheir

Chapter1

3

experiencefromthecareseekersendatthesethreelevels,nurseandmidwiferyleaderscan

sharethesideofthecareproviders,havingprovidedcareatfrontlinesofprimarycareprovision,

followingbyreachingthehighestlevelofpolicymaking.Therefore,theinclusionofnursingand

midwiferyleadersisessentialtothisthesistounderstandtheentiregamutofdeterminantsof

obstetricviolence.

Indiaishometoover1.3billionpeople(Census,2011)withthesecondhighestnumberof

birthsintheworld.Indianwomenpresentadiverseprofileindifferentstatesbasedon

attributessuchaseducation,occupation,religion,healthstatusandespeciallywhen

comparedwithmen.Forinstance,thecurrentliteracyrateforwomeninIndiais68%when

comparedtomen(86%),whichfurthervariesforwomenbyrural(62%)andurban(81%),as

reportedbytheNationalFamilyHealthSurvey(NFHS-4).Italsofoundthat27%womenaged

between20-24yearsweremarriedbeforeturning18years,whichisthelegalageof

marriageforwomeninIndiaandhave2.2childrenperwoman.Thereportfurtherssuggests

that8%womenagedbetween15-19werealreadymothersorpregnantatthetimeof

survey.Therearedisparitiesinfamilyplanningtoo,wheremorewomenundergosterilisation

(36%)thanmen(0.3%)(NHFS-4).

Indiafacesuniquechallengesinmaternalhealthcareprovision,whicharemorepronounced

inparticularIndianstates,suchasBihar.Indiaalsohasoneofthemostinstitutionalised

systemsforchildbirthintheworld,bothintermsofspeedandscale,withover79%women

givingbirthathealthcareinstitutions,whichiscreditedtohavebroughtIndia’sshareofthe

globalburdenofmaternaldeathsfrom19%(WHO,2015)to12%(WHO,2019).Although,its

impactonthequalityofcarehasoftenbeenquestionedinitsmovetowardsmedicalisation

thatfurthermakesitaninterestingsettingtounderstandobstetricviolenceduringchildbirth,

consideringover-medicalisationasoneofitsenablersinthiscontext.Thehighcaesarean

sectionrates(17%)indicatesthis,whichshowsfurtherdisparitiesbetweenprivate(41%)and

publicsectors(12%)(NFHS-4).Violenceisgenerallyhighinwomen’sliveswith31%married

womenreportedlyexperiencingspousalviolenceand4%whilebeingpregnant(NFHS-4).

Therearenosystematiceffortstocollectevidenceonobstetricviolenceandresearchonthis

sensitivesubjectistheneedofthehour.

Aim:Mythesisinvestigatesobstetricviolenceandrespectfulnessincareprovisionduring

childbirthandhowitcanbeimprovedthroughmidwiferyleadership,learningfromthe

perspectivesandexperiencesofwomenasprimarycare-receiversandnurse-midwifeleaders

fromtheirexperienceasprimarycare-providersinIndia.

Chapter1

4

1.2 Researchobjectives

Thisthesisispresentedinathreepaperformat,withanexceptionofanadditionalpaper,

addressingthefollowinginterrelatedobjectives:

• Paper1usesquantitativesecondarydatatoexaminethesocialdeterminantsofobstetric

violenceduringchildbirthinBihar,India.

• Paper2and3usebodymappingaidedin-depthinterviewstounderstandwomen’s

perceptionandhowtheyattachmeaningtorespect,disrespectandabusefromtheir

experienceofgivingbirthandtheirunderstandingofwhatdrivesrespectful,disrespectfuland

abusivecareduringchildbirthinBihar,India.

• Paper4qualitativelydocumentsandanalysetheexperiencesofmidwiferyleadersonrespect,

disrespectandabuseandrecommendnewevidence-basedpoliciestostrengthenrespectful

careforwomenduringchildbirthinIndia.

1.3 Researchquestions

• Whatarewomen’sexperienceofobstetricviolenceinBihar?(Paper1and2)

• Whatmakesawomanvulnerabletoexperiencerespect,disrespectandabuseduring

childbirthinpublichealthinstitutionsinBihar?(Paper2)

• Howdowomenattachmeaningtotheirexperiencesofrespect,disrespectandabuseduring

childbirthinBihar?(Paper2)

• Whatarewomen’sunderstandingoftheunderlyingfactorsdrivingrespect,disrespectand

abuseduringchildbirthinBihar?(Overarchingquestion-Paper3)

• WhydosomecareprovidersdisrespectandabusewomenduringchildbirthinIndia?(Paper4)

• Whataremidwives’experiencesofrespect,disrespectandabuseduringchildbirthinIndia?

(Overarchingquestion-Paper4)

1.4 Thesisorganisation

Mythesisisorganisedinto10chapters.Chapter1laysouttherationaleandneedforthePhDand

helpstounderstandtheresearchobjectivesandquestions.Chapter2presentsareviewof

literaturetounderstandthetypologyandthefactorsinfluencingrespect,disrespectandabuse

duringchildbirthglobally.Italsonarratesthechallengesinrespectfulmaternitycareprovision

alongwiththeglobalevidenceofobstetricviolenceduringchildbirth.Itincludesmypositionality

fordoingthisresearchwhichisblendedthroughoutmythesis.Chapter3setsthecontextof

maternalhealthcareprovisionduringchildbirthandthestatusofwomeninBiharandIndiato

Chapter1

5

understandtheissueinthegeopoliticallocationofmyresearch.Chapter4presentsthe

methodologyanddifferentmethodsusedtoexploretheresearchobjectiveswithaconceptual

frameworkthatconnectsthefourpapers.

MyPhDisstructuredinthethreepaperformat,whichispresentedinthenextfourchapters,

whichessentiallyareonepapereach.Chapter5investigatesthesocialdeterminantsofobstetric

violencequantitativelythroughthesecondarydatafromalargescalehouseholdsurveydonein

Biharthatincludesself-reportofthewomenwithinamonthoftheirinstitutionalbirth.Chapter6

presentshowwomenexperienceandperceiverespect,disrespectandabuseduringchildbirth.

Thisisconductedqualitativelythroughavisual-artsbasedparticipatoryresearchinBihar,India.

Chapter7discussestheimpactofgender,power,cultureandstructureonwomen’sbirthing

experienceswhichisanextensionoffindingsfromChapter6butpresentedseparatelyto

acknowledgethethematicchangeincontent.Withthefirstthreefindingschapterexploringthe

experienceandperceptionsofwhatconsistsofobstetricviolenceandwhatdrivesin,Ithen

presentthecareprovider’sexperienceandperspectiveofthesame,fromwhoarenursingand

midwiferyleadersinthecontextofIndia.Chapter8examineswhysomecareprovidersabuse

womenduringchildbirthqualitativelyfrommidwiferyandnursingleadersexperienceand

perceptionsinIndia.InChapter9bindsthefindingstogetherfromanintersectionallensand

concludesthethesis.Inchapter10summarisesthethesis,presentsrecommendationsforpolicies,

futureresearchandlimitations.Thestudytools,apublishedmanuscriptanddetailsonknowledge

translationareappended.

Chapter2

7

Chapter2 ObstetricViolence:Aliteraturereview&

positionality

Obstetricviolenceduringchildbirthisanimportantandsensitiveissueforvariousreasons.Firstly,

itisaviolationofwomen’sfundamentalhumanrights.Secondly,careprovidersandhealth

systemspolicymakershaveacknowledgeditasanindicatorofalackofqualitycarewhichcan

leadtopoormaternalandneonatalhealthoutcomes.Asevidenceonobstetricviolenceduring

childbirthevolves,itbecomesincreasinglydifficulttoignorethewidespreadnatureofthisissue

andtheeffortsrequiredtoaddressthischallenge.

Inthischapter,Ipresenthowobstetricviolenceisperceivedindifferentcountrieswithglobal

evidence,typologiesandchoiceofterminologies.Thesubsequentsectionontheimpactof

obstetricviolencehighlightstheimportanceofrespectfulmaternitycareforapositivebirthing

experience.Whilethereisadearthofliteraturediscussingthefactorslinkedwithobstetric

violenceduringchildbirth,therearesomestudiesconnectingwomen’sbackgroundcharacteristics

andcareproviderattributesthatmayinfluencematernitycareprovision.

Obstetricviolenceduringchildbirthcanbeunderstoodfromtwokeyperspectivesguidedbythe

literature:1)feminism,followingtheprinciplesofequality,equity,diversity,inclusivityand

humanrightsand2)healthsystems,guidedbytheprinciplesofethicsandqualityofcare

provision.Thestakeholdersworkinginthisareaaredividedintousergroupsandadvocatesof

women’srightsdemandingfortheirrighttoadignifiedbirthingexperience.Thecareproviders

andpolicymakersontheotherhand,aretryingtoensurerespectfulanddignifiedcarewhile

addressingtheexistinghealthsystemsconstraints.Theexistingliteratureonthedefinitions,

terminologies,typologies,impact,driversandwaystoaddressobstetricviolenceduringchildbirth

fallunderthesetwodomains,feminismandhealthsystems.

ThefeministrightsactivistAdichie(2014),warnsherreadersaboutthedangersoflisteningtoa

singlestorywithoutunderstandingthecontext.Theissueofobstetricviolenceisnoexception,

andshouldbeunderstoodfromthefeministperspectiveandhealthsystemsperspective;from

thecare-seekerandcare-provider,bothpredominantlywomen,sharingtheirsidesofthestory

fromtheirstandpointbasedontheirlivedexperiences.Thisreviewemphasisesandpresentsboth

perspectivesfromfeministideologyandunderthequalityofcareframework,bothofwhich

eventuallyleadtothecommonlydesiredoutcomeofwomen-centredcareandabirthing

experiencethatisrespectfulanddignified.

Chapter2

8

Genderisakeybackgroundfactorthatinfusestheentirenarrativeandisembeddedinallthe

chaptersofthisthesisstartingwiththisliteraturereview.Eventhoughitisreflectedinthe

narrativesaroundfeministperspectivemorepredominantly,thehealthsystemsperspectiveis

alsopresented.Inthefollowingsections,Ipresentthesetwoperspectivesincludingdefinitions,

determinants,impactandthewayforward.

2.1 Obstetricviolencefromarightsperspective

Obstetricviolenceofwomenduringchildbirthisaviolationofhumanrights(Miller&Lalonde,

2015;Allotey-Reidpathetal.,2018;Miltenburgetal.,2018).Humanrightsacknowledgesthat

“…eachindividualisentitledtoenjoyhisorherrightswithoutdistinctionastorace,colour,sex,

language,religion,politicalorotheropinion,nationalorsocialorigin,property,birthorother

status.”(UnitedNations,1948).Thereare32articlesintheUniversalDeclarationofHumanRights

whichhavebeenratifiedby192countries,includingIndia.Anycountrythatissignatorytothe

UniversalDeclarationofHumanRightsislegallymandatedtoensuretheserightstoitscitizens

(UnitedNations,1948;Khoslaetal,2016).Aspermyunderstanding,obstetricviolenceduring

childbirthisaviolationofhumanrightsunderthesesixarticles,shownintable2.1.

Chapter2

9

Table2.1 Violationwomen’srightduringchildbirth

Article

no.

UniversalDeclarationofHuman

Rights

Whatitmeansforchildbirth

1 Allhumanbeingsarebornfree

andequalindignityandrights

Allwomenandbirthingpeoplearebornfreeand

equalindignityandrightsinlife,includingduring

childbirth.

2 Everyoneisentitledtoallthe

rightsandfreedomssetforthin

thisdeclaration,without

distinctionofanykind,suchas

race,colour,sex,language,

religion,politicalorother

opinion,nationalorsocialorigin,

property,birthorotherstatus

Everywomanandbirthingpersonisentitledtoall

therightsandfreedomsincludingherrightto

satisfactorybirthingexperiencefreefrom

unnecessaryinterventions,disrespect,abuseand

withbestpossiblecareduringchildbirth.

3 Nooneshallbesubjectedto

tortureortocruel,inhumanor

degradingtreatmentor

punishment

Nowomanorbirthingpersonshouldbesubjected

toanyformofdisrespect,abuseandviolencewhen

seekingmaternalandreproductivehealthcare.

7 Allareentitledtoequal

protectionagainstany

discriminationinviolationofthis

declarationandagainstany

incitementtosuch

discrimination

Nowomanorbirthingpersonshouldbe

discriminatedonthebasisofcolour,caste,religion,

background,gender,sexuality,physicalandsocio-

economiccharacteristicswhileseekingmaternal

andreproductivehealthcare,whichwouldbea

violationofthisdeclaration.

21 Everyonehastherighttoequal

accesstopublicserviceinhis

country

Everywomanandbirthingpersonhastherightto

betreatedequallyandfairlyintermsofresource

allocationandmaternalandreproductivehealth

caretheyreceive,includingduringchildbirth.

25 1)Everyonehastherighttoa

standardoflivingadequatefor

thehealthandwellbeing

ofhimselfandhis

family.2)Motherhoodand

1)Everywomanandbirthingpersonhasarightto

qualityandrespectfulmaternalhealthcareduring

childbirthforthehealthandwellbeingofherself,

hernew-bornandherfamily.2)Everywomanand

birthingpersonisentitledtospecialcareduring

Chapter2

10

Article

no.

UniversalDeclarationofHuman

Rights

Whatitmeansforchildbirth

childhoodareentitledtospecial

careandassistance

pregnancy,childbirthandpostnatalperiodwhen

seekingmaternalandreproductivehealthcare.

Thedeclarationofhumanrightsisnotgenderneutralorinclusiveinlanguage.Amajordrawback

ofthedeclarationisthatitfailstorecognisewomenandreferstoonlymen.Itreferstopeopleas

‘he’,‘his’,‘him’and‘himself’around22timesinthedocument,ignoringtheglobalpushfor

genderneutralandgenderfluidlanguage.

TheUniversalDeclarationofHumanRightsalsodoesnotrefertowomen’srightsduringchildbirth

directly,butthisgapwasfilledbytheConventionontheEliminationofallformsofDiscrimination

AgainstWomen(CEDAW).Itisoneoftheeightmajorhumanrightstreaties,theonlyonethat

directlyreferstorespectfulhealthcareforwomenundertheprovisionofArticle11(1)(f),12,14

(2)(b)andgeneralrecommendation24onwomenandhealthfornon-discriminationinthefieldof

healthcare.Itspecificallystates,“…thedutyofthestatespartiestoensure,onabasisofequality

betweenmenandwomen,accesstohealthcareservices,informationandeducationimpliesan

obligationtorespect,protectandfulfilwomen’srightstohealthcare.”(WHO,2007,p.3).There

are180signatoriestoCEDAWthatareliabletoratifythisintheircountry,includingIndia

(CEDAW,1980).

Thethirdkeydocumentinthisregardisthecharteronrespectfulmaternitycarewhichtakesit

furtherbypresentingthesevenUniversalRightsofChildbearingWomen(WRA,2015)whichis

updatedin2019toincludetherightsofthenewborn(WRA,2019).Thischarterembedstherights

ofchildbearingwomenwithinthecontextofhumanrights,thoughitisnotlegallybindingasthe

CEDAWandUniversalDeclarationofHumanRightsare.

2.2 ‘Obstetricviolence’:Terminologies,definitions,resistance,

movementsandthehistory

Namingviolenceinpublicdiscourseisessentialtoendingviolenceagainstwomen.Althoughthere

isadisbelief,areluctancetoacceptandnameviolenceagainstwomen,whichisnotnew.I

wantedtofindoutwhenitwasthatthefirstwomansuffereddomesticviolenceand/orintimate

partnerviolence.ThenIwantedtotracehowlongittookfromwhentheseabuseswerenamed,

towhenprogresswasmadeinconsideringittobeakeyformofviolenceagainstwomen,

Chapter2

11

embeddedingender-basedviolence.Itprobablytookcenturies!Similarly,itwouldbedifficultto

tellwhenthefirstwomanexperiencedobstetricviolence.

ThehistoryoftheSim’sspeculumandthenotoriousexperimentsbyDr.JMarionSims,thefather

ofGynaecology(Davis,2019),onblackenslavedwomen’sbodiesisagorydetailinhistory(Davis,

2019).Itprobablyisasfarbackasrecordedhistorygoesregardingobstetricviolenceembedded

inandindicatingobstetricracism(Davis,2019;Cleghorn,2021;Hamad,2021).Almosttwo

centurieslater,Iseeandreadsimilaranecdotesofwomenbeingtraumatisedthroughun-

anesthetisedepisiotomyrepairs.Theexpectationsforsomewomentobearmorepainbasedon

theirraceorclassandothersocialconstructs,alsocalled‘ObstetricHardiness’,persiststwo

centurieslater(Davis,2019).Ihaveapersonalconnectiontothisconcept.Mymothertoldme

thatshewasonher‘best-behaviour’andnotmakingasound,andclenchingherteeththrough

thepainfulcontractions,asitsavedherfromfacinganyhumiliation.Shereportssatisfactionfrom

herbirthingexperienceasshehadmanagedtoavoid‘misbehaviour’(bajebaiboharinBengali).I

thinkmymotherperformedobstetrichardinesstoavoidobstetricviolencewhenIwasbeingborn

inthemid-eightiesatagovernmentmilitaryhospitalinIndia(elaboratedinChapter6).

Whiletheproblemremainedunnamedinthemid-eighties,aconnectioncanbedrawnfromthe

anecdotesofwomen’srightsactivistssuchasbellhooks,AnnOakleyandSheilaKitzingertothe

beginningofrecordedover-medicalisationofbirthintheeighties.Amanifestationofthiscouldbe

seenintheexodusofwomenfromhometohospitalbirthsandtherisingcesareansectionrates

aroundtheworld.Whilethesefeministauthorsdidnotusespecificterminologies,the

characteristicsofdehumanisedbirthingexperienceswereevidentinthecontentandbooktitles

suchas‘Capturedwomb’and‘Confinedwomen’.Espinoza-Reyes(2020)andSolispositionthis

‘colonisationofthewomb’asobstetricviolenceandahumanrightsviolationintheMexican

context.

‘Obstetric’,atermtreatedasholy,sacrosanct,andimplyingconnectiontoobstetricians,makesit

abattlegroundwhen‘violence’isattachedtoit.Thetermisconsideredfeminist,activist,

journalistic,non-academic,alarminganddangerous.Academicsfinditdifficulttopublishand

makepresentationswithobstetricviolenceinthetitle(Levesque&Parayre,2021).Forexample,

inIndia,twoofmyownpaperswereremovedfromthefinalstagesofreviewbecausetheissueis

deemedcontroversialandcouldcauseapoliticalturmoilwhenreportsofobstetricviolenceare

published.Governments,globally,donotappreciatebeingtoldthatwomenareexperiencing

obstetricviolence,it’stoostrong,harshandreal,theycan’tbearit.Theypreferbeinggentlymade

awarethatwomenareexperiencing‘alackofrespect’whentheygivebirth.Brazil’sMinistryof

Chapter2

12

Health’sdecisiontodroptheterminologyfromofficialdocumentsisanexampleofapatternseen

inmanycountriesthatarestillindenial(Ignacio,2019).

Thecompetingterminologiesinclude‘disrespectandabuse’thathavebeendefinedbyFreedman

(2014)categorisingintoindividual,structuralandpolicyfactorsthatdrivethepractice(Figure

2.1);whileSen,ReddyandIyer(2018)focusedonthecontextofIndiaandexplaineddisrespectas

thelessandabusemoreextremeinstanceswhilereferringtomanyunderlyingfactorsfroman

intersectionalperspective.Boththedefinitionsmainlyreferredtotheprocessanddriversofthe

issue.Othernoteworthytermsincludestructuralviolence(Miltenburg,2018),normalised

violence(Chadwick,2017)andsymbolicviolence(Morgan,Thapar-Björkert2006)thatcanbe

usedtoexplainaspectsofobstetricviolencebringinginthehierarchy,power,statusandcontrol

relatedargumentswhicharealsocoveredinsomewayinthepreviouslymentioneddefinitions.

Figure2.1 Definitionofdisrespectofabuseduringchildbirth

(Source:Freedmanetal.,2014,p.916)

Obstetricviolencecanbeconsideredtofallunderthelargerdomainofreproductiveviolencethat

goesbeyondthe‘obstetric’realm.Mistreatmentisthethirdmostcommonoftheterminologies,

althoughithasnotbeendefinedproperlybuthasbeenusedtopresenttypologiesbyBowserand

Hill(2010)andBohrenetal.(2015).Obstetricviolenceisalsothemostcontestedterminology

(Rost,Arnold&Clerq2018;Sadler,2016).Thefollowingtablebringstogetherthedefinitionsofall

theterminologiesdiscussedinthissection.

Chapter2

13

Table2.2 Definitionsofdisrespectandabuse;andobstetricviolenceduringchildbirth

Terminology Definitions

ObstetricViolence

“theappropriationofthebodyandreproductiveprocessesofwomenbyhealthpersonnel,whichisexpressedasdehumanisedtreatment,anabuseofmedication,andtoconvertthenaturalprocessesintopathologicalones,bringingwithitlossofautonomyandtheabilitytodecidefreelyabouttheirbodiesandsexuality,negativelyimpactingthequalityoflifeofwomen.”(PerezD’Georgio,2010,p.201)

“anassemblageofdisciplinary,bodilyandmaterialrelationsthatareshapedbyracialised,medicalisedandclassesnormsaboutgoodpatients,goodwomenandgoodbirthingbodies.”(Chadwick,2017,p.504)

Disrespectandabuseduringchildbirth

“theindividualdisrespectandabuse(i.e.specificproviderbehaviourexperiencedorintendedasdisrespectfulorhumiliatingsuchasslappingorscoldingwomen)andthestructuraldisrespectandabuse(i.e.systemicdeficienciesthatcreateadisrespectfulandabusiveenvironment,suchasovercrowdedandunderstaffedmaternitywardwherewomendeliveronthefloor,alone,inunhygienicconditions).”(Freedman&Kruk,2014,p.915)

“Inthecontextofobstetriccare,wedefinedisrespectastheviolationofawoman’sdignityasapersonandasahumanbeingonthebasisofhereconomicstatus,gender,caste,race,ethnicity,maritalstatus,disability,sexualorientation,orgenderidentity.Disrespectisoftenrevealedinthebiasednormativejudgmentsthathealthworkersmakeaboutwomenandtheresultingactsofomissionorcommission.Abusereferstoactionsthatincreasetheriskofharmtothewomanandarenotinthebestinterestsofherhealthorwell-being.Suchactionsmaybelearnedandreproducedthroughthepracticesofinstitutionalmedicine.Theymayormaynotbeintendedtocauseharmandareoftenjustifiedbyresourceconstraintsthatcanbecomeacoverforprioritisingtheconvenienceofhealthprovidersoverthewell-beingofthewoman.”(Sen,Reddy&Iyer2018,p.8)

Structuralviolence

“socialforcesthatcreateandmaintaininequalitieswithinandbetweensocialgroups,whichmakewayforconditionswhereinterpersonalmaltreatmentandviolencemaybeenacted…theessenceofstructuralviolenceliesintheindirect,systematicandofteninvisibleinflictionofharmonindividualsbysocialforcesthatdisableindividualfromhavingtheirbasicneedsmet.”(Miltenburgetal.,2018,p.2)

ObstetricviolenceisacommonlyusedterminologyintheLatinAmericaandtheCaribbean

(Savage&Castro,2017).Thedefinitionsofobstetricviolencefocusmainlyonwomenasthe

objectofvictimisationanditsimpactonherselfandherbody.Italsodrawsfromthegender

perspectiveasanunderlyingfactorinthedefinitionsthatauthorshavepresentedovertheyears

influencedbyfeministliteratureonwomen’srightsandwomen’sbodiesasmentionedinPerezD’

Giorgio’sdefinition.

Chadwick’sdefinitionshedslightonhowsocietyexpectswomentobe,whichinfluenceshowthey

areexpectedtobehaveduringlabourandbirth.Womenareexpectedtoappearandbehaveina

dignifiedway(Kitzinger,1992)ingeneral.Actionsofscreaming,notbeingabletobearpainand

beingincontroloftheactionsofthephysicalpainduringlabour,areconsideredundignifiedand

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henceneedtobedisciplined.Studiessuggestthatanyworkattemptingtounderstanddisrespect

andabuseincareduringchildbirthneedstorecognisemanyrelevanttheoriesandprinciples.At

thecoreofthisissueliesthehumanrightsviolationatthewomen’smostvulnerablephaseoflife

whichisinfluencedbytheculturalcontextonhowwomenareregardedinacommunitywhichis

bestexplainedinfeministliteratureonwomen’srights,choicesandbodies(Friedan,1963;

Oakley,1986;Kitzinger,1992;Stones,2004;Menon,2012;Nayak&Nath,2018;Davis,2019;

Criado-Perez,2019;Cleghorn,2021).

ThedefinitionofstructuralviolencebyMiltenburgetal.(2018)takesthemeaningofstructurea

levelhigherfromthebirthingenvironmentandhealthsystemstructuretothelargersocial

constructofthesociety.Themostrecentdefinitionofdisrespectandabuseduringchildbirthisa

blendofthefeministperspective,thehealthsystemsconstraintsandthedeep-rootedcultural

constructsofthesociety(Sen,Reddy&Iyer,2018).Theterminologies,relatedtoobstetric

violence(notalldiscussedhere)seemtohavedifferentterritories,whichcanappeardifferentto

thereader,basedontheirsubjectivity.Icreatedamind-mapbasedonmyreadings,tobetter

understandtheseterminologicalterritoriesshowninFigure2.2.

Figure2.2 Terminologicalterritoriesaround‘obstetricviolence’(Author’sown)

ItisnoteworthythatarecentcorrespondenceinTheLancetidentifiedthislackofconsensusin

namingtheproblem(Amorim,Bastes&Elcatz,2020).Theauthorsoftheletteradvocateforthe

termobstetricviolenceinthecorrespondence.Theauthorsrespondtoastudyreportingthat

overone-thirdofthesampleofwomenexperiencedphysicalabuse,verbalabuse,stigmaand

discriminationduringchildbirthinNigeria,Ghana,GuineaandMyanmar(Bohrenetal.,2019),

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whilenotnamingtheissueonthetitle.Amorim,BastesandElcatz(2020)arguethatobstetric

violencetranscendsstructuralandlogisticalissuesbyindicatingtheviolationofwomen’shuman

rights,equality,healthandreproductiveeconomy.Bohrenetal.(2020)respondedtoitreferring

totheissueofintentionalitythattheterm‘obstetricviolence’poses,makingitdifficulttoengage

withhealthcareworkersandpolicymakers,hencetheywerekeentocontinueengagingwiththe

issuebyreferringtotheissueas‘mistreatmentduringchildbirth’.Iacknowledgeandunderstand

whyresearchersoftenhavetopickandnavigatebetweenterminologiesforreasonsofreachand

preference,toinfluencepoliciesandpolicymakers,topublishandsecurefunding,aseach

terminologyhasacertainboundary.Ihavedonethattoo,andIamtryingtochangethatby

placing‘obstetricviolence’atthecentreinmywork.Thereasonsbehindtheneedfornavigation

betweenterminologies,theargumentsaround‘obstetricviolence’anditsmisinterpretations,can

bebestexplainedbytworecentexamples,oneeachfromtheglobalnorthandtheglobalsouth.

InItaly,Rivaldietal.(2018)reportedevidenceofobstetricviolencefromanonlinecommunity

survey.ThePresidentsofthreeobstetricianassociationsandonemidwives’associationwrotea

strongcorrespondenceobjectingtotheevidenceproduced,callingit‘presumeddeplorable

behaviour’;‘damaging’and‘alarming’toput‘violence’nextto‘obstetric’.Theystatethatthe

findings‘donottakeintoaccountthepower-dutyoftheprofessionalstoco-decide,guidewomen’s

choices,acturgently,evenwithoutconsent,toavoidseriousdangertotheperson’slifeor

integrity.’(Scambiaetal.,2018).SimilarlanguagehasbeenusedinaGermanarticlewherethe

authorreferredto‘obstetricviolence’asanattemptof‘boilinguptheproblemofviolence’

(DeutschesÄezteblatt,2019).

Rost,Arnold&Clerq(2020)respondedtothediscourseinItalyandGermanyfromanethics

perspective,condoningtheharshlanguageusedintheseresponsearticleswhicharedevoidof

empathy,andsuperciliouslydenyingtheissueratherthanlisteningtowomen’sexperiences.They

alsoraisedthepertinentquestionindicatingthelanguageoffuriousrejectionoftheterminology,

andtheassumptionthatanissueofthisnaturecanbe‘boiledup’.Thisraisesthequestionof

whetherhealthcareprovidersareactuallyunawareofthisproblem,inanyname,whileservingin

thesamesystem,nowthatthereisampleevidenceaboutobstetricviolenceglobally.Isobstetric

violencethenawell-preservedproblemtowhichthereisaseriousresistancetoacknowledge?Is

itawantedphenomenontodisciplinewomen’sbodies,toensurecontinuedoppressionof

womenthroughvariousformsofviolence,includingintheobstetricsettingandtokeepcontrolof

wombandbirth?Thishasbeennotedandexplainedinfeministwritingsasaclassicfeatureof

patriarchalpost-colonialstructurethatbenefitsfromobstetricviolencebycontinuingtheculture

ofdehumanisationofwomeninvarioussettings(Chattopadhyay,2018),alsoamanifestationof

patriarchalviolence(hooks,2000).

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Intentionalityisatthecentreofthediscourseofnamingandaddressingobstetricviolence,

frequentlyreferredtotheWHO’sdefinitionof‘violence’thatlaysemphasisontheintentof

causingharm.Whilethereissufficientliteratureondriversofobstetricviolencethatacknowledge

careprovider’schallengesandsupportthelackofintent(Barbosa,Jardim&Modena,2018),that

isnotanargumenttodenyobstetricviolenceandthefactthathealthcareprovidersinflict

violenceinbirthsettingswhetherintentionallyorunintentionally.ArecentcasestudyfromSouth

Africaexplainsthisdiscoursebest.ThisstartedwithChadwick’s(2017)bookonobstetricviolence

inSouthAfrica,specificallyreferringto‘gentleviolence’whichhidesinplainsightandis

embeddedinthecultureandisnormalisedbutregardless,isindeedobstetricviolence.Astudyby

LappemanandSchwartzmadeanargumentaboutthelackofintentonthehealthcareproviders

partwhilepresentingfindingsfromastudyconductedintwopublichospitalsinSouthAfrica,

whilestronglycriticisingChadwick’suseoftheterm‘obstetricviolence’inherresearchwitha

diversegroupofwomen’sexperienceofbirth.LappemanandSchwartzexpressconcernsthat

namingthe‘silentwardmilieu’as‘gentleviolence’,whiledrawingtheterm’ssimilaritieswithslow

violence(Nixon,2011),isdemoralisingforhealthcareproviderswhoprovidegoodqualitycare

againstall(systemic)odds.Theyfurtheraddwhetherthetermdisempowersinadvertentlythe

womenitaimstoempower.Theircentralargumentliesinthequestion-‘Howgentlemust

violencebeinorderforittonotbeviolent?’.

Threecommentaries,stronglyrejectingthiscentralargument,arepublishedinresponseinthe

sameissueofjournal‘ViolenceAgainstWomen’,allofwhomadeargumentsinsupportofusing

thetermobstetricviolence.LevesqueandParayre(2021),whilehighlightingWHO’sdefinitionof

intentinviolenceasoutdated,raiseanimportantpointofwhetheranactisviolentonlywhen

perceivedassuch,indicatingitsrootsinsexism,whichisanindicatorofapatriarchalandsexist

system.Burnett(2021),criticisedthenotionofmakingtheissueabouttime(slowvsfast)and

intensity(gentlevsharsh)whilealsodrawingattentiontothecontextofwomenthatguidestheir

perceptionofviolence.Inmyexperience,thisargumentalsoholdsfortheIndiancontext.The

authorsresttheircaseemphasisingontheimportanceoflanguagewhichhastheabilitytodrive

changeorleaveanissueunaddressedwhennotnamedfairly.Inthesamevein,Salter(2021)

arguesthattheactofcallingviolenceoutdoesnotoutweighthechallengesthehealthcare

providersfaceduetothesystemicissues,whichisinherentlydiscriminatory,disempowering,

harmfulandoppressivetowardswomenwhomitpromisestodonoharm.Theycentrethe

terminologyintothereproductivejusticeframeworkwhilereflectingontheintersectionalitythat

couldinfluencewomen’svulnerabilitytoobstetricviolence;finallyrejectingthefocusonthe

argumentfixatedonintentionalityforactsofphysicalabuse,belittling,sexuallyabusingand

humiliatingwomenwhichareevidentlyintentional(Salter,2021).

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LappemanandSchwartz(2021)acknowledgeallthethreecommentariesagreeingtoseveral

pointsraisedbytheauthorsbutre-statetheiropinionthatthetermisprovokingandundermines

thegoodpracticesbyhealthcareproviderswhoarethemselvesvictimsofsystem’sinternalised

oppression.Shamingthembymakingthemtakeblameandaccepting‘jarringterminologies’,in

theiropinion,iscounterproductivetoensuringrespectfulcare,inlinewithbehaviorchange

literature.Idon’tthinkthatresearcherswhoreportonobstetricviolence,includingmyself,

attempttogeneralisethatallcareworkersareabusers,nordotheyunderminetheeffortsofall

thosehealth-careproviderswhoareprovidingrespectfulanddignifiedcaretowomenandtaking

astandagainstallodds.Referringtomaritalrapeandintimatepartnerviolenceasmarital

dispute;orrapeandsexualabuseas‘offence’isjustasharmfulasisreferringto‘obstetric

violence’as‘mistreatment’,‘misbehavior’or‘alackofrespectfulcare’,makesusallaccomplices

inlettingaseriousissuegounaddressedwhilewellrecognisingitsconsequencesandimpacton

womenandtheirfamilies.AsimpleresponsetoLappemanandSchwartz’squestion(howgentle

shouldobstetricviolencebeforittonotbeviolence?),wouldbethatthereshouldbenoviolence

againstwomeninorderforittonotbeviolent.

2.3 Typesofobstetricviolenceduringchildbirth

ThefirsttypologyofdisrespectandabuseduringchildbirthwaspresentedbyBowserandHill

(2010)fromtheirlandscapeanalysisbasedonacomprehensivereviewofevidencefromtheir

workinTanzania.Theycategoriseddisrespectandabuseduringchildbirthinto:1)physicalabuse,

2)nonconsentedcare,3)nonconfidentialcare,4)nondignifiedcare,5)discriminationbasedon

specificpatientattributes,6)abandonmentofcareand7)detentioninfacilities.

Thesecondtypologyofmistreatmentofwomenduringchildbirthwaspresentedthroughthree

levelsofdomains,subdomainsandspecificindicators.Thedomainsinclude;1)physicalabuse,2)

sexualabuse;3)verbalabuse;4)stigmaanddiscrimination;5)failuretomeetprofessional

standards;6)poorsupportbetweenwomenandproviders;7)healthsystemconditionsand

constraints(Bohrenetal.,2015).Thistypologybreakstheactionsofabusedowntothespecifics

andhenceiseasytoidentifyinhealthcarefacilities(Table2.3).

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Table2.3 Typologyofmistreatmentofwomenduringchildbirth

Domains Sub-domains Indicators

Physicalabuse Useofforce Womenbeaten,slapped,kickedorpinchedduringchildbirth

Physicalrestraint Womenphysicallyrestrainedtothebedorgaggedduringchildbirth

Sexualabuse Sexualabuse Sexualabuseandrape

Verbalabuse Harshlanguage Harshorrudelanguage

Judgementaloraccusatorycomments

Threatsandblaming Threatsofwithholdingtreatmentorthreatsthatpooroutcomeswillensue

Blamingwomenforpooroutcomes

Stigmaanddiscrimination

Discriminationbasedonsociodemographiccharacteristics

Discriminationbasedonethnicity/race/religion

Discriminationbasedonage

Discriminationbasedonsocio-economicstatus

Discriminationbasedonmedicalconditions

DiscriminationbasedonHIVstatus

Failuretomeetprofessionalstandardsofcare

Lackofinformedconsent

Lackofinformedconsentprocess

Breachesofconfidentiality

Physicalexaminationsandprocedures

Unnecessarilypainfulvaginalexaminations

Refusaltoprovidepainrelief

Performanceofunconsentedsurgicaloperations

Neglectandabandonment

Neglectabandonmentsorlongdelays

Skilledattendantabsentattimeofdelivery

Poorsupportbetweenwomenandproviders

Ineffectivecommunication

Poorcommunication

Dismissalofwomen’sconcerns

Language&interpretationissues

Poorstaffattitudes

Lackofsupportivecare Lackofsupportivecarefromhealthworkers

Denialorlackofhealthcompanions

Lossofautonomy Womentreatedaspassiveparticipantsduringchildbirth

Denialoffood,fluidsormobility

Lackofrespectofwomen’spreferredbirthpositions

Denialofsafetraditionalpractices

Objectificationofwomen

Detainmentinfacilities

Lackofresources Physicalconditionoffacilities

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Domains Sub-domains Indicators

Healthsystemconditions&constraints

Staffingconstraints

Staffingshortages

Supplyconstraints

Lackofprivacy

Lackofpolicies Lackofredress

Facilityculture Unclearfeestructure

Unreasonablerequestsofwomenbyhealthworkers

Briberyandextortion

Source:Bohrenetal.2015

AthirdtypologyofmistreatmentduringchildbirthisanadaptationoftheBohrenetal.typology

formistreatmentofnewborns(Sacks,2018).Thisisthefirsttypologyfocusingonrespectful

newborncare.Thoughitincludessomeexampleswhichindicatedisrespectandabuseofwomen

too,forinstance“womenblamedforpoorneonataloutcomes,smallinfantandfemalenewborn”.

(Sacks,2018).Noneofthesetypologiesincorporateobstetricviolenceofwomenduringchildbirth

byfamilymembersathomeorhospitalsettings.Thesetypologieshavebeenusedtogenerate

evidenceinmanycountries,asdescribedinthenextsection.

2.4 Globalevidenceofobstetricviolenceduringchildbirth

Evidenceofobstetricviolencehasbeenreportedfromaroundtheworldregardlessoftheincome

andlevelofdevelopmentofthecountry.Whileundertakingtheliteraturereview,Ifound

evidenceofobstetricviolenceinover75countriesglobally,indicatedinredinFigure2.3.

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Figure2.3 Evidenceofmistreatmentofwomenincountriesaroundtheworld(Author’sown)

Theliteratureisdividedinreportingonobstetricviolenceduringchildbirth.Therearesome

studiesthatusetheBowserandHillandotherwiseBohrenet.al’stypologytoclassifythetypesof

mistreatmentatbirthsystematically(Abuyaetal.,2015;Srivastava&Sivakami,2020).Thereis

someoverlapwhenitcomestoreporting,ifthetypeofobstetricviolenceisunclear.Somestudies

reportonnon-dignifiedcare,verbalandphysicalabuseseparately,othersmaylookatphysical

andverbalabuseastypesofnon-dignifiedcare.Thislackofconsensusisquiteevidentinthe

literature,failingtorecognisethattheperceptionofrespectissubjectiveanddependsonthe

conditioningintowhatisacceptableandwhatisnot.Therefore,studiesemploydifferent

approachesthatincludeaskingwomenabouttheirperceptionsandexperiencesafterbirth,or

sometimesreportingdirectobservationsofthechildbirthprocess(Dey,2018;Mayra&Kumar,

2017;Jhaetal.,2017).

Kitzinger,(1992)referstotheabsenceofgreetingandwelcomingwomenintothebirthingspace

orenvironmentasakindofdisrespectthateverywomanexperienceswhenshevisitsaservice

providerforchildbirth,oftenalongsideotherextremeformsofobstetricviolence(Miltenburget

al.,2018).ThiswasreportedinastudydoneinTanzania,withauthorsindicatingthatallwomen

experienceddisrespectandabuseduringchildbirth.Womenhavesharedreportsofobstetric

violencestartingfromalackofcommunication,tounconsentedcareandsexualabuse(Reedet

al.,2017).InastudyconductedinJordan,women(averageageof28years)reportedneglect

(32.2%)andverbalabuse(37.7%)duringtheirlastchildbirth(Alzyoudetal.,2018).Across

sectionalstudycarriedoutamong173womenthroughanexitinterviewinEthiopiafound39.3%

womenreportingofbeingleftunattendedduringlabour(Asefa&Bekele,2015).Researchers

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categoriseddisrespectandabuseaspertheBowserandHilltypologyinasurveywith641women

in13Kenyanfacilitiesandreportedonnon-confidentialcare(8.5%),nondignifiedcare(18%),

neglectandabandonment(14.3%),non-consensualcare(4.3%),physicalabuse(4.2%)and

detainmentfornon-paymentoffees(8.1%)(Abuyaetal.,2015).

Studiessuggestpotentialunder-reportingofobstetricviolenceduringchildbirth(Kitzinger,1992).

Thiscanbearesultofwomen’slowexpectationsornotknowingwhattoexpectduringchildbirth;

experiencingdisrespectandabusebutconsideringitapartofcareprovision;beingawareofthe

experienceofdisrespectandabuseduringchildbirthbutconsideringitwomen’sfaultduetothe

fearofconsequencessuchasnottospeakagainsttheonlycareproviderintheareaorfearofnot

beingheardandtakenseriously(Kitzinger,1992).InEthiopia,78.6%womeninastudyhad

reportedlyexperiencedobstetricviolenceduringchildbirth,butonly16.2%reportedaboutit

(Asefa&Bekele,2015).Thischangedwhenthe‘WhatWomenWant’campaignreachedoutto1.2

millionwomenin114countriesaskingtheironedemandforqualityreproductiveandmaternal

healthcare.Womenbroketheirsilenceinsolidaritystatingtheirtopranking‘want’from1,03,584

women(10%)asrespectfulmaternitycare(WRA,2019).

Recognitionofobstetricviolenceisnotlimitedtotheindividualbutdependsonthelarger

systemsofcommunitiesandcountries,aspreviouslydiscussed.Over-medicalisation,forexample,

hasgraduallybeenrecognisedasakeyformofobstetricviolenceinmanycountries,duetothe

underlyingstructuralinequality,thatleadstoobstetricviolencewhennotprescribedfortheright

diagnosis(Sadleretal.,2016).WHOrecommendsanormalrateofcaesareansection(CS)at10-

15%,whichhasbeenincreasingexponentiallyinmanycountries.TherateofCSincreasedfrom

11%to21%inJapan(Behrouzi,2010).Around98%womengivebirthinhealthfacilitiesinBrazil,

wheretherateofCSwasashighas53.5%in2013.ItisparticularlychallengingintheBrazilian

privatesectorwheretherateofCSwas80%in2007(Dinizetal.,2018).TheCSratesinChileare

39%inpublichospitaland72%inprivatehospitals(Sadleretal.,2016).HighratesofCSare

reportedfromtheUSAandCanadaaswell,whereobstetriciansreportedlypreferCStoavoid

lawsuitsresultingfromanadversebirthoutcome,sotheyconvincewomenforanelectiveCS

(Hausman,2005;Nayak&Nath,2018).Therehasbeenanincreaseintokophobiaandcaesarean

sectiononmaternalrequest.Studiestrackingepisiotomyratesfromdifferentcountriesrange

from21%to91%.Eventhoughitisdifficulttodetermineanacceptablerate,WHOdoesnot

recommendroutineorliberaluseofepisiotomyforspontaneousvaginalbirth(WHO,2018).

Studiesreportthepresenceofdifferentformsofobstetricviolenceembeddedinthemedical

education,whichisbecomingapartofcareproviderslearnedbehaviour(Sen,Reddy&Iyer,2018;

Nayak&Nath,2018;Dinizetal.,2018;Mayra2020b;Srivastava&Sivakami,2020).Thisleadsto

Chapter2

22

particularlyextremecasesofdisrespectandabuseinthetertiarylevelteachinghospitals,where

muchattentionisgiventomedicalstudent’spractice,whichsurpassestheimportancethatshould

begiventowomen.Thiscouldbeareasonwhywomenmaybemorevulnerabletoobstetric

violencewhenexperiencingandbeingcaredforcomplications(Srivastava&Sivakami,2020).In

Brazil,astudyreportedacasein2014,whereablackundergraduatestudentwasreportedlygiven

twoepisiotomycuts,ontherightandleft,sothattwomedicalstudentscouldpracticeepisiotomy

andsuturingonthesamewoman(Dinizetal.,2018).Obstetricviolenceduringchildbirthcanlead

tosomesevereconsequences,asarediscussedinthenextsection.

2.5 Impactofobstetricviolenceduringchildbirthonhealthand

wellbeing

Discouragingandaddressingobstetricviolenceduringchildbirthisnotjustaboutsurviving

childbirth,butacknowledgingthatwomendeservemuchmorethanthat.StudiesinIndiahave

foundthatobstetricviolenceduringchildbirthleadstofearofbirth,thatcandiscouragewomen

fromcareseeking(Mayra&Kumar,2017;Jhaetal.,2017),evenwhencomplicationsarise

(Bhattacharyaetal.,2013).Itdiscourageswomenfromfacility-basedbirthduringcomplications

whichthreatensprogresstowardreductionsinmaternalmortality(Bohren,2015;Bohrenetal.,

2014).Neglectandabandonmentinacarefacilityhasnegativeoutcomesforthemotherand

newborn,asreportedintheDominicanRepublic,wheremissingheartbeatsofinfantand

ruptureduterusforthewomanwentunnoticed(Miller,2015).Lackofprivacyisacommonly

reportedfactormakingwomendecideagainstinstitutionalbirth(Afsana&Rashid2001;Oxnevad,

2011;Doctoretal.,2012;Otisetal.,2008;Sorensenetal.,2011;Mrishoetal.,2007;Hadwinger&

Hadwinger,2012;Bhattacharya,Srivastava&Avan,2013).

Obstetricviolencecanhavealastingnegativeimpactonwomenthatmayleadtopostnatal

depression,duetofeelingoutofcontrolandtraumatisedduringchildbirth(Kitzinger,1992;

Larsonetal.,1988;Greenetal.,1988;Scotland,2020).Womensufferingfromposttraumatic

stressdisorder(PTSD),havingexperiencedatraumaticchildbirthmayoftenrelivethetrauma

everyyearontheirchild’sbirthday.Theymaysufferfromguiltofnotenjoyingtheirchild’s

birthdayandhavingtoputupanacttolookhappyontheoutside,whilerecountingthetrauma

bytheminute.Womenhavereportedlychangedthenarrativeoftheirchild’sbirthsotheycan

reduceitsimpactonthem.Womenhavealsochangedtheirchild’sbirthdaytodealwiththe

traumabetter(Beck,Driscoll&Watson,2013).

AstudybyKitzinger(1992)reportsthatvictimsofrapeandviolenceduringchildbirthhave

similaritiesinhowtheyholdbackfromsharingaboutit,intheirfeelingofdepersonalisation

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23

leadingtofear,painanddistress;denialandfeelingofisolation,feelinghelplessthinkingnoone

wouldunderstand,self-disgustandself-blame(Kitzinger,1992).Womenfinditdifficultto

describetheirexperienceandoftenusethelanguageoftheiroppressor.Inthiscase,itisthe

medicalterminologiesthatthecareproviderstellthemwerenecessaryforthesurvivalofthe

babyandwoman.Whentheydofindthewordstosharetheirexperiencetheydrawparallelswith

feelingrapedandthelanguageincludesbeing‘strippedoff’,‘tethered’,‘forciblyexposed’,‘sexual

organsputondisplay’,‘disempowered’,‘shocked’,‘numb’,and‘feelinglikebeingaslabofmeat

beingbutchered’.Victimsofbothexperiencesrememberdetailsofthetraumafordecades

(Kitzinger,1992).Ihaveexperiencedandobservedthiscommunicationgapbetweenthe

informationseeker(suchasresearcher)andinformationholder(womenwithbirthingexperience)

foroveradecadeinmyresearchexperiencesoftryingtounderstandwomen’sbirthnarrativesin

differentpartsoftheworldparticularlyinfluencedbypatriarchy,genderandissuesthatare

sensitiveinnature.

Unnecessaryinterventionsduringchildbirthisalsoaformofobstetricviolencethathasbeen

reportedextensivelyaroundtheworld.Thisover-medicalisationgraduallytakesthepowerand

controlofwomen’sbodyawayfromthemandovertothehealthcareproviders,mainlydoctors

andobstetricians,whoareatthetopofthemedicalandsocialhierarchyinmostcommunities,

countriesandcultures(Oakley,1986;Kitzinger,1992;Bohrenetal,2015;Sadleretal,2016;Nayak

&Nath,2018).ThereisevidencefrommanycountriesincludingTanzania(Magomaetal.,2010),

Nigeria(Shifrawetal.,2013;Parkhurstetal.,2007),Ethiopia(Seljeskogetal.,2006),Iran(Ghaziet

al.,2012),Kenya(Mwangomeetal.,2012),Bangladesh(Afsana&Rashid,2001)andMalawi,

(Seljeskogetal.,2006)whereover-medicalisationhasleadtothefearofcutting(episiotomy),that

discourageswomenfromseekingcare(Bohrenetal.,2014).Womenmayevenchooseanelective

caesareansection,justtoavoidthehumiliationaroundover-medicalisedandaviolent

institutionalvaginalbirth,asseeninBrazil(Dinizetal.,2018).

2.6 Determinantsofobstetricviolenceduringchildbirth

Itisessentialtounderstandthedeterminantsofobstetricviolencetofindsustainablesolutions.

Therearesomestudiesthathavefounddeterminantsthatareeitherrelatedtothebackground

characteristicsofwomensuchaslevelofeducationandsocio-economicstatusorothersystemic

factorsrelatedtocare-providers.Thereissomementionofthestructuralandsystemicdriversof

obstetricviolence.Whilethereisadearthofstudiesthatspecificallytrytounderstandthe

reasonsbehindobstetricviolenceduringchildbirth(Sen,Reddy&Iyer,2018)butonecansee

patternsindriversfromtheexistingliterature.Thesedriverscanbecategorisedinto:1)individual,

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24

2)structural,and3)socialandsystemiclevelasshowninFigure2.4.Theindividualandstructural

factorshavebeendiscussedinthenextsub-section.

Figure2.4 Determinantsofdisrespectandabuseduringchildbirth

(Author’sownbasedonliteraturereview)

2.6.1 Individualandhouseholddriversofobstetricviolence

Personal,demographicandsocio-economiccharacteristicsmayincreasewomen’svulnerabilityto

obstetricviolenceduringchildbirth.Studiesreportthatsociodemographiccharacteristicscan

makewomenpronetopoorqualityofcare,onthebasisofsocietalinequalities(Gilmore,2017).

Thismayincludeeducationlevel,location,maritalstatus,age,gender,socio-economicstatus,

parityandphysicalappearance(Murray,2008).StudiesinIndiahavereportedpoorqualityofcare

provisiontowomenwhoareilliterateorlesseducated,belongingtolowincomegroups,withtwo

tofourchildren(Bhattacharyaetal.,2013;Jefferyetal.,2010;Sen,Reddy&Iyer,2018),arepoor

andlivinginruralareas(Chattopadhyayetal.,2017).Discriminationshavebeenreportedonthe

basisofthenewborn’ssex(Chawla,2019).Thesereasonshavebeenreportedintermsofintimate

partnerviolence(IPV)againstwomenwhoarepooranduneducated(Dharetal.,2018)inBihar.

Theassociationofobstetricviolencewithwomen’sbackgroundcharacteristicswasnotedinthe

northeastpartsofIndiatoo(Chattopadhyay,2018).

AstudycarriedoutintheUnitedKingdomfoundthatchildhoodexperienceofsexualabusecan

makewomenrelivethoseexperiencesduringchildbirth(Montgomery,2015).Reportsstatethat

oneineveryfivewomenhavebeensexuallyabusedasachild,whichsuggeststhatcareproviders

Individual

Women Related-Literacy

-socio economic status-marital status

-Gender-physical appearance

-Parity-Age

-History of childhoodsexual abuse

Structural

Health systems related-Hierarchy

-Level of care provision-Culture of birthing

-Perception of respect -Care provider challenges

Community related-Position of women in

society-Traditional birthing norms

-Perception of respect

Social and Systemic

-Constructs of society -Gender related barriers

-Political will -Lack of Policies

-Normalization of disrespect and abuse during childbirth

-Patriarchy-Incentive based health policies

-Lack of awareness of human rights

Disrespect and Abuse of women

during childbirth

Feminist perspective

Health Systems perspective

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25

needtobesensitiveandeducatedabouttraumainformedcare,evenwhenwomenmaynot

sharesuchexperiences(Montgomery2013;Montgomery,2015;WRA,2019).

2.6.2 Systemicdriversofobstetricviolence

Systemrelatestotheinstitutionalenvironment,includingthecareprovidersandthepolicies.

Careproviders-relateddriversfollowaspectrum,whichchangesfromtheirpre-serviceeducation

toserviceprovision,particularlymidwivesandnurses.Studiesraisetwokeychallengesthatare

cadrerelevanttounderstandinthiscontextandinclude:1)alackofrespectformidwivesand

nurses;and2)medicalhierarchy,thatincludestertiarylevelcareprovisioninteachinghospital

andtheresultingpowerdynamics.Midwives’andnurse’schallengesareimportanttoconsideras

theyareprimarystakeholdersincareprovisionduringchildbirthandtheirproblemsarestemming

fromthesetwofacts.

Alackofsupportiveattendanceduringchildbirthcanbeconsideredasignofdisrespectfulbirthing

environmentthatdiscouragescareseeking(Bohrenetal.,2014;Bohrenetal.,2015).Retaining

trainednursesandmidwiveshasbeenanomnipresenthealthsystemschallenge.Theworld

currentlylacksmorethan900,000midwivesparticularlyinthelowandmiddleincomesettings

(SOWMY,2021).Inthelastfewyears,markedincreasehavebeennoticedintheestablishmentof

trainingandeducationinstitutestoproduceskillednurse-midwives’fortheinternationalmarket

(Kodath,2013).Thishasnotnecessarilyledtoanimprovementincareprovisionbytargetting

workload.

Midwiveshavehistoricallybeencomparedwith‘witches’(Ehrenreich&English,1970)andhave

beenlabelled‘half-taught’,‘totallyignorant’(Oakley,1993)andevenblamedfornegativebirth

outcomes.Midwiferyisconsideredanextensionofawomen’sroleofcaringathome.Thismind-

setisslowlychangingwithmorereportsofmidwifery-ledcarebeingquotedasawaytomost

satisfyingbirthingexperiencesinmanycountries(Oakley,1993)andwithmoreresearchreporting

theimpactofmidwives.ArecentstudyinTheLancetreportedthatwhenenabledtoperformat

theirfullcapacity,midwivescanreducematernaldeaths,neonataldeathsandstillbirths

substantially,whilealsosaving4.3millionlivesannuallyby2035(Noveetal.,2021).Yet,most

countriesdonothaveanindependentmidwiferyprofessionandtheinvestmentinmidwifery

remainsnon-prioritised.

Thecadreofnurse-midwives’faceuniqueprofessional,economic,socialandgender-based

challengesthatleadstoburnoutandstress(Sadleretal.,2016;Sheikhetal.,2012).Studies

suggestthatburnoutandstresscombinedwithpoortreatmentofnursemidwivesascare

providers,reducescompassionincareprovision(Hall,2013;Deery,2009).The‘Midwives’Voices,

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26

Midwives’Realities’reporthighlightstheseissuesraisedby2470midwivesfrom93countries

(Figure2.5).Midwivesreportbeingdisrespectedatwork(36%)byseniormedicalstaffandfeltnot

beinglistenedto(32%).Workplaceharassmentsuchasverbalabuse,bullying,physicalandsexual

abusearealsoreportedby37%midwives.Onefifthoftheparticipantsdependonasecondary

sourceofincomeforsurvival(Filbyetal.,2016).

Figure2.5 Personalchallengesinmidwifery(Source:Filbyetal.,2016,p.15)

Thehierarchicalnatureoftheteamprovidingcarealsodeterminestheexperienceofawoman

aroundchildbirth(Deery,2009).Midwivesoftensharethattheirroleincareprovisionis

unrecognisedandissuppressedbythemedicalprofession(Philbyetal.,2016;Mayra,2019;

Mayra2020a).Figure2.6presentschallengesandbarriersthatmidwivesfaceincareprovision,as

aresultofthelargercommunityandsystemtheyareapartof.Thesearecategorisedintomacro,

mesoandmicrochallengesthateventuallyleadtoobstetricviolence.

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27

Figure2.6 Structuralandpolicychallengesinmidwiferycare(Source:Bradleyetal.,2019.p.4)

Bradleyetal.(2019)furtherreportthatmidwivesareoftentrappedandlefttostrugglebetween

the‘socialmodelofcare’andthe‘medicalmodelofcare’.Thisrequiresthemtoswitchbetween

theorganisationalsystemofcareandvalues,andthewaymidwiveswouldwanttoprovidecare

(Deery,2009).Caringforwomenduringchildbirthisemotionalwork(notbeconfusedwith

emotionallabour),whichrequirescopingmechanismstoprovidecare.Inotherwords,nothaving

ahealthystateofmindforcareprovisionmayhavenegativeeffectonthecare-seeker.Coping

withone’spersonalstrugglesandthestresstheworkbringswithit,isdoneinmanyways.Some

midwivesjust‘switchoff’andputontheir‘masks’or‘smiles’or‘happyfaces’toappeardignified

whichleadstoemotionalwithdrawingandphysicaldistancing(Hunter,2009).Theyfeeltheneed

to‘donnetheiremotionalarmour’,whichsomerefertoas‘surfaceaction’or‘impression

management’,tobeabletoperformwhatthejobrequires(Deery,2009;Hunter,2009)while

insidetheymightbefeelinglikea‘foodmixer’(Edwards,2009).Thishelpswithcareprovisionbut

itcancostthemidwives,whomaygetoverwhelmedandburnoutinthelongrun.Midwivesare

expectedtobeadvocatesforwomenandtheirhumanrightsdefenders(Gilmore,2017)butthe

challengessurroundingtheirworkneedstobeaddressedforthemtodotheirjobwell.Midwives’

humanrightsneedtobeprotectedalongsidewomen’srights.Itcannotbeside-lined,astheyare

victimsofthesamesystemicissues.

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28

2.7 Situating‘obstetricviolence’withingender-basedviolence

Obstetricviolenceisafeministissue,embeddedintheinherentgender-basedinequalitythat

appliestothewomenascare-receiverandmidwives(andnurses)ascareproviders,whoare

predominantlywomen(9outof10globally).Allthesectionsdescribedinthischapterhave

presentedaninterplaywithgender,beittheterminology,definitions,typologies,evidence,

impactanddeterminants.Itisimportanttounderstandandinvestigateobstetricviolenceduring

childbirthfromthegenderlens,toaddresstheinequalitiesitposes(Betron,2018)andthefact

thatitisaresultofgenerationsofhistoricsuppressionofwomen.

Beingawoman,makesonevulnerabletoanykindofviolenceandvictimisation(Jeejebhoy,2018).

Womenareconsideredthe‘secondsex’(Beauvoir,1949)andtheirprioritiesarealsoconsidered

secondary(Betron,2018).Asawoman,oneissupposedtobehaveinafashionguidedbythe

rules,stigmaandnormsofthesociety.Thishasbeennoticedinwomen’snarrativesofpowerand

controlaroundchildbirth,whichresembleshowtheyinteractwiththepatriarchalstructuresand

howsocietycontrolsthem(Bradleyetal.,2016).Therearerulesandregulationstodetermine

whatwomenshoulddowiththeirbodiesandthiscontrolusuallytakesthepowerovertheirown

bodies,awayfromthem.Anyresistancefromwomenisconsidered‘misbehaviour’andmeted

with‘punishment’.Womenareexpectedtoquietlyendurethelabourpainsbecausescreamingor

cryingviolatesthesocialnormsandcallsforpunishmentthroughscoldingandmanyotherforms

ofmistreatmentduringchildbirthtodisciplineherbody(Bradleyetal.,2016;Senetal.,2018).

Thispunishmentforwomenisbasedonthecontextofthecommunity,countryandculture

dependingonprevailingnormsofviolenceagainstwomen.Thediversityintheviolenceagainst

womeninacontext,makesobstetricviolencediverseaswell.

Women’sbodiesandbodily‘purity’isattachedtothehonourofmen,whoownherbodyandthe

body’s‘purity’.Onewaytoensurethis‘purity’inthehospitalenvironmentcanbeseenwhenthe

familyensuresaparticulargenderforthetreatingdoctor(Jeejebhoy,2018;Silanetal.,2012).The

controlofthefemalebodyduringchildbirthinahospitalsettingisareflectionofhowsocietyis

conditionedtotreatwomenathome,inthecommunityandingeneral(Senetal.,2018).Birth,

beinganaturalprocess,hastraditionallybeenanaffairofwomen,tobedealtwithathome,

thoughguidedbypatriarchalnormsofthesociety(Kitzinger,2012).Therehavebeenrituals

aroundbirthandpregnancythathavebroughtwomenofcommunitytogetherthathashelped

theminbonding(Chawla,2019).Thegradualshiftfromthissocialmodelofmaternitycaretothe

medicalmodel,hasledtomedicalisationofthebirthingprocess.Theobjectificationofwomen’s

bodiesduringchildbirthisstemmingfromtheasymmetricgender-basedpowerimbalance

betweenthewomenandthemedicalprofessionmanagingchildbirththatisusuallymasculine

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29

(Sadler,2016).Thisgenderinequalityissystemicandnormalisesviolenceduringchildbirthtoan

extent,wherethewomenbeingvictimised,startstoacceptit,considersitapartofthebirthing

processandmanagesherownbehaviourarounditwithanexpectationofbeingabused(Sadler,

2016;Miltenburg,2018).ThisiswhatDavis(2019)referredtoasobstetrichardiness(section2.2).

Ontheotherhand,subjectingmidwiferytohumiliationandprofessionalshamingisdeeply-rooted

ingendertoo.Thishindersthegrowthofmidwifery,graduallytakingmidwivesoutofthepicture,

andgoesagainstthesocialmodelofbirthing,bymakingbirthingariskybusinessthatneedstobe

handledbydoctorsguidedbynumerousmedicalinterventions(Oakley,1984;Davis,2019;

Cleghorn,2021).Thefemale-dominatedmidwiferyprofessionissubjectedtomanystereotypes

andhasoftenbeensubjectedtoalowerstatusinthehealthsystem.Withinthehealthcareteam

environment,midwiveshavebeenbulliedandmadetofeelundervalued.Theunduework

pressurealongwiththelackofrecognitionhasledtoburnoutandalackofcompassion(WHO,

2019;Deery,2009;Hunter,2009;Sadleretal.,2016).Thishasbeenevidentinthelackof

midwives’involvementinpolicymaking,lowersalaries,lesssecurityandlowmarketvalue

becauseitisseenasa‘women’swork’(WHO,2019).ThishasbeenhighlightedinWHO’s

‘DeliveredbyWomen,LedbyMen’report(2019).

Genderactsadoubleedgedswordinthecontextofobstetricviolenceduringchildbirth,that

negativelyinfluencesthecareseekerandthecare-provider.IexplainthisfurtherintheIndian

contextandinthecontextofBihar,astateinIndia,inChapter3.

Finally,Ipresentmypositionality,asanAsianfeministresearcherconductingresearchonAsian

womeninIndia,toknowcertainpositionsIhavetakenandhowithasguidedtheresearch-related

decisionsImadeinmyresearchandhowmybackground,experiencesandcontextmakesme

understandandapproachthecontextinwhichIconductmyresearch.Iamsharingmyassociation

withobstetricviolenceandwhatinspired,encouragedorpushedmetoplantodothisresearch

forovertenyearsofmylifeandthenmakingitpossibleforthelastfouryears.Researcher

positionalityandreflexivityareimportantaspectsofmystudy,especiallybecauseshiftingpower

dynamicneedswerenegotiatedintheprocessofconductingresearchandispresentingthe

findings.Thisisessentialbecauseobstetricviolenceisdeeplyentrenchedinandinfluencedbythe

constructsofpowerwhicharenotfixedbutfluidandisshiftingbasedontheinteractionsand

intersectionsaroundtheindividuals,theircontexts,andbackgrounds(Hamilton,2020).

2.8 Positionality:Myassociationwith‘obstetricviolence’

IamaBengaliAsianwomaninmymid-thirties,bornandraisedinlower-middleincomesettingsin

differentstatesinIndia,courtesyofmyfather’sfrequentlytransferablemilitarydeployment,with

Chapter2

30

himasasoleearnerinthefamily.Whileituprooteduseveryfewyears,italsoopenedmeuptoa

diverseupbringingandculturewherehomogeneityincultureandcontextwasneverthenormand

this diversity is my normality. I received an undergraduate degree in nursing with midwifery

embedded in it, inagovernment college,affiliated to the largest tertiary levelhospital inWest

Bengal, ineastern India (myparent’shomestate), thatpredominantlyservedpeople frompoor

incomebackgrounds.WhileIcallIndiahome,Istruggletoplacemyselfinaparticulargeography,

soIwillnotdothat.

Igotselectedinoneoftheonly15seatsavailabletomillionsofgirlsfromeightstatesintheeastern

partofthecountryandmyfeewasaround250rupeesperyear(approx.2.5pounds),whichwas

affordable for my family and it guaranteed a government job thereafter. In the four years of

'training’,mymidwiferyeducationbeganinthe3rdyearwhenIwas19andhadstartedassisting

birthsinaveryhighcaseloadfacility‘labourroom’.Myfriend(studentnurse-midwife)andIassisted

‘deliveries’sidebysidewithoutrest,althoughnightshiftswerebusierandtheywerelessviolentto

women.Exchangingsmileswastheonlyencouragementforusinabusymaternityunit.Therewas

neveradearthof‘cases’toconductwithfourorfive‘labourtables’placednexttoeachotherand

oneheavymetalricketyscreen,thatscreamedforattentionwhendragged,andwasrarelyused.

Weobservedsomeformof‘mistreatment’and‘abuse’ofwomeneveryday,numeroustimes.

Itwascommontoseedoctors,juniorandsenior,shoutatwomen.Slappingorpinchingontheouter

thighwitharteryforcepswascommonwhenassistingbirths.Slappingontheinnerthighorhitting

on the vulva with an instrument was common during episiotomy repair, when this was done

withoutanesthesiaorwhennotenoughtimewasgivenbetweenanesthesiaandrepair.Seniorstaff

nurses would shout and make derogatory humiliating remarks ‘why did you not think before

spreadingyourlegs’;‘rememberthepainnexttime’;‘yourageisn’trecedingisit,yetyoushowup

everyyear’; ‘this iscommon intheir religion’; ‘youmustgetoperated(tubectomy)oracopper-T

inserted1’.Iregisteredtheminmymindasunnecessaryabusivebehavior,thatthewomendidnot

deserve.Inmycontext,thesepracticeswerenormalised‘misbehavior’ofcareproviders.Istoodat

the centre of the scenewith obstetric violence unfolding aroundme, conditioningme andmy

friendsintoit.

Itwouldbefairtostatethattheseviolentpracticesarepartofamedical,midwiferyandnursing

student’seducation(Madhiwalaetal.,2018;Mayra,2020b).Thecontextofinequityteachesone

totakeadvantageofthepower-basedinequalityinaviciouscycle,subconsciously.Alackofprivacy

andconfidentiality,verbalabuse, repeatedvaginalexaminationswereusualandblended inour

1AlsoknownasIntraUterineContraceptiveDevice(IUCD)

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31

practice,thatwentunregisteredinourminds.Observingtheexperiencewomenweresubjectedto

everyday,whilechangingoutofuniform(abrightfluorescentyellowsareeasshowninFigure2.7)

aftershift,somefriendswouldsay‘Iamdefinitelygettinganelectivecesarean,thereisnopointof

thisembarrassmentforahealthcareprofessional!’Somesavedforyearsforanelectivecesareanin

a private hospital. After experiencing sexual abuse and violence myself, during a vaginal

examination,inthehospitalIpracticedin,whileinuniform,Iwaspositivethatmypositionhadno

positiveinfluenceonhowIwillbetreatedintheplacewhereIprovidedcare.Idecidedtonever

givebirth.Mydecision,asavirgin,involvedrefrainingfromsexualintercourse.Icouldnottakea

chanceofcontraceptivefailureoranabortion,exposingmyselfoncemoretosimilarhumiliation

and abuse. Itmademe go on ‘birth strike’ (Brown, 2018). Having experienced sexual violence

numeroustimes(Mayra2020a;Mayra2020b),IwantedtosteerclearofacircumstanceIcouldnot

protectmyselffrom.

Figure2.7 Meandmyclassmatesinouruniform

(Illustrationby:SoumiKarmakarespeciallyforthisresearch,includedwithpermission)

DuringmyundergraduatecourseItriedtofileacomplaintagainstadoctorwhoabusedthe

womanIwascaringforsaying‘howdoesyourhusbandwanttodoanythingwiththejungleyou

havegrownthere’,beforeperforminganunconsentedvaginalexamination.Beingatthebottom

ofthehierarchy,myvoicedidnotreachfar.Frustratedanddetermined,IdecidedtodoaPhDon

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32

this,somyvoiceisnotignored,andIamabletoinfluencepoliciesthatchangecarethatviolates

women.Asplanned,Ihavenotgivenbirth,Ihaveneverconceived,andIdonotintendtodoso

either.Obstetricviolenceduringchildbirthremainsmybiggestnightmareandthegreatest

mysteryandIamfinallydoingaPhDaboutit.

2.9 Summary

Thereisagrowingbodyofevidenceofdifferentkindsofobstetricviolenceofwomenduring

childbirth,whichneedstobeaddressedattheindividual,structuralandpolicylevel,asthedrivers

andimpactsareinterconnectedthroughalltheselevels.Thereissomeresearchthathelpsto

understandthedeterminantsofobstetricviolenceduringchildbirth,butmoreeffortsareneeded

tounderstandwhatmakeswomenmorevulnerableinrelationtosocialdeterminantsandwhat

canbedonetoaddressit.

Globalcampaignssuchas‘WhatWomenWant’,‘MeToo’and‘Time’sUp’haveopenedupthe

platformforwomentosharetheirexperiencesagainstabuseandaskforrespectfulmaternity

care.Itisthereforetimelytoaddresstheissueofobstetricviolenceagainstwomeninthelabour

roomstoo,aimingforquickeractionsandsustainablechanges.Obstetricviolenceofwomen

duringchildbirthhasbeencalled‘MeToointheLabourRoom’inpopularculturewitharesulting

outpouringofexperiencesofwomenfrommoreeducatedsectionsofsocietywithspecific

campaignsdedicatedtoobstetricviolencerelatedexperiencesinLatinAmerica,Canadaand

Europe.Storiesofwomenfromruralareasandurbanslumsofpoorsocioeconomicstatusand

lowereducationremainunheard.Understandingrespect,disrespectandabusearoundchildbirth

fromwomen’sperspectivesinaholisticwayisanothergapintheliterature.

Experienceofcareprovisionandofreceivingmaternalhealthcarearethetwokeyaspectswhen

understandingqualityofhealthcarethatIwillstudyunderthelargerframeworkofqualityof

maternalhealthcareprovision.Itisimportanttoexplorewhatrespectmeansfromthe

perspectiveandexperienceofwomenandcareproviderstounderstandtheproblemand

sustainablesolutionslocally.Mythreepaperthesisfillsthisresearchgapbystartingwiththe

explorationofdisrespectandabusefromtheperspectivesofwomenandofcareproviders.

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33

Chapter3 BirthinginBihar:settingthecontext

Indiapresentsadiversecontext,influencedbydifferentstates.Inthischapter,Iprovide

informationfromliteraturetounderstandthiscontextaboutIndia,asacountryandBiharasthe

statewheremostofmyresearchisgeographicallylocated.Ipresentinformationaboutmaternal

health,childbirth,women’sstatus,empowermentandviolence,tobetterunderstandthestudy

context.

3.1 QualityofmaternalcareinIndia

Indiamadeconsiderableprogressinthereductionofmaternalmortalitybetween1990to2015,

butcouldnotmeettheMillenniumDevelopmentGoal(MDG)5targets,aimedatimprovingthe

maternalhealthcareprovision(Shah,2016).Indiarepresents12%oftheglobalburdenof

maternalmortality.WHOestimatesitscurrentMaternalMortalityRatio(MMR)at145(WHO,

2017;Shah,2016).Thewiderangeinhealthserviceindicatorsisevidentinthedifference

betweenthestatesinothermaternalhealthindicators.Thenorth-easternstateofAssam,for

instance,hasthehighestMMRof237(SRS,2018)andthesouthernstateofKeralahasthelowest

MMRof46(SRS,2018).Uptakeofmaternitycareelementssuchasantenatalcareand

institutionalbirth,remainslow,incomparisontootherLowandMiddle-IncomeCountries

(LMICs).Evenwithincountry,giventhediversityandsizeofpopulation,thestatusofmaternal

healthcareprovisionvariesbetweenstates.TheinstitutionalbirthsinKerala,forexample,is

99.8%whereasinNagalanditis45.7%(NFHS4).Statewisepercentagesofinstitutionalbirthsin

IndiafromNFHS4areshowninFigure3.1.

Healthbeingastatesubject,individualstateshavetheirownpoliciestomanagehealthcareand

tacklestatebasedchallenges,andhencetherateofprogressvariesbystate.Itis,therefore

importanttounderstandthehealthstatusandservicedeliveryforeverystateinitscontext.The

upcomingsectionsdescribethecontextofmaternalhealthcareduringchildbirthinIndiaand

specificallyinBihar,wheremuchofthisstudyislocated.

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34

Figure3.1 MapshowingpercentagesofinstitutionalbirthsinIndiabystate(Source:IIPS,2015)

3.2 EvidenceofobstetricviolenceduringchildbirthinIndia

Thereisagrowingbodyofevidenceonobstetricviolenceduringchildbirthcomingfromdifferent

statesinIndia(Nayak&Nath,2018).Asystematicreviewreportedevidenceofobstetricviolence

inIndiaagainsttheBohrenetal.(2015)typologyunderallthesixkeydomainsexceptsexual

abusewhichisoftenleftoutoftheresearchduetothesensitivityofaskingquestionsofthis

naturetowomen(Srivastava&Sivakami,2020;Bhattacharya&Ravindran,2018).Inmyprevious

qualitativestudy,conductedintheeasternstateofWestBengal,participants(pregnantwomen)

reportedverbal,physical,sexualabuseandunethicalcareprovision(Mayra&Kumar,2017).

VerbalabuseisacommonformofobstetricviolenceseeninIndia.Womenoftenreportthattheir

careprovidersmakederogatoryandjudgementalcommentsparticularlywhentheyareinpain.

Thetimeofbirthhasbeenusedasasiteforhumiliatingwomenwithdifferentversionsofinsults,

inmanycountriesincludingIndia(Senetal.,2018).Inmypreviousresearch,Ihavefoundthat

careproviderswhoclaimthatobstetricviolence(notmentionedwiththatterminologybut

translatedinlocallanguages)isamyththatcanbebrokenbyhavingahusbandasyourbirth

Chapter3

35

companionduringchildbirth.Ahusband’spresenceisconsideredmoreasawitness,thana

supportinlabourandbirth.

AstudycarriedoutinAssam,Indiareportedextremeformsofobstetricviolencethatinclude

routineepisiotomywithoutanaesthesia,hittingwithastickforsoilingthebed,verbalabuseand

neglect(Chattopadhyay,2017).StudiesfromUttarPradeshstatethat90%womenreportillegal

payments,28%verbalandphysicalabuse(Bhattacharya,2015;Rajetal.,2017),80%women

reportedroutinemanualexplorationofuterusand92%werenotallowedabirthingpositionof

choice(Sharmaetal.,2019).Notinformingwomenbeforevaginalexaminationandphysical

violence,arecommonlyseeninpublichospitals,whereasroutineperinealshavingiscommonin

theprivatehospitalsinUttarPradesh(Sharmaetal.,2019).Womenfromthewesternstateof

Gujaratreportunconsentedcare(57%),verbalabuse(55%)andphysicalabuse(40%)(Pateletal.,

2015).ArecentstudyconductedinIndia’snationalcapital,NewDelhi,bringsforthseveralreports

ofunconsentedpost-partumintra-uterinedevice(PPIUCD)insertions,fromthenarrativesof

elevenmuslimwomenwhoareallhomemakersfromlow-incomebackgrounds(Nazdeek,2020).

Theincreasingtrendofunnecessaryinterventionsduringbirth,especiallytherateofepisiotomy

andcaesareansections(CS),isnoticedinIndia.Currently,theaveragerateofCSis17%(nearly9%

in2005-06)rangingbetween6%inNagalandto58%inTelangana(Radhakrishnanetal.,2017).

Therearevariationswithinstatesinthepublicandprivatesectors.Forinstance,thelowestCS

rateinthepublicsectorisnearly3%inBiharandthehighestisinTelengana(40%).ThelowestCS

rateintheprivatesectorisinRajasthan(23%)andthehighestisinJammu&Kashmir(75.5%)

(NFHS4,2015-16).Thelowestdifferencebetweenthepublicandprivatesector’sCSrateis7%in

Keralaandhighestdifferenceis52%inWestBengal(NFHS4,2015-16).Astudyconductedattwo

tertiaryhospitalsinMaharashtrainvestigatedstructuralviolencethroughinterviewswithcare

providersandfoundnormalisationofobstetricviolenceduringchildbirth.Theyalsofoundmedical

studentsengagingincarethatisdisrespectfulandabusivetowomen,similartowhatwas

mentionedintheprevioussectioninBrazil(Madhiwalaetal.,2018).Therearenostudies

specificallyexploringthedeterminantsofobstetricviolenceduringchildbirthinIndia.Thisisa

crucialgapintheliteraturethatisaddressedinthisPhD.

Afrequentlystatedreasonforpoorqualityofmaternalhealthcareisthelackofnurse-midwives

asprimarymaternalhealthcareproviders(Sheikh,Raman&Mayra,2012),atrendobserved

globally(presentedinChapter2).Indiaisyettoestablishanindependentcadreofprofessional

midwives;thishasbeenofbenefittomanyothercountriesincludingAustralia,UKandNew

Zealand,thathavebeenattheforefrontofbestcareprovisionduringchildbirth.TheGOIisnow

makingorganisedeffortstoimplementmidwiferyinIndia.Theoperationalguidelineshavebeen

Chapter3

36

launchedinDecember2018duringthePartnershipofMaternal,NeonatalandChildHealth’s

(PMNCH)Partner’sForum,hostedbyGovernmentofIndia.Iplayedakeyroleindraftingthe

operationalguidelinesasaconsultantwithWHOIndia.

Nursingandmidwiferyistaughtasacombineddegreewithtwoseparateregistrations.Thiscadre

formsthelargestproportionofthehealthworkforceandperformsmajorityofcarerelated

services.Indiarankssecondintermsofnursingandmidwiferyworkforcemigration,thoughwithin

countrythepopulationissupportedbyonly24careprovidersper10,000populations,17outof

thesearenurse-midwives(WHO,2015).Thelackofskillednursemidwivesisaseriousissuein

India.ThiswasconfirmedinWHO’s2010projectionthatIndianeeds2.4millionadditionalnurse-

midwives’toensuregoodqualityuniversalcaretoitscitizens(WHO,2010).Theissuesfacedin

preparinganursingandmidwiferyworkforcethatcouldprovidequalityandrespectfulcare,is

furtherdiscussedinthenextsection.

3.3 ThestateofmidwiferyeducationinIndia

Therearemanyinitiativesinvolvedincapacitybuildingofnurses-midwivesinpre-serviceandin-

serviceeducationaimingtoimprovecareatthefrontline(Fisheretal.,2015;Dasetal.,2016),but

thereislittleevidenceontheirutilitybeyondimmediatesuccess.Idiscussthiswithinthedomains

ofpre-serviceandin-serviceeducationofmidwivesinIndia.

3.3.1 Pre-serviceeducation

Nurse-midwivesinIndiajointhehealthcareworkforceaftercompleting2-4yearsofmandatory

pre-serviceeducation.Althoughthecoursecurriculumiscentrallydesignedandapprovedbythe

IndianNursingCouncil(INC),yetthequalityofeducationvariesacrossstatesandinstitutions.

MidwiferyeducationisimpartedaspartofthethreeyeardiplomacoursecalledGeneralNursing

andMidwifery(GNM)andthefour-yeardegreecoursecalledBScNursing,withanadditionalsix

months’internship.ThereareelementsofmidwiferyskillsintheAuxiliaryNursingandMidwifery

(ANM)education,whichisacertificatecourse.Thecurriculumofthesethreelevelsofmidwifery

educationarenotcomparablewiththeInternationalConfederationofMidwives(ICM)

recommendedskill-setrequiredtoensureknowledgeandskillsonsevencompetenciesof

midwifery(ICM,2013).InIndia,plansfordirectentrymidwiferyeducationhavebeeninthe

pipelineforyears.

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37

3.3.2 In-serviceeducation

Withthefast-evolvingnatureofhealthcare,itisessentialthatcareprovidersgetupdated

frequentlywhilein-service,throughContinuedMidwiferyEducation(CME).Overthelasttwo

decades,manyinitiativeshavebeenimplementedinIndia,withanaimtoimprovenursingand

midwiferyeducation,mainlythroughin-serviceeducation(Figure3.2).Someareimplementedin

partnershipwithGovernmentofIndiaandotherswithvariousstategovernmentsincollaboration

withnationalandinternationaldevelopmentorganisations.

Figure3.2 TimelineofmidwiferystrengtheninginitiativesinIndianstates(Author’sown)

TheSkilledBirthAttendant’s(SBA)trainingisthemostcommonamongthese,thatisdeliveredto

ANMs,staffnursesanddoctors,throughoffsitetraining,providedbyateamofdoctorsand

nursesoveraperiodof21days(GOI,2010).

OthertrainingmodelsincludetheUnitedStatedAidforInternationalDevelopment(USAID)

fundedtwodaystrainingcalled‘CareAroundBirth’underalargerinterventioncalledVriddhiin

2016(IPEGlobal,2016).ThethreedaystrainingcalledDAKSHATAhasfour‘pausepoints’based

onWHO’ssafechildbirthchecklist(GOI,2015).TheBillandMelindaGatesFoundation(BMGF)

fundedaninemonthsin-serviceeducationcalledtheMobileNurseMentoringTeam(MNMT)

trainingunderthelargerinterventionsofANANYAandAMANAT2in2014inBihar.Fewother

stateshaveimplementedtheeducationformat(Das,2017).TheMedakmodelprojectprovided

MidwiferySkillsEnhancementTrainingsinMedakdistrict,AndhraPradeshin2007.Allthese

trainingstargetedANMsandstaffnursesforimprovementinmaternalhealthcareprovision

2ApatkalinMatritvaAvamNAvjatTatparta(AMANAT)thatlooselytranslatesintoBasicEmergencyObstetricandNeonatalCare(BEmONC)

Chapter3

38

includingcareduringchildbirth.TheSwedishInitiativeforDevelopmentAssistance(SIDA)

supported(IIPH-G2010)theCentreforAdvancedMidwiferyTraining(CAMT)thatstartedskill

buildingofmidwiferytutorsfromschoolsandcollegesofnursing,whowentontobuildthe

capacityofcareproviders.TheCAMTswerealsousedforprovidingtheninemonthsNurse

Practitioner’sinMidwifery(NPM)courseintwoIndianstateswiththeSocietyofMidwivesIndia

(SOMI)asakeypartner(Prakasamma,2010).FernandezhospitalinHyderabadisimplementing

theProfessionalMidwiferyEducationandTraining(PMET)whichisbasedonUnitedKingdom’s

modelofmidwiferyeducation,foundedonICM’ssevencompetencyskills.Thisisan18months’

course,adaptedtoeducate30nursesfromKarimnagardistrict,withsupportfromTelengana

Governmentthatwaspilotedin2017.

Mostoftheseinitiativesareledbyobstetricians,withminimumtonoinvolvementofnursesand

midwiferyleadershipintheconceptualisationanddesigningphases,exceptfortheMedakModel

ProjectandCAMT.MostoftheseeducationmodelshadoverseasmidwivesvisitingIndiato

implementthem,whichmakesculturalsensitivityoftheseinitiativesquestionable.Itisalso

unclearifthesetrainingmodelsweredesignedwithsupportfromtheINCorthevariousState

NursingCouncils(SNC).In2012,theGOIbroughtoutguidelinesforstrengtheningthePSEnursing

andmidwiferyincollaborationwithINC.Thedifferenceincareprovidereducationandtraining

mayleadtodifferencesinqualityofcareprovision,thatisparticularlypoorinafewstates.The

commonfactoristheabsenceofanycontentonrespectfulmaternitycareinallthesetraining

initiatives.

Intermsofrecentprogress,theGOIisimplementingan18monthsNPMcourse.Thetimeline

(Figure3.2)doesnotincludethis18monthadaptedNPMcoursethatispilotedinthreestatesin

Indiabutit’sprogresshasbeenstalledduetothepandemic.Thiscourse’scurriculumhasbeenco-

designedbyIndianNursingCouncil(INC)andICM.IworkedwithICMasaconsultanttoco-

developthecurriculumandalsoworkedwiththeWHOtodrafttheGOI’soperationalguidelines

formidwiferyimplementationinIndia(GOI,2018).ThedraftNursingandMidwiferyBill,2020is

currentlyintheparliament.Whenpassed,itwillreplacethe75-year-oldINCActof1946.

Although,thereareseveralchallengeswiththeimplementationofthisbill.Itwouldbea

regressivestepthatwouldnotsupportmidwiferyimplementationinIndiaasthebilldoesnot

definethedesignationorthescopeofpracticeandcontinuestounderminetheprofessionby

attachingittonursingascanalsobeseeninthetitleofNPMwhichmaysuggestthatmidwifery

wilcontinuetobedependentonnursing(Mayra,Padmadas&Matthews,2021).

Chapter3

39

3.4 Bihar

Biharhasbeenanareaofinterestforinternationaldonorsanddevelopmentsectorsalikeforover

adecade,givenitscontinuedpoorperformanceofmaternalhealthcareindicators.Obstetric

violenceduringchildbirthremainsunderstudiedinBihartoo,whichcouldbeduetoalackof

politicalwill,thesensitivenatureofthisissueandthefactthatviolenceagainstwomentakestime

toreceiveattention.ThenextsectionsarededicatedtodiscussthereasonsthatmakesBiharan

interestingcasestudytoexploreobstetricviolence.

Geographyanddemography

BiharisintheeastofIndiathatsharesboundarieswiththreeIndianstatesofWestBengal,

Jharkhand,UttarPradeshandaninternationalboundarywithNepal.Thestatecoversanareaof

94,163squarekilometreswhichisfurtherdividedinto9regions,38districts,101subdivisions,

534blocksand44,874revenuevillages.Biharhasthehighestbirthrate(26)inthecountryagainst

thenationalaverageof20(SRS,2020),whichmakesitallthemoreimportanttogetbirthingright

inBihar.ThepopulationofBiharis107million,88%populationresidesinruralareasand48%

comprisesofwomen.Biharconsistsofthesecondhighestruralpopulationinthecountry(GOI,

2011).Thesexratiois916femalesper1000malesandthefemaleliteracyrateis53%againstthe

statetotalof64%andtheInfantMortalityRate(IMR)is29,againstthenationalaverageof32

(SRS,2020).Biharunderperformsinmostotherpopulationandhealthrelatedindicatorsin

comparisontothenationalaverage,asshowninTable3.1.

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40

Table3.1 PopulationandhealthrelatedindicatorsofBihar

No. PopulationandHealthindicators Bihar India

NFHS

3

NFHS

4

NFHS5 NFHS4

1 SexRatiooftotalpopulation(per1000females) 1083 1062 1090 991

2 SexRatioofchildrenborninlast5years(per

1000females)

893 934 908 919

3 Householdswithelectricity(%) 27.7 58.6 96.3 88.2

4 Householdswithimproveddrinkingwater

source(%)

96.1 98.2 99.2 89.9

5 Householdswithimprovedsanitationfacility(%) 14.1 25.2 49.4 48.4

6 Totalfertilityrate(perwoman) 4.0 3.4 3.0 2.2

3.5 MaternalhealthcareinBihar

Bihar’shealthindicatorsareamongthepoorestinthecountry,speciallythatofthematernaland

neonatalhealthcare(Dehury&Samal,2016)andimprovementhasbeenslowpaced(NIPI,2014).

TheGovernmentofIndiaclassifiedBiharasoneoftheeightEmpoweredActionGroup(EAG)3

statesthatreceivemostdonoranddevelopmentorganisationsattentionforimprovementin

healthandwellbeing.Maternalhealthcareprovisionhasbeensubjectofmuchresearchand

interventioninBihar.Though,theexpeditedprogressinimprovingtargetsandindicatorshavenot

necessarilymeanthumanisedcareduringbirth.Respectfulmaternalcareisacross-cuttingissue

whenitcomestohealthandwellness,buteffortsforimprovementareyettohappen.Giventhe

disparitiesinthestate,theurbanvsruralandrichvspoorgapsinmaternalhealthcareprovision

areevident(Awasthietal.,2016).

3EmpoweredActionGroupwasconstitutedbyGovernmentofIndiafollowing2001censustostabilise

populationin8statesthatconsistedof45%ofthecountriespopulation.

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41

ThecurrentMMRinBiharis165(SRS,2018)andtheInfantMortalityRate(IMR)is32(SRS,2020),

bothhigherthanthenationalaverageof130(SRS,2018)and33(SRS,2020)respectively.NFHS5

carriedoutinBiharin2019-20,showsmarkedimprovementsinsomematernalhealthindicators

incomparisonwithNFHS3and4from2005-06and2015-16,asshowninTable3.2.

Table3.2 BirthindicatorsinBihar

No. Birthrelatedindicators Bihar

India

NFHS

3

NFHS

4

NFHS

5

NFHS4

1 WomenwhohavehadfourANCvisits(%) 11.2 14.4 25.2 51.2

2 Womenwhohadinstitutionalbirth(%) 19.9 63.8 76.2 78.9

3 Womenwhowereassistedbyskilledcare

providerduringchildbirth(%)

29.3 70.0 79.0 81.4

4 Institutionalbirthinpublicfacility(%) 3.5 47.6 56.9 52.1

5 BirthsbyCS(%) 3.1 6.2 9.7 17.2

6 BirthsbyCSinpublichospital(%) 7.6 2.6 3.6 40.9

7 BirthsbyCSinprivatehospital(%) 17.2 31.0 39.6 11.9

8 Womenwhowerevisitedbyacareprovider

withintwodaysofbirth(%)

NA 10.8 57.3 62.4

9 Childrenbornathomewhoweretakentoa

healthfacilityforacheckupwithin24hours

ofbirth(%)

NA NA 59.3 NA

NA=Notavailable

Biharlagsbehindthenationalaverageinmanybirthindicators,includinginstitutionalbirths

(Figure3.1),evenaftersubstantialincreasesininstitutionalbirthsowingtothewidely

implementedincentivisationscheme,JananiSurakshaYojana(JSY)(Karvandeetal.,2016;Dehury

&Samal,2016).Thishasnotledtocomparableprogressintermsofantenatal,postnatalcare

(Dharetal.,2018)andneonatalcare(Dasetal.,2016),ashasbeenthetrendinIndia.

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42

Evenwithinthestate,therearedisparitiesintermsofinstitutionalbirthsatthedistrictlevel,

rangingfrom37%to87%,asshownintheFigure3.3.

Figure3.3 ProportionofinstitutionalbirthsindistrictsofBihar(AuthorsOwn)

(Source:NFHS4)

3.6 StatusofwomeninBihar

Obstetricviolenceduringchildbirthcannotbetreatedasanisolatedissuewithoutunderstanding

theculturalcontextandthestatusofwomeninBihar.NFHSreportsonseveralgender-based

indicatorswhicharepoorerforwomenwhencomparedtomen.Genderisakeyunderlyingfactor

whichshowsinthefactthatwomen’sliteracyislessthanmenbyalmost23%orsterilisationrate

being35%inastatewhere0.1%mengotsterilisedorthatdoublethewomenareanaemicthan

men(NFHS5)asshowninTable3.3.Inequalityingenderrolesmakewomenmorevulnerable

towardsvictimisationinasocietythattreatstheirwomenlessthanmen(Jejeebhoy&Santhya,

2018).Women’shighlevelofaccesstomobilephonesandbankaccountsisafalseindicatorof

theirlevelofautonomy.ThiscouldhaveincreasedtofacilitatetheJSYincentivethatisdirectly

transferredtotheclient’sbankaccount,soitmaynotsignifymorethanthat.

32.2% -53.5%53.5% - 62.1%62.1% - 71%71% - 78.9%78.9% - 86.6%

Institutional births in Bihar (%)

Chapter3

43

Table3.3 Womenempowermentandgender-basedindicatorsinBihar

No. Womenempowermentandgender-relatedIndicators Bihar India

NFHS

3

NFHS

4

NFHS

5

NFHS

4

1 Womenwhoareliterate(%) 37.0 49.6 57.8 68.4

2 Menwhoareliterate(%) 70.4 77.8 78.5 85.7

3 Womenwith10ormoreyearsschooling(%) 13.2 22.8 28.8 35.7

4 Womenage20-24yearsmarriedbeforeage18years

(%)

69.0 42.5 40.8 26.8

5 Womenage15-19yearswhowerealreadymothersor

pregnantatthetimeofthesurvey(%)

25.0 12.2 11.0 7.9

6 Femalesterilisation(%) 23.8 20.7 34.8 36.0

7 Malesterilisation(%) 0.6 0.0 0.1 0.3

8 Allwomenage15-49whoareanemic(%) 67.4 60.3 63.5 53.1

9 Menage15-49whoareanemic(%) 34.3 32.3 34.8 22.7

10 Womenwhoworkedinthelast12monthswhowere

paidincash(%)

17.2 12.5 12.6 24.6

11 Womenhavingbankorsavingsaccountthatthey

themselvesuse(%)

8.2 26.4 76.7 53.0

12 Womenwhohaveamobilephonethattheythemselves

use(%)

NA 40.9 51.4 45.9

13 Womenage15-24yearswhousehygienicmethodsof

protectionduringtheirmenstrualperiod(%)

NA 31.0 56.0 57.6

NA=Notavailable

Thisgender-basedinequalitypresentsonenarrativeofoppressionofwomeninBiharandIndia.

Asdiscussedinthepreviouschapter,women’sgeographiclocation,theirculturalcontextand

history,forexamplebeinginapostcolonialpatriarchalcontextandtheirpositioningatparticular

intersections,maymakethemmorevulnerabletoanykindofviolence.Thisisfurtherdiscussedin

thenextsection,thoughitisimportanttodrawconnectionstotheirintersectionsinregardsto

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44

theirlevelofeducation,financialindependenceandreproductivedecision-makingfromthis

sectionandtheprevioustable.

3.7 Pleasure,shame,endurance:conversationsaroundbirthing

Women’sjourneytothe‘labourroom’,pre-dominantly,isaresultofsexualintercourse.Indian

womenexperienceextremepressuretoachieveapregnancyandgivebirth,preferablytoamale

child,assoonastheygetmarried.Womenneedtoprovetheirfertilityandmentheirmanhood

throughquickprocreation,thesoonerthebetter.Butthatdoesnotmeanthatthereisalotof

franknessintheconversationsaboutsexualityandbirth.Women’ssexualityisahushedtopicand

thereisnoconversationaboutwomen’spleasure.Sexisconsideredshamefulbecausethe‘act’

hasbeenperformedtoreachthelabourroom.Shamingwomenthroughjudgementalcomments

abouttheirsexualityisacommonformofabuseseenduringinstitutionalbirths.Itistherefore

highlylikelythatawomanisviolatedduringchildbirthforbeingthereafterexercisingher

sexuality,whichisoftennotoutofchoice.Thefollowingquoteconnectsthisshame,sexuality,

silenceandviolencewell(Bhasin&Menon,1998,p.58).

‘neitherabsolutenormonolithicthisconsensusis,nevertheless,atoncedeepandwideranging

andencompassesmostformsofviolence…Ithastwocriticalanddistinguishingfeatures:it

sanctionstheviolent“resolution”ofthetroublesomequestionofwomen’ssexualityandsexual

status-chaste,polluted,impure-andsimultaneouslyinsistsonwomen’ssilenceregardingit

throughtheattachmentofshameandstigmatothisveryprofoundviolationofself.Thus,the

womanraped,thewomanwhomayberaped,therapedchild,theyoungwidowwhosesexuality

cannolongerbechannelised,thewiferapedbykinsmanorothers,thewomenwhomustbekilled

sothattheirsexualityisnotmisappropriated,thewives,daughtersandsisterswhomustbe

recoveredsothatsexualtransgressionisreversed-areallcompelledintoacquiescing.’

Thiscontinuumofviolenceandenduranceinwomen’slivespresentedbyBhasinandMenon

(1998)intheSouthAsiancontext,haspreviouslybeenexplainedbyKelly(1988)inherworkon

sexualviolence.Thenarrativeofenduranceoftentranscendsfromthebedroomtothebirthing

room,whereexperiencesthatshouldbepleasurable,endupbecomingtraumatising,anda

sourceofshameforexercisingfemalesexuality.Incaseofobstetricviolenceparticularly,aprivate

experienceofbirthingbecomespublicandtheprivateexperiencesofexercisingsexualityis

draggedoutinpublicdiscoursetoo,touseasadeviceforhumiliationandoppression.

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45

3.8 ViolenceagainstwomeninBihar

Biharisknownforitshistoricallyviolentpoliticalclimate(Rodgers&Satija,2012).Studieshave

reportedtheevidenceofviolenceembeddedinthecasteandreligion-basedfeudalsystemin

Bihar(Satija,2013;Stephenson,2013).Biharleadsintermsofviolenceagainstwomentoo.It

rankshighinIntimatePartnerViolence(IPV)duringpregnancyagainstotherstates(NFHS-5)

(Table3.1).

Table3.1 IndicatorsofviolenceagainstwomeninBiharandIndia

No. Indicatorsofviolenceagainstwomen Bihar India

NFHS

3

NFHS

4

NFHS

5

NFHS

4

1 Evermarriedwomenwhohaveeverexperienced

spousalviolence(%)

59 43 40 31

2 Evermarriedwomenwhohaveexperienced

violenceduringpregnancy(%)

NA 5 3 4

3 Youngwomenage18-29yearswhoexperienced

sexualviolencebyage18(%)

NA NA 2 NA

NA=Notavailable

Evidencesuggeststhatviolenceagainstwomenduringpregnancyhasmanynegativeoutcomes

forthewomanandherbaby(Dharetal.,2018).Dharetal,reportongenderbeingakeyfactorfor

violenceagainstwomenathome,where43%marriedwomenarestillexperiencingspousal

violenceand5%whilepregnant.Associationswerefoundwithcasteandreligionaswell(Satija,

2013).

Thereisacriticalthirdangletothecultureofviolenceagainstwomenthatneedstobe

considered,whichhappensintheirchildhood.Astudyconductedin2007found47%offemale

childrenreportbeingsexuallyabusedinIndia.Thisstudywascarriedin13statesincludingBihar,

wherethereportedfigurewas30%(WCD,2007).Childbirthisauniqueexperienceandexposes

onetonewproceduresthatmayresultinwomenrelivingexperiencesofabusefromchildhood

(Montgomery,2013).Researchsuggeststhatcompassionatecareisneededinhandlingwomen

withsuchexperiencesthatshouldbeperformedwithutmostsensitivity(Montgomery,2013).This

isyetanotherchallengethatneedstobeaddressedincareduringchildbirthandmaternalhealth

careprovisioningeneral.

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46

Biharreportshighratesofallformsofviolenceagainstwomen,althoughtherearenostudies

aimingtoinvestigatingobstetricviolenceinthestate.Otherstateswithsimilarcontextof

women’sstatusandviolencehavereportedhighratesofdifferentformsofobstetricviolence,

suchasUttarPradesh,WestBengal,AssamandGujarat,aspresentedinthischapter.Allthese

aspectsmakeBiharaparticularlyinterestingstatetostudyregardinghowwomenascare

receiversand;midwivesandnursesascareproviders,perceiverespectanddisrespectduring

childbirthandwhywomenarenotreceivingmaternalcarethatisrespectfulanddignifiedin

nature.

Chapter4

47

Chapter4 Shesmileswhenshetalksaboutviolence:

Epistemologicalunderpinningsand

methodologicalapproaches

Inthischapter,Idescribetheepistemologicalunderpinningsandthekeymethodsadoptedinthis

thesis.Thisresearchisembeddedincriticalfeministtheory.Feministapproachesandmethodsof

inquiryhaveguidedalltheaspectsofmydoctoralresearch,includingthepresentationofthe

thesis.Inthefourpapers,Iexploretheexperiences,expectations,determinantsand

recommendationstoaddressobstetricviolenceduringchildbirthfromtheperspectivesofwomen

ascareseekersandmidwives’ascareproviders.Inchapter5,Ipresenttheexperienceof

obstetricviolencefromahouseholdquantitativesurvey(Paper1)andexplorethesocial

determinantsofobstetricviolencethatmakewomenmorevulnerabletoadehumanisedbirthing

experience.Iinvestigatethedepthandthenatureofwomen’sexperiencesofrespect,disrespect

andabuseduringchildbirthinchapter6(Paper2).Chapter7(Paper3)presentswomen’s

perceptionsofwhytheyhadexperiencedobstetricviolenceand/orrespectfulmaternitycare

whichemergedfromdata.Thisisfollowedbychapter8(Paper4)withnursingandmidwifery

leader’sperceptionofthedriversofobstetricviolenceasaprimarycareprovider,particularlyin

thecontextofIndia.Ihavedescribedthemethodsforeachofthefourchaptersindetailinthe

respectivechapters5,6,7and8.

4.1 Epistemologicalunderpinnings

Violenceagainstwomeninpublicandprivatesphereshavebeenthesubjectofincredulityanda

centralfocusoffeministmovementsthatcanbecreditedforprogressinaddressingviolence

againstwomen(Federici,2018).‘Feminismisamovementtoendsexism,sexistexploitationand

oppression’(hooks,2000,p.8).Feministresearchaimstouncoverandbringforthnarrativesof

silenced,andwomenresisting,asaresultofcenturiesofoppression,owingtopower-based

imbalancethatwomenexperience,asaresultofpatriarchyandcolonialism.Feministscholars

havechampionedresearchwiththemarginalised,oppressedandsecluded,bybreakingthe

‘norms’ofacademicscholarship.FeministscholarssuchasMcKenzie,Chadwick,Montgomeryuse

innovativeparticipatoryfeministmethodssuchasarts-basedresearchtoovercomethe

challengesoftraditionalsciencethatisembeddedinsexism,racism,casteismandsystemic

biases,andthereforetendstoreproduceoppressivestructures(Weisstein,1993;Magnusson&

Marecek,2017;Criado-Perez,2019;Ali,2019).

Chapter4

48

Underepistemology,IunderstandthewayinwhichI,asascientist,produceknowledge.It

concernsfundamentalquestionssuchas‘Whatisknowledge?’,‘Howisknowledge(re)produced?’

and‘Whoownsit?’(McEwan,2001).Feministepistemologyaccountsforthefactthatnot

everybodyisequallyconsideredtobeasubjectcapableofreproducingknowledgeandthatthe

knowledgethatisproducedbytheelitebastionofuniversitiesoftenexcludestheknowledgeand

waysofknowingofthelessprivileged.ThishasbeenapointofdepartureforSouthAsianfeminist

theoristswhoexplainandcritise,fromusingthefeministpost-colonialtheory,thepatternof

researchersandacademics(westernandwhite)consistingresearchinthe‘third-world’countries

presentingahomogenousnarrativeofoppressedthird-worldwomenwithnorecognitiontotheir

resistanceandheterogeneity(TalpadeMohanty,1988).ThisisanessentialinsightIhavedrawn

frommyexperiencesofresearchinginlowincomesettingsoverthelastdecadewithparticipants

whosevoicesareseldomconsideredimportantwhilealsobeingaresearcherwhosevoicehas

beensidelinedforbeingawomanandanurse-midwife.Iamattemptingtochangethatthrough

mydoctoralresearch,becausewomenandnurse-midwives(pre-dominantlywomen)belongto

thegroupexcludedfromknowledge-production,resultinginthesilencingoftheir/our

perspectiveswithinthehegemonicscienceofobstetricsandhealth.Ihaveaimedtoresistthis

traditionalpower-imbalancebetweentheresearcherandtheresearchsubjectbyaddressingthe

womenandnurse-midwiveswhoparticipate,as‘knowers’.Ihavedonethistoensurethatthe

women’snarrativesoftheirembodiedexperienceofbirthandthenurse-midwives’experienceof

providingcareareatthecentreofmyresearch.

Withthisaim,theresearchmethodologiesIchoosetouseallcomeforthoutofcriticalfeminist

theory.Formydatacollection,Ihaveusedparticipatoryresearchandvisualarts-basedmethods

suchas‘birthmapping’,anadaptationofbodymapping.Formydataanalysis,Ihaveused

feministrelationaldiscourseanalysisandvoice-centeredrelationalanalysis.IhaveusedI-poems,

birthingstoriesandthebirthmaps,asresearchoutputs.Hence,thetheoreticalunderpinningsof

mydoctoralresearcharethoseoffeministtheorybecauseIhavebeenmindfuloftheinfluenceof

genderandpoweronmydatacollection,analysis,andontheconstructsandcontextsthatI

explore.Below,Iwillspecifytheepistemologicalunderpinningsofmyresearchasawhole,along

withhowotherspecifictheorieshaveinfluenceddifferentaspectsofresearchandmethodological

decisions,thatincludeintersectionaltheoryandfeministstandpointtheory.Thethreeaspectsof

feminismtoconsiderformyresearchare1)feminismanditsrelationtogenderandpower-based

oppression;2)feminismformedicalhealthcareresearchand3)feminismrelatedtoviolence.This

approachisbestexplainedbythisstatementfromAllen(2013,p.268)‘fromthedirectionofa

feministtheorythatstrivestobegenuinelyinclusiveoftheperspectivesandexperiencesofall

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49

women,(includingnurses-midwives’inpredominantlyfemale-ledprofessions)includingthosein

theGlobalSouth,bydevelopinganintersectionalanalysisofthecross-cuttingaxesofracial,

gender,andimperial(medicalandpatriarchal)domination;andfromthedirectionofacritical

theorythatcanonlybetrulycriticalifitcantakeonboardapostcolonialperspective.’

4.1.1 Feministtheory

Feministtheoryprimarilypresentsanexplanationofsexistthinkingandhowitcanbechallenged

andchanged(hooks,2000).Itunderstandsgendertobeanideologicalconstruct,whichmeans

thatwomenareexpectedtodisplayandperformasetroleandfollowthenormsthatarelaidout

forwomeninourparticularcontextandcultures.Thisalsoexplainswomen’sroleinwomen-

dominatedprofessionssuchasmidwiferyandnursing,thatareoftenconsideredanextensionof

women’sdomesticrole.Thisisembeddedingender-basedinequalitywhichcaninfluence

women’sactivities,experiences,choicesandvalueseverydayintheirroutinelives(Butler,1993).

Thiseventuallysubordinateswomen,generationaftergeneration,beingconsideredasthe

inferiorsex.Feministtheoristsbelievethatsexismwasnotnecessarilyconsciouslystructuredto

oppresswomen,butintheprocessithascertainlyresultedintocentralisingpowerwithmenand

establishingpatriarchalconcepts,masculinenormsandmaledominatedconstructsthatbenefit

onlymen(Keeling,2011)suchasthemale-ledmedicalmodel.

Feministresearchisabroadfield.Itconsistsofcriticismsofandrocentricresearch.Globalhealth

policymaking,forinstance,ispredominantlywhitemaledoctorled.DorothySmith(1987)refers

tothisasthecirclesofmen(usuallywhiteandintheglobalnorth)whoconductresearchrelevant

tomen,writtenandreadbymen(McEwan,2001).Formidwiferyandmaternalhealthis

supplementedbywhitewomenpublishingresearch.Thisissueexistsinmaternalhealthcare

deliveryresearchwherenurses,midwivesandwomen’sperspectivesandexperiencesareoften

measuredorexaminedthroughincompetentmethods.Thesewereparticularlyconcerningwith

sensitiveareasofresearchsuchasviolenceagainstwomenandresearchonmaternaland

reproductivehealth,whichledfeministscholarstothinkoutoftheboxanddoresearch

differently(Wigginton&Lafrance,2019).

4.1.2 Criticalfeministtheory

Criticalfeministtheoryprovidestheessentialtheoreticalframeworktounderstandwomen’s

experienceofchildbirthandspecificallytheirexperienceofobstetricviolencegivenchildbirthand

obstetricviolenceisapre-dominantlywomen’sexperience.Italsolocatesobstetricviolenceas

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50

gender-basedviolence,rootedinpower-basedimbalanceasaresultofwomen’ssocial

positioning.

Criticalfeministtheoryisacombinationoffeministtheoryandcriticaltheories.Itisimportantto

understandthisamalgamationthatcreatescriticalfeministtheory,asnotallfeministtheoriesare

criticalandnotallcriticaltheoriesarefeminist.CriticalFeministtheoryexplainstheresistanceand

deploymentofpowerandaimsto‘identify,questionandseektoreformpatriarchalideologies

thatgiverisetoasymmetricalrightsandopportunities,rolesandmaterialcircumstances’(Wood,

2015,p.293).GenderandpatriarchyaretwokeyaspectsoffeministtheoryinmyPhD,that

intersectswiththestructuresofpowerandequity-basedoppression.Intermsofobstetric

violence,itrelatestothestructuresthatupholdtheobstetricsystemofmaternalhealthcare

provision,thatallowsthisformofviolencetogoon(McEwan,2001;Ray,2020).Theimbalance

couldbeinformalandinformalpower-basedrelationshipsorinteractions(Wood,2015).Inthe

contextofmydoctoralresearch,themedicalinstitutionshaveformalpoweroverthenurse-

midwivesasaresultofahierarchicalhealthcaregovernancestructure.Thepowerofthemedical

professionalsoverwomenwhoareseekingcare,withthedoctorusuallyheadingthestructure,is

informalpower,becausethewomenarenotobligedtoformallyacceptorobeytheirorders.

Doctors,areinthemostrespectedprofession.Theyholdpowerinthesocietyinformallyoverthe

membersofthecommunityandthepeoplethey‘serve’,thatcomesmainlyfromtheknowledge

theyhold,thepowerofknowledge(McEwan,2001).Womenareconditionedtoobey,be

disciplinedandallowedtoeveryactiontheytakeduringtheirownchildbirth.Inthesamevein,

doctorsandotherhealthcareprovidersarealsoconditionedtoabusethispower,whilewomen

areconditionedtoendureit,whomayoftensharetheirexperiencesofroutineviolenceand

obstetricviolencewithasmileandevenalaughtertoneutralisetheseriousnessoftheissue,and

tonotdrawattentiontothemselves.

Criticalfeministtheoryisinfluencedbypostcolonialscholarship,whichmakesitagoodfitformy

researchinIndia,thathasahistoryofcolonisation,thataddsanotherlayerofoppressionforthe

women.Thisisakeyfeatureofthepatriarchalstructurewhereeveryoneisataparticularposition

basedontheirgender,sexualityandsocialrole,thatguideswhosevoices,perspectivesandvalues

matter,andwillbelistenedto.Thisisacontinuedbattleoftheculturallegitimacyofvoices,also

referredtoasthe‘theatreofstruggle’byStuartHall(1989).Thispower-basedimbalancebetween

doctor-patient(women)anddoctor-nurse-midwife,makestheresearchthroughfeminist

methodologiescrucial,becausethehistoricoppressionmakesitdifficulttoascertainthe

knowledgethroughtraditional,conventionalandman-mademethodsforandrocentricknowledge

(Wigginton&Lafrance,2019;Espinoza-Reyes&Solis,2020).

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Childbirthisexperiencedpredominantlybywomen,primarilycaredforbymidwives,(couldbe

referredtoasnurse-midwives’inIndia)inaprofessiondominatedbywomen.Bothcategoriesof

womenhaveahistoryofoppression.Thepower-basedimbalanceisacrucialaspectof

researchingwithboththesecategoriesofparticipants,wherewomenareatthebottomofthe

socialhierarchyandnurse-midwivesareatthebottomofthemedicalhierarchy.Bothwomenand

nurse-midwives’facetheconsequentialpowerlessnessthatrequiresforthemtocontinuallyresist

suchstructuresofoppression,henceitisimportanttounderstandhowwomenandnurse-

midwivesinteractwiththesesystemicoppressivestructuresfromtheuniqueperspectivesof

subordination,powerlessnessandresistance(McAra-Couper,Jones&Smythe,2011;Mayra

2020a).

4.1.3 Feministstandpointtheory

Standpointfeminismconsidersthatwomenandmenleadsignificantlydifferentlivesthatare

shapeddifferentlybytheirsocialrolesandexperiences.Standpointtheoryhasbeenusedin

researchaboutreproductionandrelatedexperiencessuchaspregnancy,menstruationandbirth,

becauseonlywomen,predominantly,canhavetheseembodiedexperiences(Woliver2002,Parry,

2008).Standpointtheoryalsoenablesthewomenexperiencingtheoppressivepowerstructures

toconfrontthesave‘oppressivepowerstructures’(Jaggar,1997),itistheobstetriccaresystemin

thiscase.Whilefeministtheoristshavepresentedtheirapproachesandextensionstofeminist

standpointtheory,theconsensusremainsthatfeministstandpointtheorygiveswomenvoiceto

presenttheirnarrativesfromtheirstandpoint(Keeling,2011).Ihaveoftenwonderedaboutthe

actof‘giving’voiceandstronglybelieveditisnotourstogive.Feministresearcherscanfind

feministwaysofresearchtounearthnarrativesthatwerehiddenduetotheinabilityofour

researchmethodstoexamineandourincompetencetolistenandunderstandsuchsensitive

phenomenon.Inmycase,itischildbirthandobstetricviolence,whichIdecidedtolearnfromthe

standpointofwomenascare-seekersandthestandpointofnurse-midwivesasprimarycare

providers,inacontextofcontinuedoppressioninapatriarchalpostcolonialcontext.

Generatingawarenessoftheoppressivestructuresandtheimpactithas,isacrucialstepinmy

study,aswillbepresentedinthefindings.Challengingthesesystemswillbethenextstep,which

somewomenshowintheIndianandBiharicontextintheireffortstocompletelybypasssuch

oppressivesystemsandtakebirthingintheirownhands,byeitherswitchingbirthplaces,

changingcareprovidersorcompletelyrejectingtheobstetricsettingbygivingbirthathome

withoutassistanceofacareproviderorwithatraditionalmidwife.

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Theknowerknowsbestofwhatisbeingexplored,forbeinginapositionofhavingtheexperience

inacontextthatconstructedtheirperspective,andhencesharesthenarrativefromtheirunique

standpoint(Sprague,2016).AccordingtoDorothySmith(1991)theseknowersare‘theactual

subjectssituatedatparticularsites’thatasresearcherswearetryingtostudy.Inthecontextof

myPhD,theknowerarethewomenwhohavegivenbirthinthepatriarchalculture,ina

postcolonialcontextofBihar,Indiaandareparticularlyfromlow-incomesettings.Iexplorewhat

theycanshareasavirtueoftheirstandpoint,thatotherscannotprovide.Similarly,thenursing

andmidwiferyleaderssharetheirstandpointofprovidingcaretowomeninthesamecontext,as

theirprimarycareprovider,inahealthcaresysteminfluencedbypatriarchalculturewith

remnantsofpostcolonialcontext.Thiscanbeseeninthegovernanceofthelargestprimarycadre

ofcareprovidersofnurses-midwivesinIndia,andthechallengesandstrugglestheyfaceincare

provisionandwhattheyperceiveistheresultoftheirbodilyexistencethatlocatestheir

consciousness(Smith,1991).Smithalsocriticiseshowpastattemptshaveusuallyconsidered

experienceonlywhen‘spoken’bytheparticipantswhilearguingthatitisembeddedinour

feelings,dailypractices,inlocalsettingsandIbelieve,itevenliesinthemundaneandinour

silences.

Womenhaveembodiedtheexperienceofgivingbirthandrespectfulnessand/orobstetric

violencewhilegivingbirth.Nurse-midwiveshaveembodiedgivingbirth,assistingbirths,

experiencingchallengesinensuringqualitycare,participatinginrespectfulcareand/orobstetric

violence,andobservingrespectfulcareandobstetricviolenceunfoldaroundthem.Theselived

experiencesofwomenandnurses-midwivesareatthecenterofmyresearch(Keeling,2011),who

aresharingtheirtruth,basedontheirexperience,relationandinteractionswithpower

(Ramazanoglu&Holland,2006).Itisimportanttounderstandhowtheircontinuedoppression

andresistanceshapestheirexperienceandmakesthemaddmeaningtotheirexperiences.Thisis

the‘concreteexperience’whichIenterintoresearchtoexploreandbringoutfromthe

participant’snarratives.

Howmypositionality,asawoman,fromlower-middleincomebackground,educatedinnursing

andmidwiferyintheworldtheresearchparticipantsandIinhabit,shapesmystandpointand

influencesmyresearchdecisionsandmethodologicalchoices,isdiscussedthroughoutthe

researchpresentationthroughmyreflexivity.Itisimportanttoacknowledgethatthisresearch

couldhavebeendonedifferentlywhendonebyanon-feministand/ormaleand/ornonAsian

and/ornon-healthcareworker’sstandpoint,toconsiderthatmypositionalityinthediscourse

addsvaluetothisresearch(Parry,2008).Insimplewords,itisimportanttotakenoteofwhatis

beingresearched,whoisbeingresearchedandwhoisdoingtheresearchinwhatcontext.

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4.1.4 Intersectionality

MyPhDisgeographicallylocatedinIndiawithparticipantshailingfromdifferentstates(inthe

studywithnurse-midwives’),andparticularlyfromBihar(inthestudiesaboutwomen’s

experiencesofchildbirth).Thesetwocategoriesofparticipantspresentmanytraitsthatcanbea

breedinggroundforoppression.Genderistheconnectingfactorintheirbackgrounds,

exacerbatedbytheirlevelofeducation,statusofoccupation,geographicallocation,age,caste,

religion,socio-economicstatus,maritalstatusandphysicalappearance,amongmanyothersuch

characteristicsthatmakenurse-midwivesandwomenvulnerabletobeingoppressedand

experienceobstetricviolenceduringchildbirth(Sen&Chattopadhyay,2018;Menon,2012).

FeministAmericanlawyerKimberléCrenshawiscreditedforcoiningthewordandintroducingthe

worldtotheconceptofIntersectionality,tounderstandblackwomen’sdoubledis-advantageat

theintersectionofgenderandrace(Crenshaw,1986).Whilestandpointtheoryhelpsto

understandtheperspectivefromtheparticipant’sstandpointshapedbytheiruniquepositioning,

intersectionalityexplainsthisuniquepositionattheintersectionsofallthecharacteristics

mentionedbeforeandhowthatinfluencestheirexperiences,perceptionsandexpectations.

Intersectionalityprovidesalenstounderstandthesensitiveissuesriddenwithstigmaand

stereotypes,suchasbirth,andmorespecifically,obstetricviolence(Boydelletal.,2020;Hill

Collins,2019).

Theintersectionalframinghelpstofurtherunderstandwomen’sexperiencesfromtheir

standpoint,andhowandwhytheymayexperiencewhattheyexperience,intermsofviolence

duringchildbirthaswellbasedontheirpositioningattheintersectionsofsexuality,gender

identity,racism,sexismandableism(Boydelletal.,2020).Althoughtherearecriticismsthat

intersectionalitydoesnotfocusonsexualidentityandorientation,thatledtothetheoryofsexual

configurations,whichhelpstounderstandthefluidnatureofsexualorientationandpreferences

thatkeepstheperson’sidentityflexibleandopentoconfigurations,astheorisedbyVanAnders

(2016)(Grzanka,2016).Idostronglybelievethatintersectionalityisaboutalltheattributesthat

explainstheinequalitiesandpower,thatarerelevanttoaparticularcontext,andthatsexualityis

oneofthosedeterminingfactorsaswell.Asdescribedintheliteraturereview(chapter2)andin

thecontextofBiharandIndia,(Chapter3),womenandtheirnurse-midwives’positioningat

particularintersectionscouldplayaroleinhowtheyaretreatedandhowtheyresist.Inthe

contextofIndia,birthingandmattersrelatedtowomen’sreproductionareconsideredpolluted

anduncleanrequiringsegregationinmanycommunities(Chawla,2019;Menon,2012).Profession

isakeyattributetoincludeforthenursingandmidwiferywhichhavehistoricallyoppressed

professionsinIndia(Ray,2020;Mayra2020b).Intersectionalityisessentialbecauseitexplains

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54

whois‘respectable’inasocialconstructbasedontheirsocialdeterminants(Christensen&

Jensen,2012).

Intersectionalityisthekeyframeworktounderstandmydoctoralresearch,intermsof

understandingtheparticipants,theirexperiences,thedriversoftheviolencetheybearandhow

theyperceiveitandalsotheimpactithasontheirroutinereproductiveandnon-reproductive

livesalongwithmymethodologicalchoices.Itexplainsthestigmaanddiscriminationattachedto

thepainandpleasuresurroundingthereproductiveaspectsoflifeandchoiceswhichisdescribed

indetailintheforthcomingrelevantchapters.Intersectionalityexplainsthepositioningofpeople

fromwheretheyarepresentingtheirstandpoint.

Itisimportantformyresearchtoadoptmultiplelensestounderstandobstetricviolencebecause

themultipleformsofoppressionsandtheircomplexinterrelationshipsthatshapetheexperiences

andperceptionsofwomenandnurse-midwives(McEwan,2001).

4.2 Conceptualframework

Thisconceptualframeworkconnectsallthefourpapers.Overall,Ihaveinvestigatedwomen’sand

midwives’experiencesofrespect,disrespectandabuseduringchildbirth.Ihavealsoexplored

theirperceptionofwhywomenexperienceobstetricviolenceandrespectfulmaternitycare

duringchildbirth.Thedeterminantsaredividedintothreelevels:individual,structuralandpolicy

levels,basedonparticipant’sresponses,inlinewiththedefinitionofdisrespectandabuseduring

childbirthbyFreedmanetal.(2014)aspresentedinchapter2.Theconceptualframeworkshows

thestudycomponents,experiences,determinantsandperceptionsandrecommendationsdivided

atthreedifferentlevels:individual,structuralandpolicy(Figure4.1).

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55

Figure4.1 Conceptualframework

(Author’sown,withexclusivepaintingbyS.Karmakarforthisresearch,usedwithpermission)

Paper1:Socialdeterminantsofobstetricviolence-Women’sexperiencesofobstetricviolence

arenotaonetimeoccurrence,butoftenanembodiedexperienceofmultipleexperiencesthat

furtherexplainstheseriousnessofthisissue.Thispaperpresentsthediversityandpluralnature

ofwomen’sexperienceofobstetricviolencealongwithanunderstandingoftheirsocio-

demographicbackground,thatmayincreasetheirvulnerabilitytoobstetricviolence,andmultiple

experiencesofviolenceduringchildbirthinanobstetricsetting.

Paper2and3:Women’sexperiencesandperceptionofrespect,disrespectandabuse-Paper2

discusseswomen’sembodiedexperienceofrespect,disrespectandabuseduringchildbirthto

understandhowtheyattachmeaningtothese,throughparticipatoryvisualarts-basedqualitative

research.Paper3drawsfromthesamedataonexploringwomen’sperceptionofwhythey

experiencerespect,disrespectandabuseduringchildbirthandhowbirthcanbemadewomen-

centeredandsatisfactoryforeachoftheparticipant.

Paper4:Nurses-Midwives’perceptionsofobstetricviolence-Midwiferyandnursingleader’s

experienceandperspectivesofqualityandrespectfulmaternalhealthcareiscrucialforpolicies

andpracticebecausetheyaretheprimarycareprovidersinIndia.Theirperceptionsand

experiencehavebeenexploredqualitativelytopresentthedriversofobstetricviolenceandalso

recommendationsofwhatwillmakecarerespectfulforwomenduringchildbirth.

Women’s experienceof giving

birth

RESPECT DISRESPECT ABUSE

Midwives’ experienceof assisting

birth

EXPERIENCE

Midwives’ experienceof giving

birth

PERCEPTIONS

DETERMINANTS

Midwives’ related

factors that increase women’s

vulnerability to obstetric

violenceduring

childbirth

Women related

factors that increase

vulnerability to obstetric

violence during

childbirth

Midwives’ understand

ing of respect,

disrespect & abuse during

childbirth

INDIVIDUAL STRUCTURAL SYSTEMIC

Women’s perception of respect, disrespect & abuse during

childbirth

Women’s perceived factors of of respect, disrespect & abuse during

childbirth

Midwives’ perceived factors of of respect, disrespect & abuse during

childbirth

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4.3 Studydesignandanalysis

Thisisamixed-methodsstudythathasqualitativeandquantitativecomponents.Thekey

methodshavebeenmentionedinTable4.1againsteachpaper.

Table4.1 Studydesign

No. Objectives Design Typeofdata

Datacollection

Respondents Analysis

Paper1 Toexaminethesocialdeterminantsofobstetricviolenceduringchildbirth,inBihar.

Quantitative Secondary

StructuredHHsurveyquestionnaire

Newmothers DescriptiveanalysisLogisticregressionFactoranalysisLinearregression

Paper2&3

Toinvestigatetheperceptionsandexperiencesofrespect,disrespectandabuseincareduringchildbirthandthefactorsdrivingit,inBihar.

Qualitative Primary

BodyMappingassistedIDI’s

Womenwithbirthingexperience

FeministRelationalDiscourseAnalysis(FRDA)VoiceCenteredRelationalAnalysis

Paper4 Todocumentandanalysetheexperiencesofnursingandmidwiferyleaderswithrespect,disrespectandabuse,andtorecommendwaystostrengthenrespectfulcareforwomenduringchildbirthinIndia.

Qualitative Primary

Indepthinterview(IDI)

Nursing&midwiferyleaders

Thematicanalysis

Paper1:Socialdeterminantsofobstetricviolence:Thisstudyusessecondarydata.Ihadledan

extensivedatacollectionexerciseinacourseof18months(July2016toDecember2017)before

startingmyPhD.Thisdatacollectionwasdonetounderstandthequalityandrespectfulnessin

careduringchildbirthinallthe38districtsinBihar.Thesurveycoveredallthreelevelsofhealth

careprovision:primary,secondaryandtertiary.Theprocessinvolvedvisitingwomenattheir

householdswithinarecallperiodof30daysofbirthtounderstandthequalityandrespectfulness

ofcareduringchildbirthfromtheirperspectivewiththehelpofastructuredquestionnaire.The

householdinterviewswereconductedbyfemaleenumeratorsexperiencedinconducting

interviewsinthelocallanguagesanddialectsinBihar.Atotalof2194interviewswereconducted

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withwomenwhohavegivenbirthinanobstetricsettingwithinonemonthprecedingthe

interview.

Myaimistounderstandwhichbackgroundcharacteristicsofwomeninfluencedifferentformsof

obstetricviolenceduringchildbirth.Iconductedadescriptiveanalysisonthehousehold

interviewswithwomen,followedbybinarylogisticregressionanalysistounderstandthesocial

determinantsofobstetricviolence.Iconductedfactoranalysistocreatenewvariablesofobstetric

violencethatexplainthemostvarianceinthestudyfindingsonobstetricviolence.Iconducteda

linearregressiononthenewlycreatedvariablestoexaminetheircorrelationwithwomen’s

backgroundcharacteristics.StatisticalPackageforSocialSciences(SPSS)isusedtoanalysethe

data.

Papers2and3:Women’sexperienceandperceptionofrespectfulmaternitycareinBihar:I

interviewedwomenwhohavegivenbirthinBihar,inurbanslumsandruralvillages,qualitatively

usingavisual-artsbasedparticipatorymethod,bodymapping.Womenfromboththeseareas

belongtothepoorestofstrataandseekmaternalhealthcareatdifferentlevelsofcareprovision.

Womenfromtheruralareasmostlyaccesscareatprimaryandsecondarylevelsofcareprovision

thatmainlyincludetheBlockPrimaryHealthCenters(BPHCs),CommunityHealthCenters(CHCs)

andSubDistrictHospitals(SDHs).Womenintheurbanslumshavequickeraccesstothetertiary

levelsofcareprovisionsuchasatgovernmentsuper-specialtyhospitalsandmedicalcollege

hospitals.

IconductedascopingvisitinBiharinJanuary2019,toidentifythethemestoexplore,the

methodstouseandethicalmeasurestoconsider,toensurethestudyisconductedwithutmost

sensitivity.TheinterviewswereconductedinHindiandotherlocaldialectsconvenienttothe

participant.Havingworkedextensivelyinthesedistrictsandstate,Iamawareofthelanguage

barriersthatmayexist,asaresultofmanydialectsspokeninBiharincludingBhojpuri,Maithili

andMagahi.Audiorecordingwasdoneandpicturesweretakenwhilemaintaininganonymityof

theparticipantwithwomen’sinformedconsent.Participantswererequestedtoselecta

pseudonymtobeusedinthestudythatwillmaketheresultsmorerealisticbyaddingcultural

authenticitytoit(Montgomery,2015).Ianalysedthedatausingfeministrelationaldiscourse

analysis(FRDA),withvoicecenteredrelationalanalysisembeddedinit.IusedNVivo12toaidthe

analysis.

Paper4:Nurse-midwives’experiencesandperspectivesonrespect,disrespectandabuseduring

childbirthinIndia:IconductedthiscomponentofthePhDqualitativelythroughin-depth

interviewswithseniormidwiferyandnursingleaderswhorepresentthedomainsofeducation,

regulation,unionisationorassociation,research,administrationandhealthcareprovision.This

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datawerecollectedatstateandnationallevelsinIndia,withaglobalperspectivesharedby

expertsengagedinglobalmidwiferyandmaternalhealth-relatedpolicymaking.Thestatelevel

datacollectionwascarriedoutinBihar,Rajasthan,OdishaandMadhyaPradeshthatrepresent

theunderperformingstates,intermsofmaternalhealthcareindicatorsandoutcomes.Giventhe

lackofleadershipinmidwiferyandnursinginIndia,datacollectioninthesefourstateshelpedto

understandthebackgroundandcontextofchallengesforawayforward.WestBengalwas

selectedtorepresentastatewithgoodgovernancestructureinIndiaintermsofnursingand

midwiferyleadershipinpolicymakingforhealthworkforceandhealthserviceprovision(Baggaet

al.,2010;Sharmaetal.,2010;Mayra,Padmadas&Matthews,2021).Dataisalsocollectedatthe

nationallevelinIndia.

Interviewsareconductedwithglobalexpertsforareflectiononhowmidwiferyleadershipcan

helpimproverespectfulnessincareduringchildbirthandwhatdrivesobstetricviolenceduring

childbirth.Iinterviewedparticipantsrepresentinginternationalorganisationsthatinfluence

policiesinIndiaandgloballyincludingWHO,UnitedNations,UnitedNationalsFundforPopulation

Activities(UNFPA),ICM,ICNandtheUnitedNationsHighCommissionforRefugees(UNHCR).I

alsointerviewedmidwiferyexpertsfromUnitedKingdomwhohavesuccessfullyestablisheda

midwiferyledmodelofmaternalhealthcareprovisionandcloselycollaboratewithIndian

counterpartstoaidinmidwiferyimplementationinIndia.Theseinternationalexpertsarealready

playingacrucialroleinimplementingmidwiferyinIndiawiththeGovernmentofIndia.

Interviewsareaudiorecordedalongsidethoroughnotes.Writtenconsentistakenfromthe

participantsforaudiorecording,andfortheirparticipationintheresearch.Theinterviewsare

doneinEnglish,HindiandBengali,basedontheconvenienceofparticipants.Iamfluentinthese

languageswhichensuredthattherewasnolanguagebarrier.Therecordingsaretranslatedand

anonymisedwhilecompletingthenotesbeforestartingdataanalysis.

Iselectedtheparticipantsthroughpurposivesamplingfortheinterviews.Theparticipantshold

keypositionsinthestates,atthenationallevelandinthedevelopmentorganisationsatthe

globalpolicymakinglevel.Thesemi-structuredin-depthinterview(IDI)guide,forthenursingand

midwiferyleaders,isbasedonliteraturereviewofchallengesthatthiscadresexperience

(Appendix3)andmydecadelongexperienceofengagingin,influencingandresearchingnursing

andmidwiferygovernanceandpolicymakinginIndia(Mayra2020a;Mayra,Padmadas&

Matthews,2021).Thecare-seeker’sinterviewsanalysisisguidedbycriticalfeministtheory.The

careprovider’sinterviewsareanalysedusingthematicanalysis.IusedNVivo12toaidthe

qualitativedataanalysis.

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4.4 Researchethicalapproval

TheethicalapprovalforthePhDwastakenfromtheethicalreviewcommitteeofUniversityof

Southampton.Forpaper1,ethicalapprovalwasalsotakenfromCenterforMedicalStudies(CMS)

ethicalreviewcommitteeinIndia(ReferencenumberIRB00006230),beforeconductingthedata

collection.TheGovernmentofBiharhadalsoapproveddatacollection.Thereferencenumberof

UniversityofSouthampton’sethicsapprovalforthesecondarydataanalysisoffullyanonymised

datais31910.TheethicalreviewcommitteeatUniversityofSouthamptonapproveddata

collectionforthestudyaimingtounderstandwomen’sexperienceandperspectivesofrespect,

disrespectandabuseduringchildbirthinBihar(Referencenumber49734).Duetothesensitive

natureofdatacollectionforpaper2and3,thestudyisassignedcategoryA.Forpaper4,to

understandnursingandmidwiferyleader’sexperiencesandperspectivesofensuring

respectfulnessinthecareduringchildbirth,thereferencenumberforethicsapprovalis41164.

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Chapter5 Socialdeterminantsofobstetricviolencein

Bihar:evidencefromahouseholdsurvey

5.1 Introduction

Discriminatoryhealthcareprovisiononthebasisofanindividual’sbackgroundcharacteristics,such

asgender,race,socio-economicstatus,isaviolationofhumanrights(Gilmore,2017;Khoslaetal.,

2016).Indiaisuniquelydiverseintermsofclass,caste,gender,socio-economicstatus,language,

religionandgeographicdifferences.Theculturalcontextandfactorsunderlyingmaternalhealthcare

provisioncanvaryconsiderablyindifferentIndianstates.Itisimportantthatanykindofservice

provisionbeavailabletoitspeopleinanunbiased,non-discriminatoryandequitablemanner.

Researchevidencesuggeststhatthequalityofmaternalhealthcarereceived,variesbywomen’s

backgroundcharacteristics,andinsomecontexts,influencesadversematernalhealthoutcomes

(Patel,Das&Das,2018;Khoslaetal.,2016).

ArecentstudyfromIndiahighlightedthatcaste-baseddiscriminationinreproductivehealthcare

andprovisionofincentives,suchastheJSYschemeinIndia.Aparticipantinarecentqualitative

studyreportedcaste-baseddiscriminationanduntouchabilitywhiledescribingcareprovider

attitudes(Khanna&Sri,2017).Inequalitymayresultinalackofaccesstoinformationanddecision-

makingpower,whichmayleadtopoorerhealthoutcomes.Intermsofwomen’saccesstoand

qualityofreproductiveandmaternalhealthcare,casteandsocialclasscanplayaroleincreating

inequitiesinmaternalandreproductivehealthcareprovision,alongwithotherfactorssuchas

women’sreproductivehistory,age,maritalstatusandparity(Khanna&Sri,2017).Theaimofthis

chapteristoundertakeaquantitativeanalysisofhouseholdsurveydatatoinvestigatethesocial

determinantsofobstetricviolenceinthestateofBihar,India.

AstudycarriedoutinUttarPradeshreportedthatthehighestmistreatmentscoresinhealthcare

facilitiesareforwomenolderthan35years(Sharma,2019).Anotherstudyfoundthatolderwomen

aremorelikelytoreportobstetricviolenceduringchildbirth,inadditiontoexpectationsforabribe

(Sudhiranasetetal.,2016).StudiesconductedinJordan(Fatimaetal.,2018)andGhana(Afulaniet

al.,2019)reportthatuneducatedandunemployedwomenaremorelikelytobeabused.

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62

Disrespectfulcommentsbycareprovidersoftentargetwomen’sphysicalappearance,socio

economicstatus,parityandage(Sharma,2019).Inthesamevein,treatmentofwomenmayvary

basedon‘favouritism’thatmayresultininequitableuseoflimitedresourcesandrespectfulnessin

careprovisionwhenthelabouringwomanisknowntotheteam,orcomesfromawealthyand

influentialfamily(Freedmanetal,2018).

Freedman(2014)highlightsthatitisimportanttounderstandthedifferentdeterminantsofinequity

incareprovision,thatvariesbydifferentculturesandcountries.Thisistrueforbothdevelopingand

developedcountries,asforinstancecanbelearntfromthepoormaternalhealthoutcomesfor

womenofcolourinAmerica(Shah,2019).EvidencefromBihar,Indiashowsdiscriminatorypractices,

wherebywomenfromuppercastesorsocialclassesaregivenpreferentialcareinhealthfacilities

whilethoseinthelowercastegroupareeitherignoredorforcedtowait(Patel,Das&Das,2018).

AnotherreportsuggeststhatthereisnoASHAinaparticularcommunitybecauseASHA’sarefrom

uppercastefamilieswhooftenignorewomeninthevillagefromthelowercastes.Womenfrom

poorsocioeconomicbackgroundsaremorelikelytoreceivedisrespectfulandabusivecare.Thismay

includeignoringtheirrequestsforattentionorpainrelief,beingphysicallyimmobilised,undergoing

multiplepelvicexaminations,notbeingallowedabirthcompanion,givingbirthlyingdown(supine

position),receivingfundalpressureandhavingtheirculturalandspiritualritualsaroundbirth

ignored(suchasplacentadisposal).Theyarealsomorelikelytobegivenepisiotomiesincomparison

towomenfromaffluentbackgrounds(Sen,Reddy&Iyer,2018).Genderisanunderlyingfactorthat

increaseswomen’svulnerabilityingeneral(Sen,Reddy&Iyer,2018).

Discriminationcanbeseeninhowmedical,nursingandmidwiferystudentsaretaughtandthe

womenthey‘practice’on.Thereislimitedresearchonhospitalandstudentpairingforpracticein

theirpre-serviceeducation(Madhiwalaetal.,2018).Theprivateandpublichospitaldistinctionis

alsoimportanttonotehere.Midwifery,nursingandmedicalstudentsinIndiapracticeinpublic

hospitalsordonotgetenoughpracticeiftheyarestudyinginprivateinstitutionsaffiliatedtoa

privatetertiaryhospital(Mayra,2020b;Mayra,Padmadas&Matthews,2021).Mostprivate

hospitalshaveclientsfromaffluentbackgroundwhomightnotacceptcarefromastudent.Public

hospitalspredominantlyreceiveclientsfrompoorsocio-economicbackgrounds,indicatingmore

power-basedinequitiesbetweencareseekerandcareproviders(Mayra,Padmadas&Matthews,

2021).Studentsandtheirtraininginstitutionsfinditeasiertopracticeskillsonwomenfrompoorer

backgroundseekingcareinthepublichealthfacility.Figure5.1classifiesthesesocialdeterminants

into:1)individualattributes,2)familyandpeerinfluences,3)intermediarydeterminantsofhealth

and4)structuraldeterminantsofhealthinequities.

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Figure5.1 Socialdeterminantsofmaternalhealth(Source:Khanna&Sri,2018.p.194)

Careprovidersunderstandthataneducatedwomanisoftenawareofthecareshewouldreceive

andhashigherexpectations(Downe,2019).Inlinewiththisargument,astudyfoundthatliterate

womenweremorelikelytohaveinterventionsexplainedtothem(Sudhiranasetetal.,2016).Onthe

otherhand,itisdifficultforwomenfrommarginalisedbackgroundtoreportobstetricviolenceeven

afteridentifyingit.Moststudiesonobstetricviolencefocusondifferentformsofviolence,ascanbe

seenthroughthevarioustypologies,andnotenoughonthepluralityofthesedifferentformsof

obstetricviolenceineachwoman’sexperience,whichIaddressinthisstudyalongwithexamining

thesocialdeterminantsofobstetricviolenceagainstthespecificindicatorsinthesevendomainsof

mistreatmentpresentedbyBohrenetal(2015).

5.2 Objective

• Toinvestigatetheassociationbetweenwomen’sbackgroundcharacteristicssuchasage,

caste,education,occupation,socio-economicstatusandparityandtheirlikelihoodof

experiencingobstetricviolenceduringchildbirthinBihar,India.

• Tounderstandthepluralityandcomplexmultilayerednatureofwomen’sexperienceof

obstetricviolenceinBihar,Indiathatmaybebetterexpressedquantitatively.

5.3 Methods

IanalysedsecondarydatafromahouseholdsurveyconductedinBihar,India.

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5.3.1 Datacollection

DatawerecollectedbyOxfordPolicyManagementLimitedbetweenJuly2016toDecember2017

coveringallofthe38districtsofBihar,andthehouseholdsurveywascarriedoutasapartofthe

evaluationofqualityofmaternalhealthcareprovisioninthestate.Thehouseholdsurveyincludeda

separatesectiontocapturerespectfulmaternitycare.

Thehouseholdsurveyimplementedastructuredquestionnaire,targetingasampleof2194women

whohadgivenbirthwithinamonthprecedingtheinterviewinhealthcarefacilities(obstetric

settings)inBihar.Thisdatacollectionwasrelatedtoanothersurvey,whichinvolveddirect

observationofchildbirthinpublichospitalsinallthedistrictsofBihar,thataimedtoexplorethe

qualityofcareduringchildbirththroughaquasi-experimentalstudy.Thefindingsofthisstudyare

publishedelsewhere(Ahmedetal.,2019).Consentwastakenfromwomentoobservetheirbirth

andtoalsovisitthemwithin30daysofchildbirthforaninterviewattheirhouse.Theenumerators

visitedthehouseholdofallthewomenwhohadgivenbirthinthelast30dayswhentheyvisitedthe

womanwhosebirthwasobservedinthehealthcarefacilityalongwithcontactingwomenwhose

birthwerenotobservedbutliveinthesamevillageandhavegivenbirthinthelast30days.

Theinformationaboutallthewomenwhohadgivenbirthinthesamevillagecouldbereceivedfrom

theASHA,whichwasfollowedbyinterviewingthewomenafterseekingconsent.Womenwhogave

birthathomewereexcludedfromthesample,asIaimedtoexaminethesocialdeterminantsof

obstetricviolenceinobstetricsettingsonly.

Ofthe2194interviews,964women’sbirthswereobservedbynurse-midwifeenumeratorswith

consent.Theinterviewswerecarriedoutbyfemaleenumeratorswhowerefluentinthelocal

dialectssuchasMaithli,MagahiandBhojpuri.Everyinterviewwasconductedbytwofemale

enumerators,usingComputerAssistedPersonalInterviews(CAPI)systems.Afieldsupervisorwas

deployedwitheachteamtomonitorthesurveyandsupporttheteam.

AstructuredquestionnaireinHindiwasusedtodocumentwomen’sbackgroundcharacteristics,

experienceofcarearoundchildbirth,respect,disrespectandabuse,andsatisfactionwiththecare

received.

AstheNationalQualityofCareEvaluationManageratOxfordPolicyManagement,Iwasclosely

involvedinthedesignandimplementationofthehouseholdsurveyinBiharincludingdatacollection

andprocessing.Iwasalsoresponsibleforcoordinatingthefieldworkwhichincludedhiringand

trainingtheenumeratorsandsupervisoryteamandperformingtheoverallmanagementofthedata

Chapter5

65

collection,datamanagementandqualitycontrol.Ihavealsoparticipatedinreportwritingand

disseminationofthestudyfindings.Mybackgroundinnursingandmidwiferyandinresearchon

sexual,reproductiveandmaternalhealthcareaddedvaluetothedevelopmentandimplementation

offieldwork.

Ethicalapproval:TheethicalclearancefordatacollectionwastakenfromCentreforMediaStudies

institutionalreviewcommitteeinIndiabeforestartingdatacollection(Referencenumber:

IRB00006230).Informedconsentwastakenfromalltheparticipantsfortheinterviewattheir

household.Inaddition,IobtainedethicalapprovalforsecondarydataanalysisfromtheFacultyof

SocialSciencesResearchEthicsandGovernanceCommittee,attheUniversityofSouthampton

(Referencenumber:31910).

5.3.2 Dataanalysis

Forthedescriptiveandmultipleregressionanalyses,Iuseddatafrom2194womenwhogavebirth

inobstetricsettings.Basedontheliterature,Iselectedrelevantbackgroundvariablestounderstand

thesocialcharacteristicsassociatedwithobstetricviolence.Theseinclude:women’sage,education,

caste,occupation,socio-economicstatus,religionandparity.Ihaveconsideredthehousehold’s

socioeconomicstatustobetheparticipant’ssocio-economicstatuswhichwasmeasuredthrough

questionsonthehousehold’slandandcarownershipasanindicatorofwealth.

First,IcreatednewvariablesthatmatchedindicatorsundertheBohrenetal.(2015)typologyof

mistreatmentduringchildbirth,tounderstandtheextentofwomen’sexperienceofobstetric

violence.Thesevariablesareclassifiedunderallthesevenkeydomainsofthetypology:1)physical

abuse;2)sexualabuse;3)verbalabuse;4)stigmaanddiscrimination;5)poorrapportbetween

womenandcareproviders;6)failuretomeetprofessionalstandardsofcare;and7)healthsystems

conditionsandconstraints.Second,Iconductedbinarylogisticregressionanalysistounderstandthe

statisticalassociationbetweenthesespecificformsofobstetricviolenceunderBohren.etal(2015)

typologyandwomen’sdemographicandsocialcharacteristics.

Finally,Iconductedfactoranalysistocreatescorestoquantifyobstetricviolence,therebyreducing

thedifferentdimensionsasidentifiedunderthesevendomainsofBohrenetal.(2015)typology.

BasedontheScreeplot,Iextractedthefirstthreecomponentsthatrepresentedmorethan30%of

thevarianceinmydataset.Iconductedlinearregressiononthethreenewlycreatedobstetric

violencevariableswiththebackgroundcharacteristicstoinvestigatetheirassociationwithwomen’s

vulnerabilitytoexperienceobstetricviolenceduringchildbirth.

Chapter5

66

5.4 Results

5.4.1 Participantprofile

Atotalof2194womenwhoparticipatedinthisstudygavebirthinahealthcarefacilityinBihar.As

showninTable5.1,theparticipant’sagerangedbetween18-25years(72%),only1.5%participants

wereagedabove36years.Halfofthewomeninterviewedhavenotreceivedanyformaleducation

andonly8%hadreceivedahigherordegree(5%)leveleducation.Themajorityofparticipants

belongedtoHindureligion(83%)andweremarried(99.9%).About26%ofsurveyparticipants

belongedtoschedulecaste.Scheduletriberepresentationwasinsignificant(0.5%),whileother

backwardcastesrepresented61%ofallparticipants.Littlemorethan50%ofwomenlivedin

householdswithbettersocio-economicconditionswhichmeanttheirhouseholdsownedeitherland

orcar,orboth.

Chapter5

67

Table5.1 Participantprofile

Backgroundcharacteristics Numberofwomen(N=2194) Percentage

Age

18-25 1587 72.3

26-35 574 26.2

36-45 31 1.4

46+ 2 0.1

Education

Noeducation 1084 49.4

Primaryeducation 226 10.3

Secondaryeducation 594 27.1

Highersecondaryeducation 179 8.2

Degreelevel 111 5.1

Occupation

Homemaker 2179 99.3

Farmer 10 0.5

Employee 1 0.0

Ownbusiness/selfemployed 2 0.1

Student 2 0.1

Religion

Christian 3 0.1

Hindu 1816 82.8

Muslim 375 17.1

Marriage

Married 2191 99.9

Chapter5

68

Backgroundcharacteristics Numberofwomen(N=2194) Percentage

Separated 3 0.1

Caste

General 265 12.1

ScheduleCaste 573 26.1

ScheduleTribe 12 0.5

Otherbackwardcastes 1342 61.2

Socioeconomicstatus

BetterSES 1182 53.9

PoorSES 1012 46.1

Itisessentialtoexaminetheparticipant’sbirthingrelatedprofiles.Almostallwomenreceivedsome

antenatalcare(Table5.2).About4%womenhadabirthwerereferredfromanotherfacility.Most

womenweremultiparous(70%),withamaximumninebirths.Mostofthewomeninterviewed,

reportedsatisfactionwiththeirbirthingexperienceatthehealthcarefacility(96%)andwouldprefer

toseekcareatthesamehealthcarefacilityiftheygavebirthagain(92%).

Chapter5

69

Table5.2 Participant’sbirthrelatedvariables

Birthrelatedindicators Numberofwomen

(N=2194)

Percentage

Receivedanyantenatalcare 2180 99.4

Referredfromanotherfacility 95 4.3

Receivedepisiotomy 123 5.6

Givenanesthesiabeforeepisiotomy 82(N=123)

Prefertobirthinthesamefacilityagain 2009 91.6

Womensatisfiedwiththeirbirth

experience

2106 95.9

Parity

1 652 30.0

2-3 1055 48.0

4+ 487 22.2

Womenratingrespectfulnessincare

Excellent 138 6.3

Verygood 1386 63.2

Good 488 22.2

Fair 130 5.9

Poor 52 2.4

5.4.2 Experienceofobstetricviolence

Noneofthewomenreportedexperiencingsexualabuse,beingrestrainedandbeingdiscriminated

basedoncaste.Thegraphbelow(Figure5.2)showsthepercentageofwomenwhoexperienced

obstetricviolence,classifiedunderBohrenetal.(2015)sevenkeydomains.

Chapter5

70

Figure5.2 Women’sexperienceofobstetricviolenceunderBohrenetal.typology(2015)

Thetablebelow(5.3)showswomen’sexperienceofobstetricviolencebasedonBohrenetal.(2015)

typologyonmistreatmentofwomenduringchildbirthinanobstetricsetting.Thesurveydatashow

that,whileJSYpolicyisthekeydriverforwomentogivebirthinthehealthcareinstitutions,98%of

womendidnotreceivethemoneyfromgovernmentwithin30daysofgivingbirth.Unclearfee

structureisthecommonestformofabusefollowedbybriberyandextortion(84%),whichtogether

suggeststhatallwomenhadachallengingexperiencerelatedtohealthsystemconditionsand

constraints,whichisthe7thdomainofthetypology.Thiswasfollowedbythe6thdomain,‘Failureto

meetprofessionalstandardsofcare’,underwhich,womenweredeniedfoodandfluid(27%),not

allowedtowalkaround(22%)andnotallowedtheirchosenpositiontogivebirth(12%).Theywere

treatedasapassiveparticipantduringtheirchildbirth,andwerenotinformedaboutthefindingsof

theirgeneralexamination(31%)andvaginalexamination(7%),whichindicatespoorstaffattitude.

Womenreportedpoorrapportwiththecareproviders(Domain5).Theyexperiencedalackofclarity

incommunicationintermsofnotexplainingthewardenvironment(13%),theprogress(7%)and

movement(21%)inlabour.Somewomen(5%)feltneglectedorabandonedwhentheyneededa

careprovider.Afewwomenreportedbeingdiscriminatedandstigmatizedbasedontheirage

(0.2%),socioeconomicstatus(0.4%)andHIVstatus(16%).Althoughthenumberdoesnotsuggest

thattheywereHIVpositive,insteadthattheycouldhavefeltdiscriminatedwhentheywereasked

aboutit.Afewwomenreportedbreachofprivacy(4%)andconfidentiality(1%).

Chapter5

71

Womenalsoreportedthatsomeofthemostextremeformsofobstetricviolence:verbal(5%)and

physicalabuse(2%).Womenwerehit,slappedandpinched(2%)andweresubjectedtojudgemental

andaccusatorycomments(5%),rudelanguage(5%)andwerethreatenedtowithholdservices(1%).

Somewomenreceivedanepisiotomycutwithoutanesthesia(2%),thatcanbeconsideredoneofthe

harshestformsofobstetricviolence.

Chapter5

72

Table5.3 Typesofmistreatmentduringchildbirthexperiencedbywomen

Domainof

obstetricviolence

Specificmistreatmentcategory Frequency%

(N=2194)

Physicalabuse Slapping,hitting,pinching 1.6(35)

Restraining 0.0(0)

Sexualabuse Rape 0.0(0)

Verbalabuse Judgementalandaccusatorycomments 5.0(109)

Rudelanguage 5.0(109)

Threatenedwomentowithholdservices 0.6(14)

Stigmaand

discrimination

Discriminationbasedonage 0.1(2)

Discriminationbasedoncaste 0.0(0)

DiscriminationbasedonSES 0.2(4)

DiscriminationbasedonHIVstatus(askedaboutHIV

status)

15.5(341)

Poorrapport

betweenwomen

andproviders

Nopainrelief(episiotomywithoutanesthesia) 1.9(12)

Neglectandabandonment 4.7(103)

Lackofconfidentiality 1.2(27)

Poorcommunication-wardenvironmentnotexplained 13.2(289)

Poorcommunication-progressinlabournotexplained 6.1(134)

Poorcommunication-movementforfoetusinlabour

notexplained

20.7(454)

Nonconsensualsurgery(episiotomy) 0.5(12)

Nonconsensualcare 3.7(81)

Notallowedtowalk 21.9(481)

Womanorbabydetainedatthefacility 2.4(53)

Chapter5

73

Domainof

obstetricviolence

Specificmistreatmentcategory Frequency%

(N=2194)

Failuretomeet

professional

standards

Denialoffoodandfluid 27.3(600)

Birthcompanionnotallowed 1.5(34)

Deniedchoiceofbirthposition 12.1(266)

Treatedasapassiveparticipant(GEnotexplained) 30.8(675)

Poorstaffattitude(VEfindingsnotexplained) 7.2(157)

Healthsystem

conditionand

constraints

Lackofprivacyduringbirth 3.9(85)

Bribeandextortion 84.2(1848)

Reportedgrievance 4.7(104)

Unclearfee(receivedanyfunds/JSYmoneyfromthe

institutionalbirth)

98.0(2150)

Table5.4showsthepercentagesofdifferentformsofobstetricviolencebywomen’sbackground

characteristics,basedonBohrenetal.(2015)classification.Morethan30%ofthewomenaged

between36-45yearsexperiencedstigmaanddiscrimination,whichismuchhigherthanotherage

groupsofparticipants.Thisistwiceashighsuggestingwomenmayexperiencemoreabusewhen

givingbirthatanolderagethanwomenagedbetween18-25and26-35yearsofage.Similarly,

womenwhowerehighlyeducated,withdegreelevelofeducation,didnotreportanyexperiencesof

physicalabuse.However,highlyeducatedwomenreportedcomparativelymorestigmaand

discriminationthanotherwomeninthiscategory.

Religionisalsoanimportantfactor.Hinduwomenreportedexperiences(82%)ofverbalabuseata

higherratethanMuslimwomen(5%).Scheduledtribewomenreportedexperiencingphysical(8%)

andverbalabuse(8%)atahigherratethantheaverage(2%&5%)andwomen’sexperiencefrom

othercastes.Parityisanimportantfactor,asprimiparawomenhavebeenmorelikelytoexperience

physicalabuseandpoorrapportwiththecareprovider.

Chapter5

74

Table5.4 Percentageofwomenreportingobstetricviolencebywomen’sbackground

Variables Physical

abuse

Verbal

abuse

Stigma&

discrimina

tion

Poor

rapport

between

woman&

care

provider

Failureto

maintain

profession

al

standard

ofcare

Health

systems

conditions

and

constraints

TOTAL 1.6 5.0 15.8 3.2 56.6 100.0

Age

18-25years 1.7 5.4 16.4** 4.0** 55.3 99.9

26-35years 1.4 3.8 13.4** 1.0** 60.6 100.0

36-45years 0.0 3.2 32.3** 0.0** 48.4 100.0

46yearsandabove 0.0 0.0 0.0** 0.0** 50.0 100.0

Education

Noeducation 1.6 4.8 15.9 2.2 58.9 100.0***

1-5years(Primary) 0.9 4.4 13.3 3.1 56.2 100.0***

6-10years(Secondary) 2.4 5.9 15.0 3.5 55.4 100.0***

11-12(Higher

secondary)

1.1 4.5 17.9 5.0 51.4 100.0***

13+(Degree) 0.0 3.6 21.6 8.1 50.5 99.1***

Religion

Muslim 1.1 4.5*** 15.5 3.7 59.7 100.0

Christian 0.0 66.7*** 0.0 0.0 100.0 100.0

Hindu 1.7 82.6*** 15.9 3.1 55.9 99.9

Caste

Generalcaste 1.5 4.5 19.9 4.5 58.3 100.0

Chapter5

75

Variables Physical

abuse

Verbal

abuse

Stigma&

discrimina

tion

Poor

rapport

between

woman&

care

provider

Failureto

maintain

profession

al

standard

ofcare

Health

systems

conditions

and

constraints

TOTAL 1.6 5.0 15.8 3.2 56.6 100.0

Otherbackwardcaste 1.7 5.1 15.6 3.4 57.2 100.0

Schedulecaste 1.2 4.7 14.5 2.1 54.8 100.0

Scheduletribe 8.3 8.3 8.3 0.0 41.7 100.0

Occupation

Homemaker 1.6 5.0 15.8 3.2 56.5 100.0

Farmer 0.0 10.0 30.0 0.0 70.0 100.0

Employee 0.0 0.0 0.0 0.0 100.0 100.0

Ownbusiness/self-

employed

0.0 0.0 0.0 0.0 100.0 100.0

Student 0.0 0.0 0.0 0.0 50.0 100.0

Marriage

Married 1.6 5.0 15.8 3.2 56.6 100.0

Separated 0.0 0.0 0.0 0.0 66.7 100.0

Parity

1 2.3 6.3 15.6 8.9*** 49.4*** 99.8

2-3 1.4 4.7 15.6 0.9*** 58.1*** 100.0

4+ 1.0 3.7 16.4 0.4*** 63.0*** 100.0

SocioEconomicStatus

PoorSES 1.6 4.9 13.9** 2.2** 61.2*** 100.0

Chapter5

76

Variables Physical

abuse

Verbal

abuse

Stigma&

discrimina

tion

Poor

rapport

between

woman&

care

provider

Failureto

maintain

profession

al

standard

ofcare

Health

systems

conditions

and

constraints

TOTAL 1.6 5.0 15.8 3.2 56.6 100.0

GoodSES 1.6 5.0 17.4** 4.1** 52.7*** 100.0

***significantatp<0.01;**significantatp<0.05;*significantatp<0.1

Idevelopedascoreforeachofthe29specificformsofabusetounderstandwhethereachwoman

hadexperiencedobstetricviolenceundereachofthecategories,bycodingtheresponsesas0for

‘No,experienceofobstetricviolence’and1for‘Yes,experienceofobstetricviolence’.Iwantedto

understandtheextentofeachwoman’smultipleexperiencesofobstetricviolence.Figure5.3shows

thecomplexmulti-layerednatureofwomen’sexperienceofobstetricviolence.Ifoundthatevery

womanhadexperiencedsomeformofobstetricviolence.Veryfewwomenexperiencedone(6%)

formofabuseduringtheirstayinthehealthcarefacility.Mostwomenexperiencedtwo(28%)to

three(25%)formsofobstetricviolence.Womenwhoexperiencedfour(13%),five(9%)orsix(8%)

formsofabusewasalsohigh,asshowninFigure5.3.Itisimportanttonotethat164women

reportedexperiencingseventoeightformsofabuse.Fortywomenreportedexperiencingnineand

seventeenwomenreportedexperiencing10formsofabuse.

Chapter5

77

Figure5.3 Thenumberoftypesofobstetricviolencesufferedbywomen

Tobetterunderstandthegraphaboveintermsoftheseverityofwomen’sexperiences,Ipresenta

casestudyfrommydataset.IpresentTrahi’s(pseudonym)story,astheparticipantwhoexperienced

themaximum(17)formsofobstetricviolence,whichwasthehighestinmydatasetinAppendixA.I

constructedthisstoryfromherdata,forabetterunderstandingofwomen’sexperiencesofobstetric

violencewithmorecontext,andtohighlightthevalueofeverysinglewoman’sexperienceof

obstetricviolence,thatIwillexploreinmoredetailinthenextchapters.

5.4.3 Socialdeterminantsofobstetricviolence

Binarylogisticregressionanalysis

Iconductedlogisticregressionsonfiveoutofthesevenkeydomainsofobstetricviolence

(dependentvariables)fromBohrenetal.(2015)typologytoexaminetheirassociationwithwomen’s

backgroundcharacteristics(Table5.5).Ididnotincludesexualabusebecausenoonereportedit

whilehealthsystemsconditionsandconstraintsreportingwasuniversal.Thebackground

characteristicsdescribingwomen’sreligion,age,education,caste,parityandsocio-economicstatus

aretheindependentvariablesalongwithavariableonwhethertheparticipant’sbirthwasobserved

inthesurveybyresearchersinthehealthcarefacility.Ididnotuseoccupationdatabecause99.9%

womenarehomemakers.Iusethe1stcategoryineachvariableasthereferencecategory.

Chapter5

78

Theresultsshowthatwomenhadhigheroddsofexperiencingphysicalabuse,verbalabuse,and

failuretomeetprofessionalstandardsbycareproviders,whentheirbirthwasnotobserved.Women

weremorelikelytoexperiencestigmaanddiscriminationwhentheirbirthwasobserved.These

resultswerehighlysignificant.Increasingparitydecreasedthelikelihoodofwomenexperiencing

poorrapportwithcareproviderbutincreasedthelikelihoodoffailureonthecareprovider’spartto

provideprofessionalstandardofcare.Womenwithmorechildrenweremorelikelytoexperience

failuretomaintainprofessionalstandardofcare.Inaddition,womenagedbetween25-36years

werelesslikelywhilewomenaged36-45yearsweremorelikelytoexperiencestigmaand

discriminationcomparedtowomengivingbirthatbetween18-25yearsofage.Poorrapportwith

careproviderwasmorelikelyifthewomenareeducated,withthemosteducatedwomen

experiencingthehighestlikelihoodofpoorrapportwithcareprovider.Womenweremorelikelyto

experiencepoorrapportwithcareproviderandlesslikelytoexperienceafailuretomaintain

professionalstandardofcareiftheybelongedtoahouseholdwithagoodsocio-economicstatus.

Womenfromotherbackwardcastesandscheduletribeweresignificantlylesslikelytoexperience

stigmaanddiscriminationincomparisontowomenfromgeneralcaste.

Chapter5

79

Table5.5 Binarylogisticregression(oddsratio)(95%CI)

Bohrenetal.

maindomainsof

disrespectand

abuseduring

childbirth

Physical

abuse

VerbalAbuse Stigma&

discrimination Poorrapport

between

woman&care

provider

Failureto

maintain

professional

standardofcare

Religion

Hindu 1.00 1.00 1.00 1.00 1.00

Muslimsand

Christians

0.56

(0.18,1.79)

1.09

(0.62,1.90)

0.87

(0.61,1.22)

1.36

(0.69,2.69)

1.02

(0.79,1.32)

Age

18-25years 1.00 1.00 1.00 1.00 1.00

26-35years

1.34

(0.49,3.65)

0.86

(0.48,1.56)

0.68

(0.48,0.95)**

1.20

(0.43,3.36)

0.94

(0.71,1.16)

36-45years

0.00 0.77

(0.10,6.13)

2.03

(0.89,4.62)*

0.00 0.49

(0.23,1.05)*

46years+ _ _ _ _ 0.34(0.02,5.58)

Education

Noeducation 1.00 1.00 1.00 1.00 1.00

Primary

0.52

(0.12,2.28)

0.91

(0.45,1.83)

0.77

(0.51,1.18)

1.23

(0.51,2.98)

0.93

(0.69,1.25)

Secondary

1.22

(0.57,2.62)

1.10

(0.69,1.77)

0.87

(0.65,1.18)

0.87

(0.465,1.65)

1.03

(0.81,1.27)

Highersecondary

0.54

(0.12,2.49)

0.74

(0.33,1.67)

1.05

(0.68,1.63)

0.929

(0.40,2.15)**

0.88

(0.62,1.23)

Degree

_ 0.65

(0.22,1.88)

1.35

(0.81,2.23)

1.53

(0.64,3.66)*

0.87

(0.58,1.33)

Chapter5

80

Bohrenetal.

maindomainsof

disrespectand

abuseduring

childbirth

Physical

abuse

VerbalAbuse Stigma&

discrimination Poorrapport

between

woman&care

provider

Failureto

maintain

professional

standardofcare

Caste

GeneralCaste 1.00 1.00 1.00 1.00 1.00

Otherbackward

caste

0.87

(0.28,2.71)

1.14

(0.58,2.23)

0.68

(0.47,0.97)**

0.75

(0.37,1.54)

0.92

(0.68,1.23)

Schedulecaste

0.56

(0.15,2.15)

0.96

(0.44,2.08)

0.64

(0.42,0.98)**

0.49*

(0.20,1.23)

0.75

(0.54,1.05)*

ScheduleTribe

3.85

(0.37,40.68)

1.69

(0.19,14.75)

0.32

(0.04,2.60)

_ 0.69

(0.21,2.34)

Parity

1 1.00 1.00 1.00 1.00 1.00

2-3

0.57

(0.27,1.24)

0.73

(0.47,1.14)

1.07

(0.81,1.41)

0.09

(0.05,0.19)***

1.44

(1.17,1.78)***

4+

0.57

(0.27,1.24)*

0.60

(0.29,1.23)

1.34

(0.89,2.03)

0.04

(0.008,0.20)***

1.73

(1.36-2.54)***

Socio-economicstatus

PoorSES 1.00 1.00 1.00 1.00 1.00

BetterSES

0.97

(0.48,1.95)

1.00

(0.67,1.51)

1.28

(0.99,1.64)

1.66

(0.95,2.88)*

0.71

(0.60,0.84)***

Birthobservation

Birthobserved 1.00 1.00 1.00 1.00 1.00

Birthnot

observed

1.98

(0.95,4.14)*

1.52

(1.01,2.29)**

0.61

(0.49,0.77)***

1.41

(0.85,2.34)

2.39

(2.00,2.86)***

Chapter5

81

Factoranalysis

AnalysingeachseparateBohrenetal.,(2015)categorywasonewaytoreducethedimensionalityof

theobstetricviolencedata.However,onlyfiveofthesevendatagroupscouldbeusedandthe

approachdidnotreducethedimensionalityenough.I,therefore,usedfactoranalysiswithprinciple

componentanalysisasthemethodofextraction,tocreatescoresthatcapturedthevariationmore

succinctly.Iselectedthefirstthreecomponentswhichexplainedthemostvarianceinthedata,as

canbeseenintheScreePlot(Figure5.4)whichshowsthatthefactorsstarttailingoffafterthe3rd

componentandthefirstthreecomponentsexplain32%ofthetotalvariance.

Tocarryoutthefactoranalysis,Iselected26ofthe29typesofobstetricviolencebasedonthe

entireBohrenetal.(2015)classificationbecausethreeformsofviolencenamely,sexualviolence,

restrained,anddiscriminationagainstcaste,werenotreportedbyparticipants.Table5.6presents

thethreecomponentsthatrepresentedthemostvarianceinthe25typesofobstetricviolence.I

selectedacutoffvalueforfactorloadingsat0.3(Tabachnich&Fidell,2013)andhighlightedthe

elementsthatloadedpositivelyandstronglyundertheparticularformsofviolence.

Figure5.4 ScreePlot

Component1loadedpositivelyforindicatorsconcerningphysicalandverbalabuse.Thethree

variablesthatloadedstronglyunderthiscomponentforverbalabuseare:1)rudelanguage;2)

judgementalandaccusatorycomments;and3)threatenedwomentowithholdservices.Poor

communicationhasstrongpositivefactorloadingfortwomainobstetricviolencedomainsi.e.poor

rapportbetweenwomanandcareproviderandafailuretoprovideprofessionalcare,for

Chapter5

82

component2.Thereisapatterninthehighpositivefactorloadingforthespecificvariableswhich

weremostlyrelatedtopoorcommunicationandalackofexplanation,thatinclude:1)vaginal

examinationfindingsnotexplained;2)wardenvironmentnotexplained;3)progressinlabournot

explained;4)generalexaminationfindingsnotexplained;and5)movementinlabournotexplained.

Factorsloadingwerepositiveandstrongfordenialoffoodandfluidsandnotallowingwomento

walkwheninlabour.Thisshowsafailuretoprovidecompassionatecareduringchildbirth,andcan

beconsideredrelatedtopoorcommunicationwhenwomenarerestrictedfromwalkingandeating.

Thethirdcomponent,coercion,indicatesalackofconsent,asthefactorloadingwaspositively

correlatedwith1)non-consensualcareand2)non-consensualsurgery.

Chapter5

83

Table5.6 Factoranalysis

IndividualdisrespectandabuseindicatorsfromBohrenetal’sclassification

Components

Physical&verbalabuse

Poorcommunication

Coercion

Womanorbabydetainedatfacility

0.188 0.038 0.122

AskedaboutHIVstatus -0.111 -0.197 -0.009

Nobirthcompanion 0.011 0.108 0.103

Deniedchoiceofbirthposition 0.250 0.235 -0.032

Denialoffood&fluid 0.188 0.547 -0.193

Physicalabuse 0.511 -0.155 -0.057

Leftunattendedwhenneeded 0.437 -0.017 0.202

GEexaminationsnotexplained 0.226 0.370 0.041

VEfindingsnotcommunicated 0.222 0.458 0.322

Lackofprivacyduringbirth 0.156 0.000 0.246

Confidentialitybreach 0.215 -0.085 0.245

Wardenvironmentnotexplained

0.247 0.305 0.052

Progressinlabourunexplained 0.238 0.371 0.476

Non-consensualsurgery 0.244 0.044 0.556

Non-consensualcare 0.372 -0.028 0.487

Rudelanguage 0.906 -0.271 -0.201

Receivedanyfundsfromtheinstitutionalbirth

-0.014 -0.038 -0.115

Judgementalandaccusatorycomments

0.906 -0.271 -0.201

Movementinlabourunexplained

0.223 0.816 -0.256

Threatenedwomentowithholdservices

0.483 -0.140 0.068

Bribeandextortion 0.154 0.107 0.055

Reportedgrievance 0.883 -0.270 -0.204

Notallowedtowalk 0.215 0.809 -0.270

Agebaseddiscrimination 0.185 -0.004 -0.059

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DiscriminationbasedonSES 0.213 -0.057 -0.125

Extractionmethod-PrincipleComponentAnalysis

Rotationmethod-ObliminwithKaiserNormalisation

Exploringtheobstetricviolencefactorscoresbywomen'sbackgroundcharacteristics

Icreatedscoresagainstthreeobstetricviolencevariablesfromthefirstthreeprinciplecomponents

foralltheparticipants,tounderstandthepatternofobstetricviolencebyselectedbackground

characteristics,asshownthroughthefollowinggraphs.Ahigherscoreofeachofthenewdomain,

meansmoreexperienceofobstetricviolence.Poorcommunicationscoresincreasewithwomen’s

age,whereascoercion,physicalandverbalabusescoresdecreaseswithage(Figure5.5).

Figure5.5 Meanscoresofobstetricviolencebyagegroup

Communicationimprovedandphysicalandverbalabusedecreasedwithincreaseineducation,but

coercionincreased(Figure5.6).Thecommunicationscoresdecreasedformultigravidawomen,while

primigravidawomenweremorephysicallyandverballyabusedandcoerced(Figure5.9).The

increaseinpositivefactorscoresshowanincreaseinpoorcommunicationasthepositiveloadings

indicateincreaseinobstetricviolenceandthenegativeloadingindicateadecreaseintheparticular

-0.30-0.20-0.10

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

18-25 26-35 36-45 46+

Meanfactorsc

ore

Agegroup(inyears)

Physical&verbalabuse Poorcommunication Coercion

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formofobstetricviolence.Womenfromgeneralcastewerewelltreated,whilewomenfrom

scheduletribewerephysicallyandverballyabused.Coercionscoreswerehighforwomenfrom

otherbackwardcastes(Figure5.8).

Figure5.6 Meanscoresofobstetricviolencebyeducation

-0.15

-0.10

-0.05

0.00

0.05

0.10

0ornone 1-5 6-10 11-12 13+

Meanfactorsc

ore

Educationattainment(inyears)

Physical&verbalabuse Poorcommunication Coercion

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Figure5.7 Meanofobstetricviolencebysocio-economicstatus

Figure5.8 Meanscoresofobstetricviolencebycaste

-0.08

-0.06

-0.04

-0.02

0.00

0.02

0.04

0.06

0.08

0.10

Poor Rich

Meanfactorsc

ore

SocioeconomicStatus

Physical&verbalabuse PoorCommunication Coercion

-0.10

-0.05

0.00

0.05

0.10

0.15

0.20

0.25

Generalcaste Otherbackwardcaste

Schedulecaste Scheduletribe

Meanfactorsc

ore

Caste

Physical&verbalabuse PoorCommunication Coersion

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Figure5.9 Meanscoresofobstetricviolencebyparity

Linearregressionwiththenewcomponents

Iconductedlinearregressionwiththethreenewvariables(physicalandverbalabuse;poor

communicationandcoercion)tounderstandtheirrelationshipwithwomen’sbackground

characteristics.Backgroundcharacteristicsselectedincludeage,religion,education,parity,socio-

economicstatusandcaste.Theregressioncoefficientshowsthatparityhadasignificantnegative

effectoncoercionscores,whichimpliesthatmultiparouswomenarelesslikelytoexperience

coercion.Similarsignificantandnegativeeffectwasnotedforpoorcommunication,suggestingthat

communicationtendstoimprovewithnumberofbirths.Womenlivinginbetterlivingconditions

werelesslikelytoreportpoorcommunication,andtherelationshipwasstatisticallysignificant.The

relationshipbetweenobstetricviolencescoresandwomenwhosebirthwasnotobservedwas

positiveandsignificant.Thissuggeststhatwomenwhosebirthwasnotobservedweremorelikelyto

reportcoercion,poorcommunicationandphysicalandverbalabuse.

-0.20

-0.15

-0.10

-0.05

0.00

0.05

0.10

0.15

1 2-3 4+

Meanfactorsc

ore

Parity

Physical&verbalabuse PoorCommunication Coercion

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Table5.7 Linearregressioncoefficientsofbackgroundcharacteristicsandthenewobstetric

violencescores

Backgroundcharacteristics

Coercion PoorCommunication

Physical&verbalabuse

Age 18-25years 0.000 0.000 0.000

26yearsandabove -0.007(0.060) 0.008(0.06) -0.008(0.06)Education Noeducation 0.000 0.000 0.000Primaryeducation -0.002(0.07) 0.002(0.07) -0.010(0.07)Secondaryeducation -0.002(0.05) 0.038(0.05) 0.012(0.05)H.secondaryeducation

0.001(0.08) -0.009(0.08) -0.019(0.09)

Degreeeducation 0.011(0.10) 0.015(0.10) -0.023(0.10)Religion Hindu 0.000 0.000 0.000Muslim&Christian -0.014(0.06) -0.010(0.06) -0.012(0.63)

Caste SCST 0.000 0.000 0.000Generalcaste 0.012(0.08) -0.033(0.08) 0.012(0.08)

Otherbackwardcaste

0.020(0.05) 0.031(0.05) 0.020(0.05)

Parity 1 0.000 0.000 0.000

2-3 -0.079***(0.05) 0.115***(0.05) -0.036(0.05)4+ -0.081***(0.08) 0.116***(0.07) -0.048(0.08)Socioeconomicstatus

Good 0.000 0.000 0.000Poor -0.008(0.045) -0.073***(0.044) -0.003(0.46)BirthobservationBirthobserved 0.000 0.000 0.000Birthnotobserved 0.044**(0.04) 0.225***(0.042) 0.038*(0.43)Rsquare 0.01 0.07 0.01

Note:StandardErrorinbrackets.

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5.5 Discussionandconclusion

Theforegoinganalysesshowsthatwomen’sexperienceofobstetricviolenceisnotaone-time

occurrenceduringchildbirth.Theseexperiencesaremultilayered,non-linearandconsistsof

differentformsofviolence.Acrucialfindingisthatallparticipantshaveexperiencedatleastone

formofobstetricviolenceduringchildbirth.Itisalsonoteworthythatnoneofthewomen

experiencedjustoneformofviolenceduringchildbirthbasedontheBohren’sclassification.Ifound

thatwhilenowomanreportedexperiencingsexualviolence(2nddomain),everywomanreported

experiencingdisrespectandabuserelatedtohealthsystemsconditionsandconstraints.Theleast

abusiveexperienceofwomenincluded,undergoingatleasttwoformsofobstetricviolence.Onthe

otherhand,onewomanexperienced17formsofdisrespectandabuseasperBohrenetal.(2015)

sub-classification.Whileitwaspossibletoreportdifferentformsofabuse,thequestionnairedidnot

allowtocapturehowmanyinstancesofabuseanddisrespectoccurredundereachform.Thisisa

limitationthatshouldbeexploredinthefuturetoobtainacompletepictureofthenatureand

extentofwomen’sexperiencesofobstetricviolence.

Iconductedlogisticregressionswiththemainformsofobstetricviolenceandwomen’sbackground

characteristicssuchasage,education,caste,socio-economicstatus,parityandwhethertheir

childbirthwasobservedtounderstandthesocialdeterminantsofobstetricviolence.Ifoundthat

womenwithmorechildrenweremorevulnerabletoexperiencingunprofessionalcare.Womenaged

between18-25yearsweremorelikelytoexperiencestigmaanddiscrimination,whencomparedto

womenaged26-35years.Thisisinlinewiththeassumptionthatwomenatthebeginningandthe

endoftheirreproductiveagemayexperiencemoreobstetricviolenceintheformofstigmaand

discriminationforgivingbirthtooearlyortoolate.Aseducationincreased,womenweremorelikely

toexperiencepoorrapportwithcareproviders.Thiscouldbebecauseeducatedwomenmayask

morequestions,knowtheirrightsandaskaboutprocedures,whichmayleadtopoor

communicationasthecareprovidersmaynotentertainit.Religionhadnosignificantinfluenceon

obstetricviolenceinthesedata.Itisinterestingtonotethatwomenfromschedulecasteand

backwardcastesweremorelikelytoexperiencestigmaanddiscriminationandpoorrapportwhen

comparedwithwomenfromgeneralcaste.Thiscouldbebecauseover88%oftheparticipantswere

fromlowcastesincludingschedulecastes,scheduletribesandotherbackwardcastes.Theopposite

hasbeenreportedinpreviousstudiesinadifferentstateinIndia(Khanna&Sri,2017).Inthatstudy,

womenfrompoorsocio-economicstatusweremorelikelytoexperienceobstetricviolencethan

womenfromaffluentbackgrounds,asisreportedelsewheretoo(Sharma,2019).Icouldnot

examinetheinfluenceofoccupationandmaritalstatusonobstetricviolenceasmorethan99%

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participantsaremarriedhomemakers.Giventhatasubstantialnumberofwomenwereinterviewed

afterobservationoftheirchildbirthexperience,itisimportanttonotethattheyexperiencemore

obstetricviolencewhentheirbirthisnotobserved.Thiscanbeexplainedbytheimpactof

hawthorneeffectoncareprovider’sbehaviourasaresultofbeingobserved,ashasbeenreportedin

ourpublicationfromthedirectobservationofbirthdata(Ahmedetal.,2019)andreportedbyother

researcherstoo(Goodwinetal.,2018;Choi,Jung&Grantchrov,2019).

Iconductedfactoranalysistoexaminethevariationinthevariablesofobstetricviolencethrough

whichIcreatedthreenewobstetricviolencescoreswhichrepresentalargeproportionofvariance

in(32%)thedataset.Thepatternsinthespecificvariableshelpedtonamethem:1)coercion;2)

poorcommunicationand3)physicalandverbalabuse.Parityisanimportantfactorandsignificant

forallthethreevariables.Whileprimigravidawomenweremorephysicallyandverballyabusedand

coerced.Withmorenumberofbirths,multigravidawomenexperiencedpoorercommunication

fromthecareproviders.Ialsoconductedlinearregressionanalysisagainstselectedvariablesfrom

women’sbackgroundcharacteristicsasdependentvariable.Ifoundthatwomenexperiencedpoor

communicationwithincreaseinparity.Ialsofoundthatgoodsocio-economicstatusresultedin

bettercommunicationwithwomen.Finally,morewomenwhosebirthswerenotobservedwere

coerced,physically,verballyabusedandexperiencedpoorcommunication.Theseresultsareinline

withtheresultsfromlogisticregressiontoo.

Studiesconductedgloballyhavefoundthatwomenfrommarginalisedcommunitiesmaybemore

vulnerabletoexperiencingobstetricviolenceduetotheirage,socio-economicstatus,race,gender

expression,sexualorientation,healthstatusandmigration(Khoslaetal.,2016;Chadwick,2019).

Obstetricviolence,asIdiscussedinChapter2,makeswayfornegativehealthoutcomes,for

maternal,reproductiveandsexualhealth.InthecaseofIndia,women’ssocialanddemographic

characteristicssuchaseducation,parity,obstetrichistory,socialposition,culture,valuesandnorms

playakeyroleindeterminingtheirvulnerabilitytoobstetricviolence(Nambiar&Muralidharan,

2017).Someofthesefactorshavebeenfoundtoinfluenceintimatepartnerviolenceaswell,inthe

contextofBiharandotherstatesinIndia(Dharetal.,2018;Sharmaetal.,2019;Deyetal.,

Sudhiranasetetal.,2016),asIdiscussedinChapter3.Futurestudieswouldbenefitfromexploring

obstetricviolencealongsideallotherformsofviolenceexperiencedbywomenastheprevalenceof

violenceinwomen’slives,increaseswomen’svulnerabilityforviolenceinotherphasesoftheirlives.

ThecultureofviolenceisprevalentinBihar(NFHS,2020;Dharetal.,2018).Women’spositioningat

theintersectionsoftheirbackgroundcharacteristicsincreasestheinequalities,furtherincreasing

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theirvulnerabilitytoobstetricviolence(Sen,Reddy&Iyer,2018).Obstetricviolenceisanegative

outcomeofcareprovisioninitself.

ThisstudyisthefirstofitskindbasedonarepresentativehouseholdsurveyinBihar,whichcovers

allthedistrictsofthestateandaddressesthesocialfactorsunderlyingobstetricviolenceand

respectfulmaternitycare.Amongstthebackgroundcharacteristics,Ifoundparity,ageand

educationtobesignificantassocialdeterminantsofobstetricviolence.Ifoundthatparitymade

womenmorevulnerabletobeingcoercedwithanincreaseinparityandexperiencepoor

communication,whilewomengivingbirthforthefirsttimeexperiencedmorephysicalandverbal

abuse.

Thereisanevidenceofunder-reportingoftheextremeformsofobstetricviolencesuchasphysical,

verbalandsexualabuse(Afulanietal.,2019).Thiscouldbebecauseofwomen’slackofawareness

aboutgoodqualityandrespectfulcare,theiracceptanceofviolenceandreluctancetoshare

sensitiveanecdotesofviolence(Afulanietal.,2019).Thissuggeststhatnewermethodsarerequired

tounderstandwomen’sembodiedexperiencesthatcutacrossthestigmaandshameofsharingbirth

andobstetricviolencerelatedstories.Iexplorethisinthenexttwochapters.Thisisoneofthefirst

studiestopresentthemultilayeredandcomplexnatureofwomen’sexperienceofobstetricviolence

withadetailedunderstandingoftheirexperiences,whichIfurtherpresentedthroughTrahi’sstory

(AppendixA),thesurveyrespondentswhoreportedexperiencingthemostformsofobstetric

violence.DevelopingTrahi’sstoryismyattempttohelpdrawthereader’sattentiontowomenas

peopleandunderstandtheircontextandthecontextofobstetricviolence(Jeffery&Jeffery,2010).

Women’sstoriesofviolence,birthingandobstetricviolenceareuniqueandimportanttobe

understoodinthewholegamutoftheirsexual,reproductiveandmaternallives,whichIpresentin

theupcomingchapters.

5.6 Limitations

ThesurveydatadoesnotcaptureeverythingaboutthenatureofobstetricviolenceinBihar,India.

Whileitcapturesthedifferentformsofobstetricviolence,itdoesnotreportonhowmanyaccounts

ofviolencewomenexperienceundereachcategory.Surveysaresubjecttosamplingerrorswhich

cannotbeunderestimated.Underreportingcouldbeachallengeinlowresourcesettingssuchas

Bihar,wherewomen’sexpectationsofcarecouldbelow,whichmayleadtoacceptanceofpoor

quality,disrespectfulandabusivecare.Thiscouldalsobedrivenbywomen’slackofawarenessof

whatqualityandrespectfulcarestandardsforthehealthcaredeliverysystemsareorcouldbefrom

theawarenessthattheyarenotimportantenoughinthesocialhierarchytobetreatedrespectfully.

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Thiscouldlimitthecapacityofthehealthcareprovidersandfacilitiestolearnfromwomen’s

experiences,toaddressthemwellandtoprovidewomen-centeredcaretothecareseeker’s

satisfaction,particularlyforwomenfrompoorandmarginalizedcommunities,giventhediverse

natureofpopulationsinIndia.

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Chapter6 Whatdoeswomen’sexperienceofrespect,

disrespectandabuselooklike?Breakingthe

silencesurroundingobstetricviolence

6.1 Background

Respectoriginatesfromthelatinwordrespecterewhichmeansto‘treatwithdeferentialregardor

esteem’.The‘WhatWomenWant’campaignreceived350,696responsesinIndia,whereitisalso

called‘HamaraSwasthyaHamariAwaaz4’(WRA,2019).Thereisagrowingbodyofliterature,

indicatingthatrespectfulmaternitycareistheneedofthehour(Jeejebhoy&Santhya2018;Mayra,

2017).Studieshavebroughtoutevidenceofvariousformsofobstetricviolenceduringchildbirth

acrossmanyIndianstates.Insomestates,reportssuggestthatalmosteverywomanexperiences

somekindofobstetricviolence(Bhattacharya,2015;Shreeporna,2015),butthesewomenmaynot

reporttheirexperience.ThisisofparticularconcerninIndia,whichaccountsfor12%oftheglobal

burdenofmaternaldeaths(WHO,2019),andhasapoorlyresourcedhealthsystem.

Respectfulmaternitycareisafairlynewareaofresearchforaneverexistentissue.Contextplaysa

keyroleinunderstandingobstetricviolenceduringchildbirth,becausethemeaningofrespect,

disrespectandabusechangeswithpeopleandacrossculturesandgeographies.TheLancetserieson

maternalhealthbroughtoutthechallengesofwomenwhoreceivedcarethatiseithertoomuchtoo

soonortoolittletoolate.Thisvariationinthequalityofcareisdependentoncultureandcontext.

Researcherscontinuetoexplorethemeaningofrespectfulmaternitycareandhowtoprovide

person-centeredcare(Downe,2019;Afulanietal.,2019).Theresponsibilityofwomen-centered

careisontheteamofcareproviders,toensurethathealthcareprotectswomen’srightsanddignity,

andissatisfactoryforthem.Healthcareprovidersneedtounderstandwomen’sperceptionof

respect,disrespectandabusefromtheirexperienceofchildbirth,tobeabletoproviderespectful

maternitycare(Bhattacharya,2013).Inthepreviouschapter,Ipresentedhowwomen’sexperiences

consistofmultipletypesofobstetricviolencewhichcontinuesthroughouttheirpresenceinthe

obstetricsetting.Women-centeredcarerequiresadeeperunderstandingofwhatwomenwant

duringchildbirth.Thismaynotbesameasthecareproviderorthepolicymaker’sperceptionof

obstetricviolenceandrespectfulcare,whichIexploreinChapter8.

4Translatesto‘Ourhealth,ourvoice’

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Becketal.(2013)aptlydefinesthatitisnotjustbeautythatliesintheeyeofthebeholder,itisalso

traumaticchildbirth.Previousstudiessuggestafewreasonswhyrespect,disrespectandabusecan

beperceiveddifferentlybywomenandothers,includingcareproviders.Firstly,asKitzinger(2005)

showsinherwork,womenoftenlackthelanguagetonarratetheirbirthexperience.Painisoften

thecommonexplanationoftheirexperienceofchildbirth.Womenmaynotbeaccustomedto

medicallanguageandterms.Theymaybesilencedbythestigmaandshamerelatedto

conversationsthatinvolvereferencetobodypartssuchasreferringtoone’sgenitalsandthefact

thatbirthisaresultofintercourse(Chadwick,2018;Becketal.,2013;Kitzinger,2005).‘Theclinical

languageusedbycareproviderscouldbedifficultforwomentounderstandandincorporateinto

theirnarrative.Allthesefactorsindicatetheneedforamethodofexploringwomen’sembodied

experienceofsuchsensitiveareasofstigmaandshame(Chadwick,2017)particularlyinapatriarchal

postcolonialsetting,suchasIndia.

Studieshavefoundthatwomen’snarrativesoftraumaticbirthexperienceareoftensimilarto

narrativesofrapevictims(Beck,Driscoll&Watson2013;Kitzinger,2005).Thesameistrueofnon-

verbalcommunication,suchastouch.Touchcanbecomfortingaswellasdiscomforting.Giventhe

experienceofthispainusuallyendswiththebirthofachild,thereusuallyisadilemmaforwomen.

Reportingatraumaticbirthingexperiencebecomessecondarywhenawomanisexpectedtobe

gratefulforsurvivingchildbirthandreturninghomewithalivebaby(Kitzinger,2005).Somewomen,

havingexperiencedtraumaticchildbirth,mayrelivethebirthtraumaeveryyearontheirchild’s

birthdayastraumaanniversary.Thisdilemmaleadsthemtofeeldisgustedanddepressedeveryyear

onadaytheyaresupposedtocelebrate(Beck,Driscoll&Watson,2013;Scotland2020).

Secondly,womenmaynotbeawarethatcertainactionsorbehaviourarenotpartofcare(Downe,

2019),eventhoughtheyfelt‘bad’whentheyexperiencedit,ortheymayexpecttobemistreated

(Lambertetal.,2018).Theymaynotobjecttoobstetricviolence,thinkinghealthcaredoesnothave

tobeapleasantexperienceandsometimesneedstobeendured.Theirexpectationsareoftenso

lowthatsatisfactionisnotapriority.AstudyinIndiareportsthatwomenconsideredtheavailability

ofhealthcareprovidersandhealthsupplies,suchasmedicines,astwokeyaspectsofgoodquality

care(Bhattacharya,2013).Theyrecommendthatreducingwaitingtime,provisionofseating

arrangementandgoodlaboratoryserviceswillincreasewomen’ssatisfactionwiththeservices(Das

etal.,2010).

Womenmayrefrainfromreportingtraumaticchildbirth,astheymayfeelthatishowhealthcareis

supposedtobe(D’entremont,2014)andevenblamethemselvesfortheviolencetheyexperience.

Personal,socialandculturalcontextplaysanimportantroleinshapingwomen’sperceptionsof

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respectanddisrespect;andinfluencestheirintenttoreportit(Sen,Reddy&Iyer,2018).Findings

fromChapter5showthatwhileeverywomanreportedexperiencingsomeformofobstetric

violenceintheobstetricsettingsinBihar,only5%(2194)consideredreportingtheirgrievance

formally.Notopeninguptogivinganaccountofobstetricviolenceduringbirthcanbeduetothe

starkinequalitiesinsocietyleadingtoapower-basedimbalanceandthefearofconsequences(Sen,

Reddy&Iyer,2018;Roberts,1981).

Finally,women’sautonomyanddecision-makingpowercoulddeterminewhatasatisfactory

experienceofchildbirthcanbe.Indeeplypatriarchalcultures,womenhavealimiteddecision

makingrole,especiallyabouttheirsexual,reproductiveandmaternalhealthandneeds(Jeejebhoy&

Santhya2018;Koski,Stephenson&Koenig,2011).Thereareseveralindicatorsthatconfirmalackof

women’sagencyinBihar.TheNFHS-5reportsthatonly29%womenhadcompletededucationupto

10yearsand41%(agedbetween20-24yearsatthetimeofthesurvey)weremarriedbeforethey

turned18.Thishighlightsthatchild-marriageisapersistentissueinthestate.Thehighratesof

gender-basedviolenceandcrimeagainstwomenshowsfurtherdisempowermentandoppressionof

women(Dharetal.,2018;Jejebhoy&Santhya,2018).Intimatepartnerviolenceisanotherkeyissue

inthestate(Dharetal.,2018),with40%womenhavingexperiencedspousalviolenceand3%

experienceditduringpregnancy.Amongstthewomensurveyedbetween18-29years’age,8%

reportedexperiencingsexualviolencebeforetheyturned18.Gender-baseddiscriminationisevident

inotherindicatorsaswell.Forinstance,femalesterilisation(35%)ismuchhigherthanmale

sterilisation(0%)(GOI,2020).

Acultureofviolenceandsubjugationispartofapatriarchalstructure,wherewomenandgirlshave

limitedagencyovertheirbodiesandlives.Thisextendstoobstetricsettingstoo.Lackofconsentand

explanationofobstetricinterventionsarekeyindicatorsinthiscontext,whichisoftenveryhigh

(Bhattacharya,2013;Patel,Das&Das,2018)asseenforBiharinChapter5,whichconfirmsalackof

women’sconsentandchoiceinobstetricbirthenvironments.Thisisacharacteristicofthemedical

modelofcare,asaresultofthegradualtransitionofhomeasthemorecommonandacceptedbirth

setting,todominationbytheobstetricbirthsetting,overlastmanydecadeswhichcontinuedthe

alienationofwomen’sreproductiverights(Oakley,1984;Menon,2012;Hill,2018;Cleghorn,2021).

Allthesereasonsnormaliseobstetricviolence,asanextensionofwomenbeing‘allowed’todo

anythingintheirroutinelives.Itisaresultofgirl’sandwomen’spositioningattheintersectionsof

several‘female’disadvantages,whichincreasewomen’svulnerability(Sen&Iyer,2012:

Chattopadhyay,2018;Chadwick,2018).Itmayfurtherindicatethatwomenfindabusivecare

acceptableorfeelthatwomendeservetobetreatedordisciplinedduringchildbirthandact

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accordingly(McAra-Cooper,2011).Womenmaychangetheirplaceofbirthandnotgivebirthina

healthcarefacilitybasedontheirpreviousbirthexperience(Silanetal.,2018),ratherthanreporting

theirexperiences.Alltheseexplanationspointtothenormalisationofobstetricviolenceduring

childbirthastheextremeformsofabuse(includingphysicalabuse)becomeincreasinglyacceptable

andpartofcareprovision(Bradley,2016;Freedmanetal.,2018;Senetal.,2018;Lambert,2018).

Thischapter,aimstoexplorehowwomenattachmeaningtorespect,disrespectandabusethrough

theirexperiencesofchildbirthusinguniqueparticipatoryarts-basedresearchmethodsthatenable

understandingoftheirembodiedexperiences.

6.2 Researchquestions

• Howdowomenattachmeaningtotheirexperiencesofrespect,disrespectandabuseduring

childbirthinBihar,India?

• Howcanwomen’sembodiedexperiencebeexploredthroughsensoryinterviewing?

6.3 Objectives

• Tounderstandhowwomenperceiveandattachmeaningtorespect,disrespectandabuse

duringchildbirthinBihar.

• Toundertakefeministparticipatoryarts-basedresearchinexploringsensitiveembodied

experiencesofchildbirth.

• Todocumentwomen’sexpectationsofrespectfulcarenecessarytoensureapositive

birthingexperience.

6.4 Methods

ThisisaqualitativestudyundertakeninBihar,whereIconductedin-depthinterviewsaidedbya

participatoryvisualarts-basedresearchmethodcalledbodymapping.Criticalfeministtheory

informedallaspectsofthisstudy,whichenabledanunderstandingofchildbirthasahuman

experience,whichisembodied,inter-subjective,contingent,andwovenintopersonalandcultural

websofsignification.

WomeninIndiausuallygivebirthinfourtypesofsettings:1)publichospital;2)privatehospital;3)

homeand4)onthewaytohospital(Figure6.1).Thefigureshowstheareasthatwereexploredin

datacollectionineachofthesesettings.Someofthemhaveoverlappingdomains.Thecommon

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themesofrespect,disrespectandabusewereexploredineachofthesettingwiththehelpofsome

overarchingquestionsoncommunication,touch,information,decision-makingandconsentduring

childbirthtounderstandthenatureofthisineachofthesebirthsettings.Allthesekeyareasof

explorationhavespecificprobesasshowninthein-depthinterviewguide(AppendixB)andmay

indicaterespect,disrespectandabuseduringchildbirth.

Bothprimigravidaandmultigravidawomenwereselectedfortheinterviews,underthecriterion

thatstudyparticipantshadgivenbirthatleastonceinBihar.Iselectedeightwomenpurposively,to

participateinabodymappingassistedin-depthinterview.

Figure6.1 Themesofexplorationforrespect,disrespectandabuseduringbirth(Author’sown)

TheparticipantswereselectedfromanurbanslumfromPatnaandaruralvillagefromMuzaffarpur,

bothinBihar.Patnaisthecapitalofthestateandhasaccesstospecialisedtertiary-levelhealthcare

facilities,whichismoreaccessibletowomenlivinginurbanslumswhicharelocatedindifferent

partsofthecitycapital.TheinstitutionaldeliveryrateinPatnaisamongthehighestinIndia,

between79-87%.Muzaffarpur,ontheotherhand,hasanoverallinstitutionaldeliveryratebetween

62-71%,whichmatchespercentageofinstitutionalbirthsatthestatelevel.Itisalsoadjoinedby

neighbouringdistrictslikeSamastipurwhereinstitutionalbirthrateisbetween53-62%and

Darbhanga,Seohar,Sitamarhi,WestChamparan;whereitisthelowest,between32-53%(NFHS4).

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6.4.1 Bodymapping

Bodymappingisauniqueparticipatoryapproachthatcombinesvisualartsandtherapeuticpractice

toguideparticipantsintheartfulcommunicationabouttheirembodiedlifeexperiencesinwaysthat

aresafeandsupportive(Orchard,2017).BirthingmapsisatermIcoinedtorefertomyadaptation

oftheestablishedbodymappingmethod,wherebyIuseittoexplorewomen’sexperiencesofgiving

birth.Thiswasanidealmethodfordatacollectionasitreducedliteracy,stigmaandpower-related

barrierstorespondents’abilitytocommunicatetheirexperiencesandtheresearcher’sabilityto

listenandlearn.Collectingnarrativesofbirthinvolvestalkingaboutbodypartsthatareshamefulto

talkaboutinthelocalcontext.Birthmappingisaculturallyappropriatemethodbecauseofits

flexiblenature,whichgivesroomforadaptionandenableswomentobypassstigmaandsharerich

accountsoftheirexperiences.Theexercisestartswiththeinterviewerrequestingtheparticipantto

liedownonthesheetinthepositiontheygavebirthinordertodrawalivesizeoutlinearoundthe

person.Idemonstratethisbylyingdownonthesheet,whichIfoundhelpedtoovercomeany

hesitationthatwomenmayhavefeltaboutlyingdownonthepaper.Talkingaboutbirthissensitive

andbodymappinghelpswomentoopenupoverthecourseofafewinteractionsthatallow

developmentoftrustbetweentheinterviewerandinterviewee.Birthmappinghavethree

components:1)thebirthmap;2)thebirthingstory,and3)thebodykey.

Bodymappingisarelativelynewmethodofdatacollectioninpublichealthresearch.Itwasfirst

developedbyMacCormackandusedinruralJamaicaforastudyonwomen’sunderstandingoftheir

fertility(MacCormack,1985).ItwassubsequentlyusedinZimbabwetoinitiateconversationsabout

sexuality,reproductivehealthandtheanatomyofwomen(Cornwall,1992)andinotherpartsof

AfricainthecontextofHIV/AIDs(CATIE,2006).Thismethodhasprimarilybeenusedinstudies

involvingwomen’sbodieswheretheirunderstandingabouttheirbody,aparticularfunctionofit

(reproduction)orimpactofacondition(e.g.obesity,HIV/AIDS)hasbeenexplored.Researchers

havefoundittobeagoodapproachwhentryingtounderstandsensitiveissues.Theyreportthat

bodymappingisanapproachtobridgethegapsbetweenembodiedexperiencesandtraditional

researchmethodswhilealsoempoweringthepeoplewhoparticipateintheprocess(Cornwall,

1992).Bodymappinghelpstounearthdifficultand‘meaningful,embodiedexperiencesandlife

events’,whichjustifiesusingthisapproachtounderstandwomen’sexperienceofchildbirth

(Orchard,2017).

Thoughotherstudieshaveusedbodymappingtounderstandconstructsofgenderandbody,there

islittleornoattentiongiventobodymappingtounderstandbirthingexperienceasaparticularform

ofparticipatoryvisualarts-basedresearch.Otherformsofarts-basedresearch,suchasI-poems,

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havebeenusedintheanalysisofbirthingexperiencesbefore(Montgomery,2014;Chadwick,2018;

McKenzie,2021).Studiesthathaveusedbodymappinghavefoundhighsatisfactionfromthe

participantsabouttheapproachtodatacollection.Theyalsoreportthatresearchersgoingbackto

themandfinishingthemappingexerciseoverafewdayshelpsthemtoformulatetheirthoughtsand

experiencesbetter,enablingakeenerengagementintheprocess(Orchard,2017).

Whiletherearegeneralguidelinestoconductthebodymappingmethod,Iadaptedthoseguidelines

forbirthmappinginBihar.Itisessentialtoallowthisflexibilitytoincorporatethecontextand

setting-basedchanges.

Aspectsforbirthmapping

1. Peopleinvolved-Apartfromtheparticipant,theprocessofbirthmappingconsistsoftwo

researchers:afacilitatorandanotetaker.

2. Facilitator-Guidestheprocessofbirthmapping,demonstratesonthesheet,drawsthe

outlineofparticipantwithconsent,answersanyquestions,asksthequestionswhile

facilitatingtheprocessofbirthmapping.

3. Notetaker-Takesthoroughnotesoftheparticipantresponsesandpreparesthebodykey,

assistsintheprocesswiththearts-basedsupplies.

4. Indexbirth-Theparticipantisrequestedtopickanindexbirth,whichwillbethebirththe

mapwillmainlyfocuson.Butthatwillnotrestrictherfromsharingaboutherotherbirths.

Thismayormaynotbehermostrecentbirth.

5. Outline-Theexercisebeginsbytracinganoutlineoftheparticipant’sbodyonalargesheet

ofpaper.Theparticipantisrequestedtoliedownonthepaperinthepositionthatshegave

birthin.Ifshegavebirthinastandingposition,wewillshowitthroughverticalarrows.The

facilitatorliesdowntodemonstrate.

6. Colours-Theparticipantisrequestedtochooseanycolourshewantstoshowthegoodand

badfeelings,skin,clothes,environmentandotheraspectsofthenarrativewhiletryingto

maintainascloseresemblancetothedayofbirthaspossible.

7. Symbols-Theparticipantchoosesanysymbolstosignifytheexperiences(holdinghands),

people(birthcompanion;careproviders)oremotions(pain;shame;fear;disgust;

happiness).Shemaydraworwriteaboutherexperiencesonthemap.Shecanalsowrite

quotesofpeoplearoundher.Thefacilitatorcanparticipateinwritingthequoteswiththe

participant,basedonparticipant’sliteracylevelandrequestforhelp.

8. Bodykey-Thenotetakerkeepsanoteofwhatthecoloursandsymbolssignify,whichguides

thebirthingstorytounderstandthebirthmapwell.

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9. Birthingbody-Theparticipantisrequestedtoshowherexperienceofgivingbirthby

indicatingtheexperiencewithintheoutlineofthebodythatmayincludeemotionsand

interventions.

10. Birthingenvironment-Theparticipantisrequestedtoshowotheraspectsofthebirthing

environmentoutsidetheoutlineofthebody.Thismayincludethenumberofpeople

around,whotheywereandtheirrole.Thiscanincludeimportantaspectsofthenarrativesin

thesocialenvironment,familialenvironment,community,alongwiththehospital

environment.

11. Birthingstory-Itisaone-pagesummaryoftheconversationsandinteractionsco-created

withtheparticipantandisapprovedbytheparticipantonthelastmeeting.Thisisalsoan

analyticoutcomeoftheprocesswhichbeginsinthefieldwiththeparticipant.

12. Finalmeeting-Theparticipantisrequestedtocheckthebirthmapbeforeendingthelast

interactiontoseeifanythinghasbeenleftoutthattheywouldliketoadd.Sheisasked

abouthersatisfactionwiththeinterviewprocess.Theco-createdbirthingstoryisreadbyor

readouttotheparticipantintheirlanguagetotaketheirapprovaloftheinformation

sought.

13. Pictureofbodymap-Theparticipantisgivenanoptiontotakepicturesofthemapandthe

birthingstory.

6.4.2 Planningthedatacollectionwithbodymapping

IconductedascopingstudyinJanuary2019inanurbanslumandaruralvillageinPatnadistrictof

Bihartounderstandthefeasibilityofbirthmapping.Thescopingstudyalsohelpedtodevelopa

semi-structuredguidewiththeadviceofwomentoaidtheexercise.Thestructureandmethodsof

conductingbodymappinghaveevolvedsince.Istartedwitharoughoutlineofapersonona

notepad,followeditbyabodyoutlineonlytoshowafewthingswithcolouredpens(Figure6.2).

Finally,Iconductedtobodymappingduringthedatacollection,whereIusedmanyotherarts-based

supplies.Expertconsultationswithqualitativeresearchers,midwivesandpeoplewhohavebeen

involvedinarts-basedmethodsandstorytelling,helpedtoshapetheprocess.Thereareveryfew

publishedstudiesonhowtoconductbodymaps,whichincludesacoupleofguidelinesthathave

beenusedtoprepareadetailedguideforthisstudy(Gastaldo,2012).

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Figure6.2 Birthmappingpilot

Researchethicsapproval-Ethicalclearanceforarts-basedresearchmethodsisimportantand

severalethicaldimensionsneedtobethoughtthroughandplannedfor,whichincludes

understandingthesensitivityofthemethod(Orchard,2017).Itrequiresmanyinteractionsand

seekingtimefromparticipants.Giventhisisaparticipatorymethod,itneedsparticipant’sactive

involvementwheretheywillbespeaking,lyingdownonthepaperforanoutlineandthen

participateinshowingtheirbirthingstoryonthemap.Mystudyinvolvedrecallingsensitiveaspects

ofthebirthingexperience,soIhadinformationofthenearestcounsellorinapublichospital,incase

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theparticipantsfeltandexpressedtheneedtotalktoacounselororahealthcareproviderabout

theirexperience.TheethicalclearancewasprovidedbytheethicalreviewboardoftheUniversityof

Southampton(Referencenumber49730).Theethicalconsiderationsofconsent,confidentiality,

anonymityhavebeenaddressedintheethicsapplicationwhichisbasedontheintegralprinciplesof

autonomy,beneficenceandnon-maleficence.Participantswererequestedforwrittenorverbal

consentinlinewiththeuniversityethicalclearance.Sevenoftheeightinterviewswereaudio

recordedwithconsent.Ialsorequestedparticipant’sconsenttotakepictureswhilemaintaining

theiranonymity.Everypicturewasshowntotheparticipantbeforekeepingthemforthestudyand

onestheydidnotapproveofweredeletedinfrontoftheparticipant.Participantswererequestedto

selectapseudonamewhichisusedtoaddresstheminthestudy.

6.4.3 BirthmappinginBihar

IconductedthedatacollectioninurbanslumsandruralvillagesinBihartoexploreexperiencesof

birthingindifferentbirthsettingsatdifferentlevelsofcareforwomenwhoweresocio-economically

disadvantaged.TheslumswereselectedinthestatecapitalPatna,whichhasoptionsfortertiary-

levelofcareinbothpublicandprivatehospitals.TheruralvillagesareselectedinMuzaffarpur

district.Iselectedthesedistrictsbasedonthematernalmortalityratio,whichisveryhighinPatna

andmoderatelyhighinMuzaffarpur.Ihiredafemaleresearchassistant(note-taker)fromBiharto

assistmewiththedatacollection.Theresearchassistanthadpreviousexperienceofqualitative

interviewingandisadeptinmanyofthedialectsinBihar.SheworkedwithmeinBiharonadifferent

initiativeforacoupleofyears.

Womenwhohavegivenbirthinthelast5yearsinBiharareincludedinthestudy.Wevisitedurban

slumsinPatnaandruralvillagesinMaraulblockinMuzaffarpurdistricttorecruitparticipants.We

wentfromdoortodoortotalktowomenandseekconsent.Weplannedtointerviewwomen

regardlessofwheretheyhavegivenbirth.Therewerenoexclusioncriteria.Betweentwotofive

interactionswerearrangedwithalltheeightparticipants.Allparticipantsprovidedtheirconsentand

sharedbackgroundinformationinthefirstinteractionandweinitiatedthebirthmappingexercise.

Intwocases,womengaveusanotherappointmenttobeginworkingonthemapwiththem.Thelast

interactioninvolvedclarifyinganyqueriesfromtheinterview,takingwomen’sapprovalofthe

completedbirthmap,makinganyfinalchangesonthemap,andreadingandfinalisingthebirthing

story.Theresearchteamspentonaveragetwotosixhourswitheachparticipant.

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Wecarriedlargesheetsofthickwhitepaper,7feetlongand3.5feetwide.Wecarriedcoloured

sketchpens,markers,crayons,andcutoutsoffacialexpressions,smallminiaturecutoutsofpeople,

children,fetusandcareproviders,medicalequipment,cut-outsofinjections,intravenousfluids,

weighingmachineandbloodtransfusions.Wecarriedthesheetsinalargepostercarriertube

(Figure6.3).

Figure6.3 Birthingmappinginaction

(Includedwithethicalclearanceandwomen’sconsent)

Wemaintainedtheprivacyofthewomenatalltimes.Weconductedtheexerciseintheirbedroom

onawoodenplank,onthefloorofastoragearea,ontherooftopandinthebackyardofamud

house.Womenfromtheneighbourhoodandfemalefamilymemberswouldoftenvisittoseewhat

wearedoing.Weexplainedourpurposeandrequestedforprivacy.Weoftenengagedindiscussions

notrelevanttothestudy,becausethewomenwantedtotalk.Wetoldparticipantsaboutourrole,

researchandaboutourbackgroundwithpeople.Intwointerviews,themother-in-lawhad

interruptedtheinteractionafewtimes,butwemadesuretonotworkonthemaporaskinterview

questionstotheparticipantwhenwewereinterrupted.Everyparticipantselectedapseudonymfor

herselftoputonthebirthmapandtobeaddressedasinthestudy.Noneofthepicturestaken

showedtheparticipant’sfacesandallwereapprovedbythem.Audiorecordingsweremadein

sevenoftheeightinterviewswithparticipant’sconsent.Detailednotesweretakeninallthe

interviews.

Body Mapping Body Mapping

Pictures taken by : Ritu Kumari

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6.4.4 Methodologicalchallenges

Weexperiencedmanychallengesoverthecourseofdatacollection.Wefacedahighrefusalrateto

participateinthestudybecausebirthmappingistimeconsuming.Refusaltoparticipatewashigher

intheruralareas.Inonevillageeverywomanweapproachedrefusedtoparticipate.Thiswasa

smallvillagewherewereachedoutto12households.Someofthesewomendidnotrefuseinitially,

gaveconsentandaskedustocomebackanotherday.Inournextvisitwerealisedtheydidnotwant

toparticipatebutcouldnotsaynotous,expectingthatwewillnotreturn.Onoursubsequentvisit

wewouldwaitforthemtotalktousforhourswhentheywoulddotheirhouseholdworkafter

givingusanappointment.Womenoftendidnotsaynotousbutratherignoreduswhilewetriedto

talktothem.Oftentheeldersofthefamilysuchasmother-in-lawwouldtellustogoaway.Often

womenwhowouldwanttotalktousbutcouldnotbecausetheirhusbandoreldersinthefamilydid

notapprove.Thiswasapatternwhichweunderstoodafteraseriesofexperiencesoverafewdays.

Thecooperationofthefamilywasimportant.Beforeinterviewingoneparticipant,wesatoutside

thehousewiththemother-in-lawwhoinvitedustotellhermoreaboutourwork.Womenwe

interviewedhadonetofourchildrenandagedlessthanten-year-old.Innuclearfamilies,itwas

difficultforthemtostaywithusforlongstretchesoftimeandtheywouldoftentendtotheir

children’sneedsmid-interviewwhilewepausedtherecorderandwaited.Wehelpedtomindthe

childrenwhenpossible.Childrenwouldoftenappearintheareaofinterviewbecausewewere

workingwithcoloursandcut-outs,whichmadethemcurious.Wegaveawaycoloursandpaperto

keepthembusy.Onelittleboytriedtotearawaythemapwithanailandtriedtoprickuswiththe

nailtoo,hewastakenawaybyanelderinthefamily.

Mosthouseholdshadpetsandrodents.InRia’shouseholdwehadtoentertheroomcrossingavery

tinyroomwhichwasanurbancowshed,withtwocows.Intwohouses,UrmilaandSita,therewere

ratsthatwouldcomeoutofholesonthegroundorthewallsandtwiceIhadtoliedownonthe

sheettodemonstratewhiletheratwasveryclose.Iamscaredofrats.Thisdatacollectiontested

manyofmyfearsbutithelpedtowintheparticipant’strust.ThereweregoatsinAmrita’s

household,whichweretakenoutsidewhilewedidtheexerciseinthegoat-shedaftercleaningthe

goatfaeces.Pratimahastworabbits,whoappearinherbirthmapaswell.Shetooktherabbitsto

theroofwhentheystartedchewingthemap.Husbandswereinthehouseinafewcases,butthey

usuallydidnotinterrupt,exceptonewhokeptcallinghiswifeandaskinghowlongitwilltakeus,

whileAmritakeptconfirmingthatit’sfineforustotalktoher.Itwasarareexperienceforthe

participanttotalktosomeoneandshewantedtotalktousasshesaid‘nooneevercomestomeet

me’.

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Findingspacetospreadthesheetandworkarounditwaschallenging.Theparticipantswerevery

helpfulinmakingspace.Itwasdifficulttoencouragethemtoparticipateaswellbecausesevenout

oftheeightparticipantswerenotusedtoholdingapen,andwereconcernedtheywouldnotbe

abletodoagoodjob.Theywerenotusedtowritingordrawing,butoverthecourseofinteractions

theybecamecomfortableandparticipatedactively.Theyalsoopenedupmoreinlatterinteractions

astrustdevelopedandtheyrealisedweourselvesdidnothaveanyartisticabilities,butfoundthe

processeasierandmoreengagingasitunfolded.

Womenfoundverylittletimeforthemselvesawayfromtheirdomesticchoresandoutsidework,

whichstretchedourworkinghours.Weoftenconductedinterviewsintheeveningandlatenight,or

startedbefore6amtogetanhourwiththeparticipantbeforetheirday’sworkbegan.Wemade

suretomakeourselvesavailableatallhourswhenevertheygaveustime.Wehadadayofthorough

disinfectionafterwerealisedoneofourparticipants,whomwecameinclosecontactwithwhile

creatingthebirthmap,complainedofliceinfestation.Theresearchassistant’sroleintheexercise

waschallengingandunpredictable.Sheparticipatedintakingreflexivenotesandnotesoninterview

environment,providedtheresourcestopreparethemapandalsohelpedinmindingthechildren

andattimesengagedinconversationswiththeparticipant’sfamilysothattheywouldnotinterrupt

theparticipantand‘allowher’tocontinuetalkingtous.Thiswasoftenrequestedbytheparticipant

herself.

Workwasdonealsowhenwewerebackinourhotel,whichincludedgettingmorecut-outsthatwe

wouldneedintheongoingexercise.Weaccomplishedsomeofthecolouringworkforthelast

interactionandwithpermissionfromtheparticipantwhenwefilledintheskincolour,orother

parts.Theparticipantsselectedthecoloursthatwestartedfillinginherpresenceatherhome.We

alsoworkedonthebirthingstoryafterlisteningandre-listeningtotheaudiorecordingsofthe

interviews,manyofwhichwereindicatedtobeimportantaspectsofthestorybytheparticipants.

Thebirthmapshavemanycut-outspastedonthemwhichwerefixedwithadhesivetape.Thismade

themapsveryheavy.Themapsarescannedinlivesizeandthenprintedonwhiteclothintheirtrue

sizetomakeiteasiertocarryanddisplay,becausethepaper-basedmapsarepronetowearand

tear.Theseclothmapsareverygoodfordissemination.

6.4.5 Dataanalysis

Phenomenologicalconstructsofdifferenttheoristswereemployedtounderstandandpresenthow

womenattributemeaningtorespect,disrespectandabusefromtheirexperienceofchildbirth.Van

Manen’sworkonexistentialismthatdrawsonlivedtime,livedbody,livedspaceandlived

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relationshipshelpedtoexplorehowwomenexperiencebirthing.Thishasbeenusedinthecontext

ofchildbirthinpreviousstudies(Thomson,2011).Ifurtherexploredtheconceptsofunpleasant

sight,unpleasantsound,unpleasantfeel,unpleasanttouchandunpleasanttastewhichwerealso

introducedbyVanManen.Theseconceptsareimportanttoexplore,giventhechallengesdiscussed

byotherresearcherswithregardtolanguagebarrierswhenitcomestounderstandingchildbirth

throughwomen’sexperience.

Criticalfeministtheoryincludestheconstructsfromcriticaltheoryandfeministtheory(Keedleetal.,

2009)aselaboratedinChapter4.Feministphenomenologycanbedefinedasacritical

phenomenologysinceitenablesunderstandingofhumanexperiencessuchaschildbirth,whichis

embodied,inter-subjective,andcontingent,andwovenintopersonalandculturalwebsof

significationandareinfluencedbyimbalancesinpower.Experiencesofchildbirthalsovarybasedon

cultureandcontext.Thismethodhelpstointerpretwomen’sexperiencesfromtheperspectiveof

imbalanceofpowerandpositionintheircommunityinacriticalperspective(Simms&Stawarska,

2013).Therearestudiesthatreportthattheissueofdisrespectandabuseduringchildbirthcanbe

attributedtogenderandgender-basedsubordination.ThisisseeninBiharaswell,asdescribedin

Chapter3.Sincechildbirthisinfluencedbypowerimbalancesinthesocietyattributingtoaperson’s

gender,andthelivedexperiencenarratesabout‘women’ssubordinationinthesociety’,feminist

theoryprovidesalensforanalysis.

Ianalysedthedatausingembodiedfeministmethods(Chadwick,2017).Mydataincludeaudio

recordingsoftheinterviews,thetranscriptswithreflexivenotesandthebodymapsalongwiththeir

summaries.Iusedfeministrelationaldiscourseanalysistoanalysethedata,whichisdividedinto

twokeydomainsofpost-structuralistdiscourseanalysis(steps1-6)andemergentvoicesinrelation

todiscourses(steps7-10)(Thomson,Rickett&Day,2018).FRDAguidesanalysisthroughaseven

stepprocess(Figure6.4):1)readingthetranscriptsandlisteningtotheaudiorecordings;2)

‘chunking’thetalkintosections;3)labellingthechunksoftalkwithdescriptivecodes;4)identifying

recurrentcodesorthemes;5)identifyingdiscourses;6)identifyingdiscursivepatterns;5)filtering

outtheI-voice;6)listeningtotherecordingforreflexivity;7)multiplelistening;8)generatingtheI-

poems;9)listeningforcontrapuntalvoices;and10)puttingthepersonalinthepolitical.Icreated

memosandannotationsthroughouttheanalysis.Thisanalysismethoddoesnotguidehowto

analysethebirthmapsandbirthingstories.Ithereforeadaptedthemethodtoaddtwomoresteps

intotheprocess:11)applyingthethemesandcodestothebirthsmaps,12)arrangingtheI-poems

againstthebirthmapsandbirthingstories.Thisisamultilayerednon-linearembodiedanalysisthat

ensuresthattheparticipant’svoicetakesdominanceintheanalysis,overtheresearcher’s

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interpretation(Frost,2008;Chadwick,2017).Thedetailedcodesincludedin-vivo,process,emotion,

values,attribute,provisional,causation,simultaneousandsub-coding.

Figure6.4 Feministrelationaldiscourseanalysis

(AdaptedfromThompson,Rickett&Day,2018)

Voice-centredrelationalanalysisamplifies‘voicesofthesilencedbydominantculturalframeworks’

especiallyinthecontextthatinvolvesexperiencingstigmaandshame(Sorsoli&Tolman2008),

includingchildbirth.Poeticenquiryallowsthereadertodeeplyimmerseintheparticipant’sjourney

andexperiencesthroughtheI-poemswhichareveryemotiveandtelling(McKenzie,2021).This

couldmeanlookingintotheirprivateandpublicexperiences,wherechildbirthisaprivate

experiencemadepublic.Previousstudieshaveusedittounderstandwomen’sexperiencewith

maternalhealthcare,toexplorematernaldepressionandwomen’sdecisiontofreebirth,which

makesitanappropriateanalyticchoiceforthisstudy(Montgomery,2012;Edwards&Wellers,2012;

Fontein-Kuipers,2018;McKenzie,2021).Thelisteningguideisstructuredtoenable:1)listeningfor

theplot;2)listeningforthevoiceof‘I’whichinvolvestracingoutandarrangingparticipant’s

referencetoselfinfirstpersonstartingwith‘I’,scatteredthroughoutthetranscript;3)listeningfor

contrapuntalvoicesandrelationshipswhichenablestheresearchertounderstandthecomplex

multiple,andoftenoverlappingvoicesthatexistwithinthesamesentenceorsectionofthe

narrative;and4)listeningforbroadersocial,politicalandculturalstructuresthathelptothawout

thelargerdiscoursesinfluencingthewomen’sconceptionsoftheirpositionality,linkingtheir

narrativestosocioculturalfactors.Theprocessincludesthegenerationof‘I-poems’whichcaptures

1. Reading the transcripts & listening to audio recordings

2. ‘Chunking’ talk into sections

3. Labelling chunks of talk with descriptive codes

4. Identifying recurrent codes or themes

5. Identifying discourses

6. Identifying discursive patterns

Post-StructuralistDiscourse Analysis

1.Multiple listening

2.Generating I-poems

3.Listening for contrapuntal voices

4.Putting personal in the political

Emergent voices in relation to discourses

1.Applying the themes and codes to body maps

2.Arranging I-poems against the body maps & birthing stories

Analyzing body maps

Source: Thompson, Rickett & Day 2018

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theiractualvoices.Inourstudytheparticipant’sreferencesto‘I’weresupplementedbyreferences

to‘my’and‘me’onafewoccasions,toensuremoredetailanddepthinthenarrativeandfora

richerunderstandingofthecontext.Thereareotherpronounpoemsthatresearchershaveusedto

addtopresentadifferentperspectiveandanotherangle(Chadwick2017).Therearedifferentways

ofcreatingandconstructingtheI-poems,Ifocusoncreatingthe‘full’poemstoallowsomecontext

intothepoemsandaddmoredepthtothenarrative.Partsofthetextsarebold,basedonmy

subjectivitytoemphasisecertainaspectsofthepoem.

6.4.6 Positionalityandreflexivity

Itisessentialformeastheresearchertobeina‘reflexiveengagement’withmyownassumptions

andknowledge.IsoughthelpfromProf.GillThomsonatUniversityofCentralLancashiretoconduct

apre-understandinginterviewwithmebeforeIstarteddatacollection.Ithelpedmetounderstand

andidentifymy‘forehaving5’,‘foresight6’and‘foreconception7’.

“Idon’tthinkIwentthroughanabusivebirth.Iknewaboutthedoctorwhowasgoingtodeliveryou.

Ihadheardthathedoesn’tlikewhenwomenscreamduringchildbirth.Iwasinmybestbehavior.

WitheverypainthatIclenchedmyteethanddidn’tmakeasound.Soitallwentverywell.Ididnot

getscoldedatallbecauseIdidnotgiveanyoneachancetoscoldme.”–Mymother

Thisismymother’snarrationofmybirththatIhaveincludedwithherconsent.Iremembersaying

thatsheshouldhavescreamedifshewantedtoscream.Itwasarespectfulbirthfrommymother’s

perspective,becauseshewastreatedwell.Butitwasnotapositivebirthingexperience,inmyview.

Asastudentnurse-midwife,Iwitnessedmanyexamplesofobstetricviolenceduringchildbirth,most

ofwhichwasnormalisedtoanextentthatwentunnoticedbythecareprovidersandwerenot

reportedbythewomenwhowereabused.Inmythirdyearasastudentmidwife,Iprovidedcarefor

awomanwhowassupposedtoundergoavaginalexamination.Therewasanareawithcurtainsand

alabourtable.Iaccompaniedherwherethedoctorwoulddotheexamination.Therewerethree

morepeopleinattendance,includingstaffnursesandapeonwhoevenafterImentionedthereare

toomanypeople.Thedoctorworeagloveinonehand,liftedthewoman’spetticoatandsaree

withoutanyexplanationandsaid,“howdoesyourhusbandwanttodoanythingwithyou,withthe

jungleyouhavegrownthere?”.EveryonestartedlaughingandIfrozenotknowingwhattodo.The

5Forehaving-myfamiliarityandbackgroundtothestudy.6Foresight-myperspectivewhichisinfluencedbymybackground.7Foreconception-whatIfeelIamgoingtofind.

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womandidnotsayawordbutjustcoveredherfacewiththepallu8ofhersaree.Italmostfeltasif

sheexpectedtobeabused.Thestaffnurselookedatmeandsaid,“thedoctorisjustjoking!”.The

doctorwasjustjoking.Ireportedtheincidenttothenurse-in-chargeinthelabourroomandalsoto

mysupervisor.Theycould,atbest,advisemetoneverpracticewhatIwitnessed.

OverthenextcoupleofyearsIsawwomenbeingslappedontheirface,ontheirthighs,pinchedon

theirthighswitharteryforceps,pulleddownbyherhair,leftnakedonthelabourtableswithout

curtainsorclothes,givenepisiotomywithoutanesthesia,fundalpressure,subjectedtomultiple

vaginalexaminations(asaresultofbirthinginateachinghospital),screamedat,commentedon

(basedontheirageornumberofchildrenorphysicalappearanceorlevelofeducation)bycare

providers.“What’sthepointofscreamingnow,didn’tyouthinkaboutthispainwhenyoulaidwith

yourhusband?”,wasacommoncommentwhichIlaterheardbeingsaidtowomeninmanyother

states.Privacyandconfidentialitywerenotmaintained.Iidentifiedmanyexamplesofwomennot

beingrespectedbyhospitalstaff.Forinstance,notgivingwomenalltheinformation,callingwomen

bytheirbednumberorthecolouroftheirsaree,notintroducingthemselvestowomenandnot

encouragingwomentoaskquestionsoranswerquestionswomenhave.Manyoftheseexamplesof

obstetricviolence,IcontinuetorealiseasIreadmoreliteratureonthesubject.

6.5 Findings

Theeightwomenwhowereinterviewed,focusedonanyonebirthexperienceoftheirchoice,in

detail,topresentontheirbirthmap.Intotal,theyhad20livebirths(10eachfromurbanandrural)

andtwostillbirths,atdifferentlevelsofgovernmenthospital,atprivatehospitalsandathome.

Womensharedtheirexperienceandperceptionsofrespect,disrespectandabuseduringvaginaland

cesareanbirth.MoreinformationabouttheparticipantsisprovidedinTable6.1.

8Palluisapartofsareethathangsfromshoulderwhenworn.

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Table6.1 ParticipantsProfile

Pseudonym Age

(Years)

Education Occupation Ageat

childbirth(s)

(inyears)

Birthsettings

Urmila 25 6thstandard Home-maker 19,21&23 Sameprivatehospitalfor

eachbirth

Ria 32 12thstandard Cleaner&milk

seller

26 Birthintertiarypublic

hospital

Sujata 28 12thstandard Home-maker 23,25,27&

28

Onebirthinaprivate

hospital,theotherthreein

differentpublichospitals

Pratima 19 5thstandard Home-maker 15&19 Onebirthinaprivate

hospitalandonehomebirth

Amrita 22 Noformal

education

Managesa

groceryshop

18&20 Twobirthsindifferent

primarypublichospitals

Sita 22 8thstandard Home-maker 19,20,22 Threebirthsindifferent

publichospitalsatprimary

&secondarylevels

Anju 25 Noformal

education

Farmlabourer 20,21,22,23

&25

Birthsingovernment

hospitalstwice,homebirth

thrice

Pairo 29 MA,B.Ed,BA Teacher 25&28 Birthsindifferentprivate

hospitals

Participantsdidnotusewordssuchas“samman”or“izzat”thatareliterarytermsusedinreference

to‘respect’and‘dignity’inHindi.Thevocabularytheyusedwascolloquial.Theyconveyedtheir

feelingsthroughsimplerwords,suchasacchcha(good)andbura(bad)whicharemore

conversational.Theycommunicatedthroughfacialexpressionsandbysayingwhetheraparticular

experiencemadethemfeelangry,afraid,shy,ashamed,regretful,letdown,happyorexhilarated.

Womendescribedexperiencesdetailingthebirthplace,interventions,birthingenvironment,people

Chapter6

111

aroundbirth,beingtouchedduringbirthandcommunicationandabouttheirdecision-makinginall

oftheseareas.Theysharedtheirexperiencesofgivingbirth,howtheirbirthingexperiences

influencedtheirsubsequentbirths,andtheimpactonebirthingexperiencehadonanotherinterms

ofperceptionandexpectationofrespect,disrespectandabuse.Theyexplainedwhattheymeantby

a‘goodbirth,’whichalsoinfluenceddecision-makingduringchildbirth,theirexpectationsoffuture

birthsandthebirthingexperiencesandexpectationsofwomenaroundthem.

6.5.1 ‘Good’births,‘Bad’birthsandexpectedbirths

Womenwererequestedtochooseoneoftheirbirthingexperiences(incaseofamultigravida)to

showonthebirthingbodymap.Riawastheonlyprimi-gravidaparticipant.Amrita,Pairo,Sujataand

Urmilachosetonarratetheirmosttraumaticbirthingstoryonthemap.Pratima,SitaandAnjuchose

tonarratetheirgoodbirthingexperiences.Womenweresuggestedtoranktheirbirthing

experiencestohelpthemchoosewhichbirthtocreateonthemap.Thishelpedwomento

understandwhataccordingtothemisa‘goodbirth’ora‘badbirth’.Agoodoutcomeintheir

perceptionwaspartofagoodbirthingexperience.Theyreportedthebirthofasonasagood

outcome.Thisisanindicationofsonpreference,reflectingthepatriarchalsocietalstructure,ascan

beseeninAmrita’sbirthingbodymap(Figure6.14).

“Theboy!IfeltbetterwhenIhadtheboybecauseIhadgoodpainandtookverylesstime.Mygirl’s

birthwasverypainfulforme.Ihadsomuchproblem.Iwouldliketoshowthegirl’sbirthonthe

map.”(Amrita)

Women’sunderstandingofanidealbirthwasexpressedinparts,throughoutthemultiple

interactions,totheextentwherebirthswhichwereconsidered‘better’became‘bad’.Asthetrust

developedovertheinteractions,theyopenedupmore.Theexpectedbirthwasaskedintermsof

respectfulness,apartfromexperiencedbirth,ascompiledinTable6.2.

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Table6.2 Women’sunderstandingofgood,badandexpectedbirth

Participant

(livebirths)

Experiencedbirth Expectedbirth

Goodbirth Badbirth

Amrita(2) -shortdurationof

labour

-toopainful

-neglectand

abandonment

-verbalabuse

discriminatedagainst

onthebasisofsexof

newborn

-notouching

-propercommunication

-timelyexamination

-nodelayincare

-politecareprovider,servewitha

smile

-abed

-careprovidershouldtreatas

familymember

-nondiscriminatorycare

regardlessofnewbornssex

-availabilityofhospitalsupplies

-nodisrespect

-noextortion

-notmorethantwopeople

aroundherduringchildbirth

-incentiveforinstitutionalbirth

Pairo(2) -betterpreparedfrom

experience

-lowerexpectation

thanpreviousbirth

-toomanyvaginal

examinationsby

differentcareproviders

withoutmaintaining

privacyorseeking

consent

-extortion

-blindfolded

-inhumanetreatment

-manymenaroundin

thebirthingroom(OT)

-vaginal(normal)birth

-comfortingtouch

-novaginalexaminations

-seekconsentbeforetouching

-explanationandconsentbefore

interventions

-birthcompanioninOT

Chapter6

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Participant

(livebirths)


Goodbirth Badbirth

Pratima(2) -homebirth

-betterneonatal

outcome

-respectful

communicationin

hospitalbirth

-privatehospitalbirth

-unaffordablecare

-journeytohospitalto

givebirth,travelalong

abumpyroad

-unexplained,

unconsented

augmentation

-homebirth

-novaginalexamination

Sita(3) -cleantoilet

-quickambulance

-swellingoflegsand

arms

-difficultywalking

-unconsentedand

forcedvaginal

examination

-restrained,physical

abuse

-notouching

-verbalabuse(hopeditwon’t

happen)

-nodelayincare

-nocomplications

-respectfulcommunication

-birthcompanionofchoice

-foodtobeprovidedathospital

-cleanbed,birthingroomand

bathroom

-birthinthehospital

-incentiveforinstitutionalbirth

Ria(1) -comfortingtouch

fromanotherbirthing

woman’scompanion

-affordablecare

-verbalabuse

-shoutedat

-uterineprolapserepair

withoutanesthesia

-Babydeclareddeadby

daiswithoutnewborn

assessment

-nophysicalabuse

-comfortingtouch

-birthcompanionofchoice

-extortion,buthopeditwon’t

happen

-1:1care

-onebed,oneroom

-curtainsforprivacy

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Participant

(livebirths)


Goodbirth Badbirth

-respectfulbehaviourfromcare

providers

-careprovidersshouldintroduce

themselves

-babyshouldbereceivedwith

careandassessedproperlyafter

birth

-properlight&ventilation

Sujata(4) -presenceof

‘guardian’thoughnot

ofchoice

-careproviders

followedherbeliefs

(norms)afterinsisting

-careprovidersdid

notdovaginal

examinationafter

refusal

-extremepain

-forgottentoremove

gaugepiecebefore

episiotomyrepair

-extortion

-unexplainedand

unconsentedvaginal

examination,

episiotomy,episiotomy

repair,uterine

explorationand

augmentation

-noanesthesiabefore

episiotomyrepair

-husband’spresenceasabirth

companion

-noepisiotomy

-birthingwoman’snormsand

beliefstobefollowed

Urmila(3) -nomedicine

-novaginal

examination

-lesspain

-quickdelivery

-privacyprotected

-shoutedat,verbally

abused

-unconsented,

unexplainedvaginal

examination,

episiotomy,episiotomy

repair,augmentation

-nocut

-littlepain

-nostitchingwithoutanesthesia

-nounnecessarytouching

-seekpermissionbeforetouching

andinterventions

Chapter6

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Participant

(livebirths)


Goodbirth Badbirth

-restrained,physically

abused

-detentionofnewborn

-extortion

-respectfulbehaviourfromcare

providers

-comehomealiveafterbirth

-nobirthcompanion

Anju(3) -homebirth

-threelivebirths

-samedagarin

-hospital

-twostillbirths

-homebirths

-continuityofcareacrossall

births

Disrespectfulandabusivebirths

Womenreferredtovariouskindsofdisrespectfulandabusiveencounterswiththehealthandnon-

healthcareprovidersduringtheirstayatthehospital.Theyreportedhearingsimilarexperiences

fromtheirfriends,familymembersandwomenintheneighbourhoodwhooftenmadesimilar

choicesofbirthplace.Storiesofrespect,disrespectandabusewereconsideredwhengivingbirth

again,andthesestoriessymboliseddesiredbehaviours,self-disciplineandwaystoavoidbeing

violated,humiliatedandhaveasclosetoadignifiedbirthingexperienceaspossible.Womenoften

saidthattheydiscussedobstetricviolenceinahushedmanneramongstpeerswhensomeoneisdue

togivebirth.Thesestorieswerenotsharedwithauthoritiesasagrievance,notevenwithsenior

membersofthefamilyincludingtheirhusband,withwhomtheconversationsaboutbirthwererare.

Alltheparticipantshadexperiencedobstetricviolenceduringchildbirth.

Verbalabusewasthemostcommonformofviolenceexperienced.Somecareprovider’scomments

weresodisgustingthatwomenrefusedtorepeattheirwords.

“Twosisters(nurses)wereverybadbecausetheywereabusingmeandshoutingatmelikeanything,

Ican’teventellyouthethingstheysaidtome.”(Urmila)

“ThedoctorinsertedherfingersinsidemeandIscreamedveryloudly.Shesaid,‘Pairohasnopain

threshold,shecanneverhaveanormalbirth!’”(Pairo)

“Shesaid,‘Shutup!Whyareyouscreamingsomuch?’…‘behave!Lookhowyouarescreaming!’”

(Ria)

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116

Incidentsofphysicalabusewerementioned.Womendidnotperceiverestrainingasabuse.They

reportedthatitiscommonandtheyconsidereditasabadtouch,butapartofqualitycare.Women

dislikedbeinghelddown,butwerehesitanttosaythatbecauseoftentheirfamilymemberswere

theonesrestrainingthem.Episiotomyrepairwithoutanaesthesiaisacommonkindofphysical

abusethatwomen(Ria,Urmila,Sujata)haveexperienced,buttheyconsideredthatapartofcare

duringchildbirthaswell.Everywomanwastouchedwithoutconsent.Theyreportedfeeling

‘uncomfortable’and‘ashamed’butcouldnotsaythistothepeoplearoundthem.

“Theydohitwomeninthatcondition…Awomanhadcome,shewasscreamingsomuchfromthe

painthatshecouldnotstayinherbed.Thesister(nurse)gavehertwotightslapsacrossherface.”

(Ria)

“Peopledon’tlikebeingtouched,buteveryonehastogothroughit!”(Sita)

Womendidnotspeakaboutexperiencingsexualabuse,butthenarrationandnon-verbal

communicationsconveyedotherwise.Oneoftheparticipantsreferredtocommentswithsexual

connotationas‘colourfulthings’whilealsosharinghowuncomfortableitmadeherfeel,butshe

believedthateveryonehadtoendure.

“Thedoctorsaid‘youarenotscaredofotherthings,ofdoingit,butyouarescaredofinjections!’

Manypeopleabuselikethat.Theysaid‘ifyouaresoafraidthenwhydidyouconceive?Whenthe

babyhadstayed,youshouldhavetakenthepilltogetridofit!What’stheneedofhavingchildren

then?’”(Ria)

Extortionisthecommonestformofabusethatwasmentionedbyeveryparticipant,exceptAnju.It

hasbecomeatraditionforcareproviderstoaskfor‘khushikepaise’(happinessmoney),thatalso

determinesrespectfulnessandqualityofcarebasedonacareseeker’saffordabilitytotipthem.

Moneyissoughtassoonasthebabyisborn.Thecareprovidersdonotmissanopportunityto

demandmoney,astheydonotknowwhenthefamilymightleavethehospital.Participantshave

reportedthatalltypesofhealth(doctors,nurses)andnon-healthcareproviders(ASHA,Mamta,

cleaner,dagarin/dai)askformoneyalthoughhowthemoneyisdividedbetweentheteamcould

notbeascertained.Theydemandmoney,foreveryoneinthehospital,regardlessofhowmany

peoplewereinvolvedincare.

“Happinessmoney!Shesaid‘yourgrand-daughterislikeGoddessLakshmi’theneveryoneaskedfor

money.Myhusbandgave100-150rupeestoeveryone.Therewere11-12peoplethere…Happily!?

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117

Somepeoplegiveithappilybuttheyhavemadeahabitoutofit.Peoplewhocan’tafford,theyask

themtoo.Thatisgreed!”(Pairo)

“Myhusbanddoesgarbagework(rag-picker)…helosthisjobandwehave300rupees.Shouldwego

tohospitalortakecareofthehouse!Wehadnomoneytogotohospitalinthesecondbirth…

everyonehadtaken100rupeeslasttimeinthenameofhappiness,therewereninepeople.”

(Pratima)

AparticipantmentionedthatshehadtobribetheNew-bornIntensiveCareUnit(NICU)staffevery

timeortheydidn’tlethervisithernew-borndaughter.Thiswastraumaticforher.Asimilar

experiencewasreportedbyUrmila,whichledtoherbaby’sdetentionintheprivatehospitaluntil

theypaidextra,overthehospitalfees.Thebabywaskeptforhoursuntilthecareprovidersreceived

the‘happinessmoney’.

“Thereweretwobadsisters(nurses).Myfathergavethem1000rupeesbuttheywerenothappy.

Theytoldusthatotherpeoplegivethemgoldearringsandnecklace.Myfatherwasnotgivingthem

moneysotheykeptthebabyfortwohoursandwhenmyfatherfinallygavemoremoneythesisters

(nurses)handedoverourbabytous.”(Urmila)

“Someguardianscannotpayasmuchasthedoctorsaskfor.Thenursesdetainthebabysaying‘we

wantthismuchorwewon’tgivethebaby’.Manypeopledon’thaveenoughmoneytofreethebaby

fromthem.Sometimesitturnsintoconflicts.”(Sujata)

Unconsentedproceduresshowedafailuretomeetprofessionalstandardsandtherearemany

instancesshowingpoorrapportbetweencareprovidersandwomen,whichincludesalackof

explanation,detentionandtreatingwomenaspassiveparticipants(asshowninPairo’sexperience

inFigure6.11).

“Thedoctorsaid,Ionlywenttobedat1amandyoupeoplestartedcallingme.Stopthischaos!Go

away!Iwillcomeinthemorning”(Amrita)

Theaccountsofobstetricviolencebasedonthefindingsreportedbyeightparticipants,areshown

(Table6.3)againstanupdatedtypologyofmistreatmentduringchildbirthbyBohrenetal.(2015).

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Table6.3 Women’sexperienceagainstBohrenet.al’sadaptedcategoriesofmistreatment

duringchildbirth

3rdOrder

Themes

2ndorderthemes 1storderthemes Women’s

experience

Physicalabuse Useofforce Womenbeaten,slapped,kickedor

pinchedduringdelivery

P

Physicalrestraint Womenphysicallyrestrainedtothebedor

gaggedduringdelivery

P

Sexualabuse Sexualabuse Sexualabuse P

Rape P

Verbalabuse Harshlanguage Harshorrudelanguage P

Judgementaloraccusatorycomments P

Threatsorblaming Threatsofwithholdingtreatmentorpoor

outcomes

P

Blamingforpooroutcomes P

Stigmaand

discrimination

Discrimination

basedonsocio-

demographic

characteristics

Discriminationbasedonethnicity/race/

religion

P

*Discriminationbasedongender P

Discriminationbasedonage P

Discriminationbasedonsocioeconomic

status

P

Discriminationbasedonparity P

Discriminationbasedonotherobstetric

factors(Example-previousneonatal

death)

P

Discrimination

basedonmedical

conditions

DiscriminationbasedonHIVstatus P

Discriminationbasedondisability P

Lackofinformedconsentprocess P

Chapter6

120

3rdOrder

Themes


experience

Failureto

meet

professional

standardsof

care

Lackofinformed

consent&

confidentiality

Breachesofconfidentiality P

Physical

examinations&

procedures

Painful(and*forced)vaginalexaminations P

Refusaltoprovidepainreliefand

*anaesthesia

P

Performanceofunconsentedsurgical

operations

P

Neglect&

abandonment

Neglect,abandonmentsorlongdelays P

Skilledattendantabsentattimeofdelivery P

Poorrapport

between

womenand

providers

Ineffective

communication

Poorcommunication P

Dismissalofwomen’sconcerns P

Language&interpretationissues P

Poorstaffattitudes P

Lackofsupportive

care

Lackofsupportivecarefromhealth

workers

P

Denialorlackofhealthcompanions P

Lossofautonomy Womentreatedaspassiveparticipants

duringchildbirth

P

Denialoffood,fluidsormobility P

Lackofrespectforwomen’spreferred

birthpositions

P

Denialofsafetraditionalpractices P

Objectificationofwomen P

Detainmentinfacilities P

Lackofresources Physicalconditionoffacilities P

Chapter6

121

3rdOrder

Themes


experience

Healthsystem

conditions&

constraints

Staffingconstraints P

Staffingshortages P

Supplyconstraints P

Lackofprivacy P

Lackofpolicies Lackofredress P

Facilityculture Unclearfeestructure P

Unreasonablerequestsofwomenby

healthworkers

P

Briberyandextortion P

Thehybridbirthmap-Thehybridbirthmapconveyswhatcouldbetheworstorbestexperience

forawomancollectively,fromtheexperiencesofallthewomeninterviewedfromthe

researcher’sperspectivebasedonwomen’snarratives.Iplacedthemapstogetherandanalysed

women’sexperienceondifferentpartsoftheirbodyfortheworstexperiencetoemergefromthe

participant’scollectiveexperience,althoughthisisasubjectiveprocess.Alltheworstexperience

onthebodyseparately,suchasonthehands,legs,head,chest,waistandgenitalarea,areput

togethertocreateahybridbirthingbodyportrayingthecollectiveworstexperiencethatwomen

cangothroughduringchildbirthinBihar(Figure6.5).Thebirthingenvironmentisanessential

partofwomen’sbirthingexperiencewhichwasanalysedtoaddtotheenvironmentofthehybrid

map.

Chapter6

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Figure6.5 Thehybridmapoftheworstexperiencefromtheeightbodymaps

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123

RespectfulBirth

Womenoftenjustsaidthey‘feltgood’aboutaspectsofbirthwhentheytalkedaboutrespectful

birth.Butasstatedbefore,betterbirthdidnotalwaysmeanagoodandrespectfulbirth.Women

sharedtheirexpectationsthatcouldmaketheirbirthsrespectful.Amritahadvisitedatertiary

levelhospitalinadifferentstateforafewantenatalvisitsbeforemovingbacktoBihartogive

birth.Shetalkedaboutthecleanlinessandgoodbehaviorofthehospitalstaffthere,comparing

withherbirthingexperiences.Gettingacleanambulancetogotothehospitalontimewasthe

onlypositiveaspectfromherexperience.Sheexpectedcleanlinessintheentirehospital.Shehas

averyclearvisionofwhatrespectfulcaremeanstoher.

“Careshouldbelike,whenItoldthemwhatproblemIhave,theyshouldcomeandcheckme

completelyandtellmeaboutmycondition,thatinhowmuchtimeIwilldeliver.Iwillfeel

respectfulwhentheywilldomydeliveryontimewithoutdelay,whentheywillspeakwithme

politelywithasmile.Whentheywilltakecareofmenicely.Iftheygaveusabed.Thingsshouldgo

well.Theyshouldtreatuslikefamilymembers.NomatterwhetherIambirthingaboyoragirl,I

shouldbetreatedwell.Iftheytalktomenicely,thenonlyIwillcomehere…nomatterwhetheritis

thenurse,doctorordai.Theyshouldgiveimmunization,injection,medicinesandothersupplies

fromhospitalifitisavailable.Ifitisnotavailable,theyshouldbringitfromoutsideandgiveus.

Thenonlywewillshareourgoodexperiencewithotherwomenintheneighbourhoodthatweare

notdisrespectedthereandpeoplearenotgreedy.What’sthepointofgoingthereotherwise!”

(Amrita)

Atouchthatfeltgoodwasmentionedasacalmingandrarelyexperiencedaspectofbirth.Pairo

wasrelievedtohavebeengivenbirthpain-free.Afterhavingatraumaticbirthexperience(Figure

6.11),itwasdifficultforhertogothroughanothercesareaneventhoughshehadchangedthe

hospitalandthedoctor.Memoriesofherfirstbirthexperiencecausedsevereanxietywhenshe

waslyingontheoperationtable,blindfolded,andshegotsupportfromastrangerwhoheldher

handandhelpedhercalmdown.Riahasasimilarstoryofhervaginalbirthinapublictertiary

hospitalwhenshewassurroundedbyfiveotherwomeninlabour,withoutanyprivacy(Figure

6.9).Bothofthemdidnothavethesupportfromfamilywhentheyweregivingbirth,butwere

supportedbyastranger,whichwasthebestaspectoftheirexperience.ForPairo,itwasthe

‘stem-cell-guy’andforRiaitwasthebirthcompanionofanotherwomanbirthingnexttoher.

CordbloodbankingisavailableinmostprivatehospitalsinIndia,whichexplainsthepresenceof

thispersonintheOTwhomPairoreferredtoasthe‘stem-cell-guy’.

“ThereweremanypeopleintheOTandIhadthestemcellguyintheOTwithme.Heheldmy

hand.IknewIwasgoingtobeoperatedsoIwentcompletelynumbinmyheart.Itwashurtinglike

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124

aninjectionduetofear.Itoldhimtopresstightlyonmyheart,onmychest.HeofferedwaterbutI

refusedtodrink…‘justpresstightlyhere’andhedidso.(laughs)Noonewilltellanyonelikethis

butIwasblindfoldedandIdidn’tevenknowwhohewas.Ididn’tseehisface.Aftersometimehe

asked‘areyouokay?’,Isaid‘yes’…Ifeltlikeheismyown,someonefamiliar.”(Pairo)

“Iwantedonlytwopeoplearoundme,anurseandadoctor.Thepeoplewhogivemedicineand

injectionshouldremainandtheothersshouldnotbethere.”(Amrita)

Theabsenceofbadbehaviorincludingwhattheyconsiderbadtouch,wasalsoexpected.Pairo

recallednovaginalexaminationsbeingareliefinhersecondbirth.Goodbehaviorcouldbeseen

inusualandunusualforms.

“She(doctor)wasverynicebecauseshealsostartedprayingwithus(forthebaby).Shewasan

innocentnicelady.Shewassogood.Ifeltgoodbecausethoseweregoodpeople,doinggood

thingsandtakingcareofmenicely.Wewerehappy!”(Pratima)

Theplaceofbirthmattersaswell.Pratimafeltthatshewasmostrespectedathomewhen

comparedtoherpreviousbirthinaprivatehospital.Riaperceivedthatwomenareabusedin

governmenthospitalbecausetheyhavenotpaid.Inprivatehospitalonepaysfortheservices,so

canexpecttobetreatedwithrespect.Thisalsowasrelatedtoworkloadinthegovernment

hospital.Havingfamilymembersmayalsoensurerespectfulcareandifnot,oneatleastfelt

supportedwithfamily’spresence.

“Ingovernment,theydoonework,thenleavethatandgotodoanother,thenleavethattoo.They

areconstantlyjugglingbetweenyouandotherpatients.Theyonlycomewhenthebabyiscoming

out.Butintheprivatehospitaltheywillstandnexttoyoufromthebeginninguntiltheend.The

moremoneyyougive,themoreconvenienceyouget.”(Ria)

Participantsoftenchangedbirthplacesafteratraumaticbirthingexperience.Inmanycasesthat

wasnotanoption.Anjugavebirthathomethreetimesaftertwostillbirthsatthehospitaland

sheisconvincedthathomeiswhereherbabiessurvived,whichwouldnothavehappenedina

hospital.Sujata,PairoandSitachangedhospitalsaswell.Pratimahadahospitalbirthwhich

wasn’tverybadinheropinion,butaffordabilitywasachallengeforherandhomebirthwaslight

onthepocket.

“ObviouslyIwillbemostrespectfullytreatedathomeduringbirth!Yougetgoodcareathome.If

yougivebirthathome,thenitishomeonly.Thereisnoneedtogoanywhereelse.Didnothaveto

reserveavehicle.Thereisnoneedtogorunningaround,arrangingthings.Everythinghappensat

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125

home.Theroadshavepotholes,itsbumpy,whichisoneofthereasonsofdiscomfortwhile

travellingtothehospital.That’swhyIgotmybirthdoneathome.”(Pratima)

ReceivingtimelyattentionfromthecareproviderswasmentionedbyAmritaandSita.Thiswasa

causeofworryformostparticipantswhogavebirthinahospital,andexperiencedneglectand

abandonment.Apartfromgoodbehavior,thereweremanybirthingenvironment-relatedaspects

thatSitathoughtwouldberespectfultothebirthingwomen.

“Theyshoulddodeliveryquicklywithoutmuchdelay,Imeanontime.Thereshouldnotbeany

problemorcomplication.Theyshouldtalknicelywitheveryone.Mealsshouldbegiveninthe

hospital.Bathroomshouldbeclean,roomshouldbeclean,bedshouldbeclean.Ifyouarealone,

youwillbescared.Nobodyshouldtouch.Idonotwanttobetouchedbyanyone.Thereshouldbe

someonewithyou,it’simportant.”(Sita)

Birthcompanionsareconsideredimportant,althoughthehusbandisnotconsideredabirth

companion.Husbandsareusuallykeptaway,asitisdeemedinappropriateculturallyformento

bearoundbirth.Birthcompanionor‘guardian’couldensuretheygetrespectfulcarebecause

theirpresencewillmeanthecareproviderswillgetmoneyafterthebirth,whichwillensurethey

treatthewomenbetter.Womenfromthefamilyaccompanyabirthingwoman,thoughtheyare

notallowedintheOT,aswasseenforPairo.Thepresenceofhusbandisdebatableandismostly

frownedupon.AsmentionedbyPratimaandSitawhofelttherewasnoneedforherhusbandto

bethere.Box6.19hasAmrita’sI-poemonherfeelingsabouthavingherhusbandaroundwhile

givingbirth,andexpressingthatshefeelsshehadtogothroughpainfulbirthsbecauseofhim.

Anju’shusbandplayedakeyroleinallherbirthsastheonlypersonaround,otherthanthe

dagarin.Hewasalsotheonetocatchthebabyinherfirsthomebirth,thoughhewaitedoutside

inthetwofollowingbirths.Urmila’shusbandwasinprisononetimeandnotaroundherduring

restofherbirthsandRia’shusbandabandonedheraftershegotpregnant.Sujata’shusbandhad

towaitoutsidethebirthingroominallofherfourbirthsandthatisoneaspectofherbirthshe

wantedtochange.

“ThebenefitwouldbethatwhenIwascryingoutofpain,Icouldhaveheldmyhusband’shand.I

couldhavesharedmypainwithhimandthatwouldbegoodforme(laughs).Hemaynothavefelt

anything,butIwouldhavefelteverything.Itwasallaboutme,Iwasinpainsolet’sfocusonhow

thatwouldhavehelpedme(laughs)Iwouldhavebenefitedfrommyhusband’spresenceforsure.

Hewasoutside,waitingtohearaboutthebaby.Iwantedhimintheroomwithme.Ifmyhusband

wouldhavebeenthere,Iwouldhaveaskedhimtocomenearme(laughs)…Justthefeelingthat

someonefromfamilyisthere.Buthavinghusbandnexttoyouissomethingdifferent…holdinghis

handwillbemorethanenough(laughs)Inthisconditionhusbandisneededmore.Hecanalsohug

Chapter6

126

me.Iwillbeinpainbutbecauseofmyhusband’scompany,mypainwillbeless.Iwillfeelrelaxed.

Beingwithhimwillmakemehappier.”(Sujata)

Womenwanttoavoidunnecessaryinterventionsduringchildbirthandgivebirthnaturally.Some

oftheseinterventionsareperceivedasbadtouchtothemandtheywanttogivebirthwhere

thereare‘nocuts,nochecks’becauseepisiotomy,repairandvaginalexaminationsaresomeof

themostdisrespectfulandabusiveaccountsnarratedbyparticipantsincludingunnecessary

exposure,thatisshamefulandtraumaticforthem.Theywanttheirprivacytobemaintainedatall

times.Itisimportanttoensurethattheirnormsandbeliefsarevalued,asSujataexperienced

whenshefeltthebabyisnotcomingoutbecausethefanneedstobeturnedofftoincreaseher

bodyheat.ThenursedidthatforherandSujatareportedthatherbabycameoutquicklyafter

that.Whenwomenhavetoundergointerventions,theywanttobetoldaboutthemandbegiven

enoughinformationtounderstandthepurposeofit.

“Theyshouldhaveexplained(aboutvaginalexamination)tome.ThenIwouldhavethought,okay

theywilldothistomeanditisrequired.SoIwouldhaveconvincedmyselftohavecourage.I

wouldhavepreparedmyself.”(Pairo)

Manyoftherespondentssharedwhattheir‘birthingexperienceofdreams’wouldbelike,ifthey

hadalltheresourcesimaginable,vestedtomaketheirbirthingexperiencemorerespectfuland

satisfactory.ThefollowingquoteshowsRia’shopesforherdaughter’sbirth(Figure6.9),because

shedoesnotplantogivebirthagain.

“Thereshouldbeonlyonebed,surroundedbycurtainsonallsides…hereeveryonewasscreaming,

hereandthere,everywhere.Thereshouldbeasister(nurse)whowilltalknicelyandpolitelywith

love.Theywillguideuswhattodosaying‘dearthisisthisandit’saboyoragirl’…Iwillgivebirth

lyingdownonly,inaseparateroom.Theyshouldbeencouraging.Iwanttobefamiliarwiththem

(doctor,nurse).IwouldthinkthatsomeoneisthereandIwillfeellessafraidandnotpanic.

Encouragingenvironment!Everythingshouldbedonewithloveandcare,thenIwillfeelhappy

andsatisfied…oncethebabyisreceivedwithcare,checkthegeneralconditionofthebaby,assess

thebabythoroughly,identifythepresenceofanyproblem…providecare.Aftercleaningthebaby,

itshouldbeshowntomesoIknowwhetherIbirthedasonordaughter.Theroomshouldbeclean,

nosmells,thefloorshouldbeclean.Thebedshouldbesuchthattheheadrisesup.Thereshould

beproperlight,ventilation,workingairconditionerandrunningfanspeciallyinhotweather.If

televisionistherethatwouldbebetter.Thereshouldbeabedformyfamilytoointhesameroom.

Ishouldnothavetospendsomuchmoney,buteverythinghappensasperincome.Can’tspread

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thelegssomuchthatitgoesoutofthequilt!9Thepoorandneedyshouldgetallthesefacilitiesin

thegovernmenthospital.”(Ria)

Participantsgavebirthinarestrainedsupinepositioninthehospitalanddidnothaveanopinion

onanidealpositiontogivebirthin,thoughAnjugavebirthsquattinginthreeofherbirthsat

homeasshowninherbirthmap(Figure6.7).Havingthesamedagarin10forallherbirthswas

comforting,assheknewhercarerandhaddevelopedarelationshipoftrust.Urmilawasalso

caredbyateamofhealthcareprovidersknowntoherinallthreeofherbirthsinaprivate

hospital.Thebirthmapsarealsoanalysedinanotherwaythatincreasedunderstandingofthe

differentwayswomenbirthinBihar,inoneimage.Forthis,Itracedalltheeightmapsleavingout

alltheotheraspectsofthemapstofocusonlyontheposturewomentakeoraremadetotake

whentheyaregivingbirthathospitalorhomeandinnaturalorcesareanbirth.Therangeof

birthingpositionsshowshowdiversebirthingcanbe(Figure6.6).

Figure6.6 Birthingposturesofwomen(Author’sown)

Thefinalaspectwasaboutthechoiceofhowtogivebirth,andallwomenwantedtogivebirth

‘normally’.Pairospentdayscryingwhenshecouldnotgivebirthvaginallyeventhesecondtime,

becauseherfirstbirthwascesarean.Eventhosewhodidhaveavaginalbirthreportedhaving,

9ThisisacommonIndiansaying.10Dagarinisdaiortraditionalbirthattendant.

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whattheycalled,a‘mini-operation’(episiotomy)whichwasthemosttraumaticaspectoftheir

birth,asUrmilaandRianarrated.Theirhappiestexperienceswereinterventionfreevaginal

births,buttheyfelttheydidnothavetherighttomakethatchoiceovertheirownbody.

AhybridbodymapofthebestexperiencescouldbecreatedbutthatwouldequatetoAnju’s

originalbirthmap(Figure6.7)thatmajorlydepictedthebirthingpositionandbirthing

environmentofoneparticipant,Anju,whochosetogivebirthathomethrice,withthesame

traditionalbirthattendanti.e.adaiaftertwostillbirthsathospitals.Anjusquattedtogivebirth

everytime,takingsupportfromthetwobamboopoles,inthepresenceofherdai.Acoupleof

otherparticipants,oneofwhomfeltthatquickaccesstoacleanambulanceandthecleantoilets

inthehospitals,werekeyaspectsofhergoodbirthingexperience.Incontrast,Pratima,whoalso

gavebirthathomewithadai,feltthepresenceofherrabbitsduringherbirthassomethingshe

wouldpreferifshegavebirthagain.

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Figure6.7 Anju’sbodymapshowingherhomebirths

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6.5.2 Respect,disrespectandabuseduringmedicalinterventions

Womenexperiencedarangeofmedicalinterventions.Alltheeightparticipantsgavebirthina

hospitalatsomepoint.Theseinterventionsincludegettingintravenousfluids(IV),augmentation,

episiotomy,episiotomyrepair,perinealshavingandvaginalexamination.Theinterventionsalso

includebloodtransfusion,fetalmonitoringanduterineexploration.Cesareansectionhasalso

beenincludedasanintervention.

Augmentationandintravenousfluidtransfusion-Allwomenwereaugmented;exceptone

womanwhogavebirthathome.Mostofthemwereinducedwithoutconsentandsomewere

inducedmultipletimes.Someofthemunderstoodonlyafterrealisingthatsuddenlytheintensity

oftheircontractionshadincreasedafteraninjectionwasaddedtothe‘bottle’,withoutany

communication.Sitawantedtobeinduced,toavoidvaginalexaminations.Womengenerally

reactedtoaugmentationwithannoyance,thoughoneofthemfeltitwasanactofcare.Itis

difficulttosayhowmanyofthesewomenwereinducedonprescription,butitiscertainthat

augmentationinlabourisaroutineprocedurethatwomenarewellawareof.

“My‘dard’(pain)increasedalotafterthetwoinjections.Ididnotnotaskthemtoincreasemy

pain”(Urmila)

“Theygavemedicinetoincreasemypain.Ididnotask,butshegaveitsothatthebabywillbe

bornquicklyasshewaswatchingmeallnight,Iwasrestlessduetopain.Shewasverynice!”

(Pratima)

IVfluidswerecommonlygiventowomenwhentheywereadmitted.InfusingoxytocinintheIV

fluidisacommonpractice.WomenunderstoodthisandoftenacceptedIVinfusedoxytocinas

partofthecareduringchildbirth.

“Shesaidmouth(cervix)isnotopenenoughanditisleakingwater,soitneedstobeinfused.

Otherwisethebabywilldryupinside.Theyranwaterdayandnight.19bottlesin3days!”(Pairo)

“Shehungthebottleofwater,addedtheinjectioninitandwhenitfinished,thenurseaskedme

‘how’syourpain?’,gavemetwoinjectionsandafterthatmyconditionwaspatheticandIstarted

cryingandscreamingloudly.”(Sujata)

Episiotomyandrepair-Womenreportedunpleasantandtraumatisingexperiencesofepisiotomy

andrepair.Noneofthewomenwereaskedfortheirpermissionbeforethecareprovider

subjectedthemtoanepisiotomy.Manywerenotinformedaboutitbeforegiving‘thecut’or

‘chotaoperation’(mini-operation),asitiscommonlyreferredto.Womenoftensaidtheygave

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birththrough‘chota-operation’andnotnormal/natural/vaginalbirth.Theseexperiencesare

etchedintheirmemorywithgreatdetail,eventhoughyearshavegonebysincetheygavebirth.

“…8stitches!Iknowfromtouchingit.Whenshewasstitchingme,itwashurtingalot.Whenever

theneedlewouldpiercemefromoneend,Iwouldcountwhenitwouldturnaroundandcome

backagain.Icouldfeelallofit!ItoldthemtogivemeaninjectionsoI’llbeunconscious.Somany

timesItoldthem.Butshedidnotgivemetheinjection.Iscreamedalot!Shekeptsaying,‘it’s

done!’.Itwasverypainful!Itwasverypainful!”(Ria)

Riagavebirthinatertiarylevelgovernmenthospitalinthestatecapital.Urmila,23yearsold,

motherofthree,alsohadaverysimilarnarrativeofherepisiotomyandrepair.Shegavebirthina

privatehospital.Sujata,experienced‘thecut’inhertwoinitialbirthsinthegovernmenthospital.

Shewasscared,anticipatingshewouldbecutinherthirdchildbirth,inaprivatehospitalthis

time.Shewaspreparingherselfmentally,butwasrelievedwhenthisdidnothappen.

“…that’swhyIcalleditagoodbirth!”(Sujata)

Pairosharedastoryofherdistantauntwhohadgonethroughpainfulepisiotomyandrepair,

whichtookverylongtoheal,leavingherinpainformonthsandunabletosit.Sheultimately

decidedtoneverhavechildrenagain.

Vaginalexaminationanduterineexploration-Women’saccountsofvaginalexaminationsare

harrowinganditisanexperienceeverywomanhasenduredmultipletimes.Theycalledit‘bauaa

walacheck’.Everyvaginalexaminationisunpleasantandmanyaretraumatic.Aparticipantwould

usuallyknowaboutvaginalexaminationwhenthecareprovidersays‘liftyoursaree’orwould

announce‘Iamgoingtocheck’.TheI-poeminBox6.1isanarrativeofPairo’sexperiencesof

multiplevaginalexaminationsbydifferentcareproviders.OneofSujata’sIpoemstitled‘Iamtoo

important!Ishouldnotbecheckedfrombelow’isanotheraccountofanequallydisturbing

experienceofvaginalexaminations.

“Shesaidliedown,holdyourlegswithbothhands,Iamcheckingyou!...liftyourclothes.”

(Pratima)

“Peoplecomeineachshiftandeveryonechecks.Therewasnodoctor.Everyhourshewas

checkingandsaying‘mouthisnotopen’.(expressionofdiscomfort)Don’tyouthinkitfeelsbad?...

Firstmymothertoldmethatlethercheckonce.Itoldher‘no’Iamalreadyhavingalotofproblem

withmybaby,Idon’twantthesethings.Butmymotherinsisted‘howwillsheknowifshedoesn’t

check.’(Sita)

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Womendidnotalwaysknowbeforeexperiencingvaginalexamination,thatitisaprocedure.This

isalackofcommunication.Theywonderedwhytheywerebeingtreatedlikethat.Theywerenot

toldwhatwasfoundintheexaminationandwhentherewasanexplanationitwasvague,suchas

‘there’stime!’or‘itwilltaketime’.

“Iwouldneverhaveselectedtheonewheretheyputtheirhandinsideme(ifIhadachoice)”

(Pratima)

Box6.1 Pairo’sI-poem-Thisisthefateofwomenandwomenmustendureit!

“Thisisthefateofwomenandwomenmustendureit!”

Ifeltveryuncomfortable!

Iwasscared!

Ikeptshouting.

Icomplainedtothedoctorlater,“Whyiseveryonecheckingmelikethis?”.

Itoldthedoctorwhyareyourpeoplecheckingmelikethis.

Icomplainedtothedoctor.

Ifounditoutallintheend.

Iwasfindingitverydifficulttoacceptthattheyshoulddolikethat.

Ifeltveryuncomfortable!

Ihavemyownroom,menarearound,thereisacrowdandthereareotherpatients,thentheyshouldnotcheckmeinfrontofeveryone.

Ididnotunderstandwhenthenursediditforthefirsttime.

Ithought,whatwasshedoingandinfrontofeveryone?

Iwaswearinganightie.

Ithoughtwhatisshedoing?

Itoldthistomymotheragainandagain,aftergoinghomethatwhatevershehasdoneinfrontofeveryone,itwasnotright.

Iusedtosayhertheyshouldnothavedonethat.

Ishouldhavebeentold.

Iusedtofeelveryuncomfortable!

Iwouldhavethoughtthatokaytheywilldothistomeandit’srequired.

Iwouldhaveconvincedmyself,tohavecourage.

Iwouldhavepreparedmyself.

Ithoughtwhataretheydoingwithme?

Iwasfeelinguncomfortable.

Iwasnotatallsupportingthattheytouchmelikethis.

Iwouldhaveneverselectedtheonewhentheyputtheirhandinsideme.

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Uterineexplorationwasalsoreportedbeingcarriedouttoremoveany‘kachra’(dirt)fromthe

uterusafterchildbirthorwasdonetotakethefoetusout.Thedifferencebetweenuterine

explorationfromvaginalexaminationwasunderstoodwhentheyspecificallymentionedthattwo

fingerswereinsertedassomeonealsosaid‘twophinter’buttheymentionedthatthe‘whole

hand’wasputinsideincaseofauterineexploration.Twoparticipantsreportedthisexperience

andnonewereinformedorconsentedbeforeitwasdonebyunqualifiedcareproviders.

“Sheworeagloveandputherwholehandinsideme.Mypainincreasedalotafterthis.”(Sujata)

6.5.2.1 Painmanagement

Painisthecommonaspectthateveryparticipantknewandfearedaboutchildbirth.Theytalked

oftheextentofpainandhowunbearableitwas.Theydescribedthatitwasthekindofpainthat

couldleadtodeath.Contractionswerereferredtoaspain.Womendidnottellthefamily

memberswhentheystartedgettingpain,theywaiteduntilitgotunbearable.Theyhadwaysto

describethedegreeandnatureofpain.Sujatasharedthatthepainbeforeone’swaterbreaksas

‘drypain’,evenafterthepainisnotintenseandisinfrequent,itiscalled‘sweetpain’.Topush,

wasalsoreferredtoas‘givingpain’.Theydiscussedthedurationofpainintermsofdaysand

sometimesjusthoursbutthenatureofbirthwasdependentonthekindofpaintheyhad.Agood

birthmaymeantheshortestdurationandlowestintensityofpaininaparticularbirthoutofall

thebirthingexperiencesawomanmayhavehad.

“WhenIaminpainobviouslyIwillgetveryangry.”(Amrita)

“IwaslaughingandgoingtothehospitalbecauseIhadnopain…IwashappybecauseatleastI

wasbirthingwithoutpain(cesareansection)”(Pairo)

“Iwasinsomuchpain,Ikeptonturningallnight.”(Pratima)

Women’smobilitywasdependentonthepain.Theposturetheytookduringcontractionsand

givingbirthoftendependedonwhatpositionmadeitalittleeasiertobearthepain.Participants

didnotmentionbirthinginapositionofchoiceandoftenbirthedinasupinepositionina

hospital,asshowninmostofthebirthmaps.Theysharedthatitissupposedtobethebest

positiontogivebirthbecausetheyhavebeentoldaboutthatorthatthebabymayfallifbirthed

inadifferentposition.Thiswasoftennotencouragedbythecareproviders,whodidnot‘allow’a

positionofchoiceanddisciplinedwomenwhentheyreactedtopainbycryingorscreaming.

“Iwasinsomuchpain.Iwassittingonthefloor.Iwaslyingdownbeforebutthepainwas

increasingsoIgotdownandmymother-in-lawwasholdingmyhandandIwascrying.”(Amrita)

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Painwasconsideredinevitableandwomendidnotaskaboutpainrelief.Thelanguageusedto

converseaboutpaininthehospitallacksclarity.Womenwouldoftenaskfortheinjectionfor

pain,orthecareproviderwouldsaytheyhavegivenmedicineorinjectionforpain.Thisoften

meantaugmentationandnotpainrelief.Womenwereoftenshockedwhenthecareproviders

increasedtheirpain,withoutinformationorconsent.Painwasrelatedtomanyother

interventionsthatthewomenhadnotconsentedto.Givinganepisiotomycutwithoutanesthesia

wascommonwiththenotionthatwomenwouldnotfeelitalongsidethepainfulcontractions.

Womenreportedfeelingeverything,includingwhentheywerebeingsuturedwithoutanesthesia.

Thecareproviderscontinuedsuturingthroughthepainregardlessofwomen’spleastostop.

Womencomplainedofpainwhenforcedvaginalexaminationswereconducted,fundalpressure

wasappliedanduterineexplorationwasconducted.Painwasalsooftentheonlyquestioncare

providersaskedwomenandwomenaskedcareproviders.

“Mypainincreasedwhenshegavemetheinjection.”(Sita)

“Afterthenursegavemethesecondpaininjectionmyconditionwaspathetic.Istartedcryingand

screamingloudly.Ihadtoomuchpain.”(Sujata)

“Itoldherdon’tputyourhandinsidebecauseit’shurtingbutstilltheycontinuedtodosoand

didn’tlistentome.”(Urmila)

Twoparticipantssharedtheyhadtoliedowntobearthepainandwalkwhenitwasless.One

participantwaskeentohaveherhusbandholdherhand,eventhoughhewouldnotunderstand

herpain,buthispresencewouldmakeiteasiertobearthepain.

6.5.3 Birthsetting/placerelatedrespect,disrespectandabuse

Theparticipantshave22birthingexperienceswhichincludedgovernmenthospital(10),private

hospital(8)andhomebirths(4),including20livebirthsand2stillbirths.Thegovernmenthospital

birthsincludefouratmedicalcollegehospitalsinthestatecapital,whichareatthetertiarylevel

ofcareprovisionandtheremainingfourareattheprimaryhealthcentres(PHCs),whichareat

theprimarylevelofcareprovision.Thewomenoftenchosebetweenthesethreeoptionsofbirth

placeintheirsubsequentbirthsexceptUrmila,whobirthedallherthreechildreninthesame

privatehospitalclosetohermaternalhouseandRia,whogavebirthonce.Women(Sujata,

Pratima,Sita,Anju)havechangedtheirbirthsettingsintermsofsectoraswell.Pratimagavebirth

ataprivatehospitalthefirsttimeandathomethesecondtime.Somewomen(Pairo,Amrita,

SujataandSita)changedtheplaceofbirthsometimeswithinthesector.Pairogavebirthtwicein

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twodifferentprivatehospitals.Figure6.8showsmoreaboutbirthsettingchangeswherethe

orderofarrowsshowtheorderofbirth.

Figure6.8 Birthplaceoptionsandchanges(Author’sown)

Theplaceswomenchosetogivebirthwasnotnecessarilytheirnearestaccesstohealthcare,as

seenwithPairo,Sujata,AmritaandSita.Thewomenchangedthesetting:1)togivebirthcloserto

thematernalhome,2)avoidhighfeesatprivatehospitals,3)avoidcesareansection,4)provision

ofahigherfacilityforbetterservicessuchasbloodtransfusionand5)alastminuteshiftto

hospitalafterdaicouldnotmanagethebirthathome.Themostunusualreasonwasbecausea

mobilecompanywentbankruptandtheparticipantcouldnotcontactherhusbandwhowould

havetakenhertothegovernmenthospital,whichledtohergivingbirthatthenearestprivate

hospital.Thisalsosuggeststhattheclosesthospitaltoherwasnotpublic.Manywomenchanged

thevenueofbirthtoavoidobstetricviolenceduringchildbirth.Theirnarrativesshowthatthey

arelookingforrespectfulcareandcontinuityofcare.

Womenpreferredtohavethesamebirthplaceunlesstheyexpectedbettercareorwerelooking

foraffordablecare.Urmilabirthedinthesamehospitaleverytime,atanaddedunaffordable

cost,butherpreferencewassupportedbyhermaternalfamily.Riahadonebabyinthetertiary

governmenthospitalandvowstonevertakeherdaughterthereforherbirthunlesssystems

improve.Hermothergavebirthtoherinthesamehospital.SitachosetogotoaparticularPHC

becauseitwasclosetohermaternalhouseasdidAmrita.Anjucalledthesamedagarintoher

homeallthreetimes,asdidPratima.However,Pratimahadtobetransferredtothenearby

privatehospitalinthelastminute.

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“Ingovernmenthospitaloneneedstocallthedoctorandnurseeverytime.Theywaitforyour

death.Youhavenorighttosayanything,youhavenotpaid.Inprivatehospital,Iaskformyright

sinceIhavepaid(money).Ihaveheardsomanycasesofexchangingbabiesingovernment

hospitals.Thosewhowantamalebaby,getmalebaby…thereisnoguaranteeyouwillleavethe

hospitalwithyourownbaby…inprivate,eventhoughyoupay20,000rupeesatleastyoucome

homealive.”(Urmila)

“Isawthedoctorcheckingallthewomenqueueingup,downthere(vaginalexamination)wearing

apolytheneglove.IwassoscaredtoseeitIranfromthere!”(Pairo)

“Thereisanadvantageofgovernmenthospitalthattheywillnotoperateonyouimmediately.

Theyletnormalbirthtakeitscourse,aslongaspossible.Privatehospitalslookforeveryexcuseto

cutyouopen,allformoney.Normalbirthisnotprofitabletothem.Ingovernment,Icangivebirth

inthemorningandleaveintheevening.Inprivatetheykeepyouadmittedforminimum2-3days.”

(Ria)

Sita’sstoryisuniquetooanditshowssomeamountofdecisionmakingbyher,inchoosingthe

birthsetting,whichisrare.Hermother-in-lawisadagarinwhoassistsalltheneighbourhood

births,butSitarefusedtoletherassistherbirthandwenttoahospitalallthreetimes.

“Thesedaysnoonegivesbirthathome.Igavebirthtoallmythreebabiesathospital.Hospitalis

betterforme.”(Sita)

“They(hospital)killedtwoofmybabiessoIdidnotgotherethethirdtime.EverytimeIhad

bleedingallthroughmypregnanciesandeverytimeIwenttothehospitalmybabiesdied.Every

timeIgavebirthathome,mybabiessurvived!”(Anju)

HomebirthsweretheprimarychoiceforPratimaandAnju.ThoughPratimacouldonlyhavea

homebirthforhersecondchildbirth,Anjuhadthreehomebirthsassistedbythesamedagarin,

followedbytwostillbirthsatagovernmenthospital.Pratima’shomebirthingexperiencehasbeen

narratedinherI-poeminBox6.2.

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Box6.2 Pratima’sI-poem-Bornathome

Bornathome

Ilikedthehomebirth!

Ihadmyfirstchild.

Ihaveonemoresister-in-law,shealsohasfourmembersinherfamily.

Ididnotreleasewater11.

IhadcompletedallmyworkintheeveningandmymotherwasinPujarituals.

Iwashavingpainsincethatthemorning.

Ihadameal,Ikepteatingandworking.

Ididallmyworklikecooking,cleaningupanddownworkfromterrace.

Idideverything.

Ididalltheworkevenintheevening.

Iwashedtheclothes.

Imoppedthecorridorandterrace.

Ipreparedthedinner.

Ihadpreparedthemeal.

Iservedthedinnertoeveryone,thenIwentupstairswithamobile.

Iwaswatchingamovie.

IwaswatchingtheBhojpuriMovie.

Idon’trememberthename.

Idon’tknowheroandheroine.

Iusedtohangupthephoneandroamaround.

Iusedtogoupanddownthestairs.

IgotdownfromtheterraceandIinformedmymother-in-lawthatIamhavingpain.

Ihadthesametypeofpain.

Iwaslyingonit.

Ilaydownthisway.

Iwasholdingthemtightly.

Iwasholdingmythightoo.

Iworeasareebuttheyremovedit,petticoatwasthere.

Iwasonajuterag.

Iamshameless!

Ihadpainforanhour.

Iwasaloneinthatroom,thenIcalledmysister-in-lawtoholdmeatthetimeofbirth.

Itookabathintheevening,sothehairremainedopenandsoitremainedopenallnight.

Ifeeltwokidsareenough.

Isay,‘see,asonisbornbygod’sgrace!’

IgotmybirthdoneathomeandIwouldnotliketochangeanything.

11 Amniotic fluid

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NoneoftheparticipantsmentionedanyaidtheyreceivedoraresupposedtoreceivefromJanani

SurakshnaYojana,oranyothergovernmentincentivepolicies,asareasonforgivingbirthatthe

governmenthospital.Itwasoftenseenthatwomenwouldgetantenatalcarefromprivateor

missionhospitalsandwouldonlygotothegovernmenthospitaltogivebirth,asseeninRiaand

Anju’sstory.

“Ireceived(JSYmoney)formyfirstbirthbutnotforthesecond.ASHAblamedmesaying‘howdoI

know?Youprobablyreceivedthemoneyanddidnottellme’.Ihavearight!...ifgovernmentdoes

notgiveanythingtoyouhowcanyoutrustthem?…Iwillnotgetit,sowhythinkaboutit

unnecessarily!Whygetworried!”(Amrita)

Sita’snarrativeisverysimilartoAmrita’sinthisregard,asshowninherI-poeminBox6.3.There

wereothercomparisonstoowhichweremadebetweengovernmentandprivatethatincluded

participant’slackoftrustintermsofcleanliness.

Box6.3 Sita’sIpoemonJananiSurakshaYojana(JSY)

“JananiSurakshaYojanamoneyisforthemotherandthebaby,Iheard”

Ireceived[themoney].

Ihadmythirdchildalsobutdidnotreceive[themoney].

Iupdatedthepassbookbutitwasnotshowinginthat.

ItoldASHAtotakemyaccountdetailsandcheckitiftheydon’ttrustme,buttheydidnotdoso.

Ididnotknow,butwhenIwenttomymother’shousethenmymothertoldme.

Ididn’tgetit.

Ihavenotchecked.

Idon’tknowwhetherIreceiveditornot.

Idon’trememberexactly,butitwasapproximatelyRs3400/-.

Iusedtotalktomymothereveryday.

Ididnotchecktilldate.

Iheardthatthemoneyisgiventoutiliseforthemotherandthebaby.

6.5.4 Respect,disrespectandabuserelatedtobirthingenvironment

Thebirthingenvironmentincludestheinfrastructureinthatarea,thepeoplegivingcareandthe

toiletaswell.Womennotonlydescribedthebirthingenvironmentintheirbirthmapsbutalsothe

onesthatarenotonit.Thenumberofpeoplearoundbirthwasrelatedtowhethertheygave

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birthinagovernmenthospital,privatehospitalorhome.Evenwhengivingbirthatagovernment

hospital,birthingatatertiarylevelofcaremeantbirthinginacrowdedhallwithmanyother

women,ascanbeseeninRia’sbirthmap(Figure6.9).

“Birthwashappeningallaroundme!Therewere6beds.Itwasfull!Everyonewasscreaming,

whichwasmakingmemoreanxiousandscared.Everyone’sbirthwashappening!Someonewas

receivingwater(IV).Doctorwasscoldinganotherfornotpushing,‘Push!Push!’.”(Ria)

Theinfrastructureofthebirthingroomoftenmadeitmorechaoticwheremultiple‘labourtables’

werekeptnexttoeachother,asnoticedinthestoriesofRiaandSujata;bothbirthstookplaceat

governmenttertiaryhospitals.Theprivatehospitalsonlyhadtheparticipant(Urmila,Pratima)in

thebirthingroom.Thehomebirthswerealsoconductedprivately,eitherjustwiththedagarin

(Anju)orassistedbythewomeninthefamily(Pratima)alongwiththedagarin.A‘Labourtable’

wascommoningovernmenthospitalbirthingstoriesandinprivatehospital.Therewerewomen

whoalsobirthedonawiderbed.Womenathomegavebirthonthefloor.

“Windowswerecoveredwiththicknetandglasses.Thelabourroomhadairconditionerandfan

butbothwereswitchedoff.Thelabourtablewasquitehigh.Therewasabluecolourmattresson

thebedandstepsnexttoit.Therewasathickrodattheheadendtoholdandbeardown.”

(Urmila)

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Figure6.9 Ria’sBodyMap

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Privacyisakeyaspectofthebirthingenvironmentandismentionedinallthewomen’s

narratives.Womenwanttheirprivacytobeprotected,theyalsodemonstratedaforced

acceptanceofthislackofprivacy.Theirprivacyneededtobeprotectedatsixlevelsasseeninthe

narratives,showninFigure6.10.

Level1-iscoveringtheirbodyduringinterventions,notexposingitunnecessarilyandexposing

onlyasmuchasneededwithconsent;

Level2-protectingprivacyfromthebirthcompanionandtheimmediatehealthcareproviders

whoareassistingthebirth;

Level3-protectingprivacybetweenotherbirthingwomenandtheirfamilymembers,ifmultiple

womenarebirthinginthesameroom,byensuringcurtains/screensbetweenthem;

Level4-ensuringthatoutsidersarenotabletopeepinfromanyopenwindowsbyputting

curtainsinthewindowsoraroundthewomen;

Level5-protectingprivacyfromalltheothercareandnonhealthcareproviderssuchascleaners,

whomaybeinthebirthingroom,atthenurse’sstationorweighingstation;

Level6-fromthefamilymembers,outsiders,othersinthewaitingareaoutsidethedoorwhich

usuallyopenstoahallway.

Figure6.10 Levelsofprivacytobeprotectedforthewomeninbirthingroom(Author’sown)

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Curtainswerementionedwheremultiplewomenwerebirthinginthesameroombuttheywere

toprotecttheprivacyofallthefourtosixwomenbirthingtogetherfromoutsiders.Therewere

nocurtainsbetweenthelabourtablestoprotecttheprivacyofbirthingwomenfromeachother

andtheirbirthcompanions.

“Iwasabletoseewithmyowneyeswhentheladyinthecornerwasgivingbirth.Therewereno

curtains.Therewasonlyahall.Whenyougoinsideyouwillfindeveryonenakedthere.Evenif

attendantswouldcomethentheywillalsosee…Dhat!(Ohgod!)It’ssoembarrassing!Ifeltvery

bad!Youdon’twantanyonetolookatyouinthatstate.”(Ria)

“Myprivacywasmaintained…mybodywasnotexposedmuch.Doctoronlyexposedmylowerleg

toknee.Restofitwascoveredwiththenightie.Theladydoctorwasgood.”(Urmila)

Theissueofprivacyworsenedifmenareallowedaroundbirthingwomen.Thatisconsidered

shameful,ahugeinvasionofprivacyandsomeevenconsiderthisprivacytohavebeenprotected

ifnomenwereallowedinthelabourroom,regardlessofhowmanywomenareinthevicinity.

Thebirthingareaforthecesareansectionisverydifferentfromthelabourroom,asseenin

Pairo’sstory.Thisalsoincludedalotofmenaroundbirthinanoperationtheatreasshownin

Pairo’sbodymapinFigure6.11.

“Theywerenottakingmypermissionforanything…Ifeltsomeoneremovedmypetticoat.Ifeltit.”

(Pairo)

“Notasinglemanwasthere.Menarenotallowed.Ladiesstaytherewithladies!Mendonotgo

therebecausewomenarenaked…Assoonastheyseemen,theystartchasingthemaway.‘Go…

Go…whatareyoudoinghere?’Theydonotletanyonein.”(Sujata)

“Theywereallmen.Therewerenowomen(intheOT).Gentswhodoultrasoundwerealsothere.

Therewerearound8-9men.Thedoctorwasalsomale.Ifeelallthosemenshouldhaveworn

uniform…Theywerethereasiftheyaretourists.”(Pairo)

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Figure6.11 Pairo’sBodyMap

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Cleanlinessofthebirthingenvironment,includingthelabourtable,thetoiletsandtheoverall

cleanlinessofthehospital,isofutmostimportance.Thewomenwhogavebirthathomehadno

complainsaboutcleanliness.Mostoftheissueswerereportedamongthosewhohadabirthin

governmenthospitals,excludingoneofSita’sbirthataPHCwhichshereportedtobeveryclean.

Itiscertainthatthisisakeyaspectintermsofrespectfulnessforwomen.

“Mygoodness!Thetoiletwasdirty.Itwasverymuchdirty!Toomuchdirty!Dirtwaseverywhere.

Therewasevenmoredirtbecauseofnowater.Thewaterwasnotdrinkableandtheywereasking

ustodrinkfromthetoilettap.Ithadsuchastench!Dirtypiecesofclothdrenchedinbloodand

fluidseverywhere.”(Sujata)

“Theentirehospital…therewasbloodanddirtyliquideverywhere.Supposeyouhavesomeillness

andIusedyourdirtytoilet,willInotcatchitthen?Bloodyfloorseverywhere!Ididnoturinate

there.That’swhyIdidn’tgothere.Iwenttothejunglebehindthebushes.Thereweresome

abandonedbrokenhousesnearbyandjungle,butitwascleanerthanthehospital.Iwentthereto

urinate.Imightbedarkskinned,butIamverydisgustedbydirtI”(Amrita)

6.5.5 Respectful,disrespectfulandabusivecommunicationaroundchildbirth

Womenbarelyspokeinthebirthingroomanditbeginsfromtheminutetheysteppedintothe

hospitalcompound.Theyusuallycomeincontactwithhealthcareproviderssuchasdoctors,

nurse-midwives’andnonhealthcareprovidersincludingtheMamta,cleaner,daiandASHA.They

rarelyaskanyquestionsorobjecttoanythingthatisdonetothemduringandaroundchildbirth.

Asurrogatedecision-makerfromthewoman’sfamily,whomshemaynothavechosenatthefirst

place,takesontheroleofcommunicatingonthewoman’sbehalfwhowasoftenreferredtoby

thewomenas‘guardian’.Allthesewomenareabovetheageof18atthetimeofgivingbirth,

exceptone.

“Ihavenotaskedanythingtoanyone.Mymother-in-lawaskedeveryonewhateverIhadtoask…I

didnotfeelliketalkingtoanyone.”(Amrita)

“Iwasallalonethere…Icouldnotsayanything.IwasfeelingbadbutIcouldnotsayanything

becausewewereinthehospital.WhoamIsupposedtotell?...ifIsaysomethingtothemtheywill

say‘youarenottheonlyonehavingababyhere.Thereareotherstooandtheydon’thaveany

problem.Youdon’thavesomethingspecialdownthere.”(Ria)

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“WhywouldIaskthem?Whatisthepointofaskingthemthingsunnecessarilywhentheeldersare

there?They(parents)needtoknowanddecidethings.”(Urmila)

Thelackofcommunicationfromthecareprovider’ssidebeginswhenthewomanisadmitted

undertheircare.Thelackofawelcomeisthefirstinstanceofdisrespecteverywoman

experiences.

“Welcome?!(laughs)…Whotalkswithyouanyway!...loudlyshesaid‘liedown’,Itoosaid,‘where

toliedown?’.‘Findanemptybedandliedown’shesaid.Iwentandlaydown”(Ria)

Thereisnointroductionoranyefforttoknoweachother’snamesbecauseknowingnamesisnot

consideredimportantwherecareprovider’sfirstwordsorinstructionstothewomanistolie

downandpartherlegs.Thatis,ifsheisspokentodirectlybythecareproviders,theusual

scenariowouldbeanurse,doctor,daiorMamtapartingthewoman’slegsforcefullywithout

sayingawordtoher.

“Theydon’tcareaboutthenameofpatient.Theywerenotcallingbyname.Theywerecallingby

whatishappening,ortoknowhowmuchpainoneisin.Therewasnoneedtocallaswewereall

justlyingdown.Therewasnohelloorthankyou!...whatwillIcall?Ishouted-‘listen’,‘Iamin

pain’,‘pleasesomeonecomehere’.”(Sujata)

Therewasalackofcommunicationaboutexaminationsandinterventions.Careprovidersdidnot

tellthewomenaboutthecaretheywerereceiving.Theywouldcomeandstartintravenousfluids

andgiveinjectionswithouttellingthemwhatitisfor.Itisnotjustaboutwhatisbeing

communicatedandhowitisbeingcommunicated;butalsowhoiscommunicating,asseenwith

Sita,whichwassomethingthatshouldsurelyhavebeenconveyedbyamedicalpersonnelandnot

aMamta.

“Theykeptmeinthehospitalforthreedaysandsaid‘wecansaveonlyone,eitherthemotheror

thebaby’Mamtasaid.”(Sita)

“Theycheckedwiththatmachineonmyabdomenandsaidthebabywillnotsurvive!”(Anju)

Thecommunicationaroundvaginalexaminationisespeciallysensitiveanditisanintervention

which,asSujataexplains,‘theworstaspectofgivingbirthinahospital!’.Clearly,itrequiresan

explanationandseekingconsentbeforestartingthevaginalexamination.Thedoctorsandnurses

wouldatbestsaytheyarecheckingifthe‘mouth’isopenornot.Participant’swerehorrifiedat

thelackofsensitivityandcommunicationaroundthisinterventionandwereleftfeelingashamed

andhumiliated.Thislackofcommunicationalsosubjectedthewomentoafearofnotknowing

whatisnextandleftthemexpectingtheworst.

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“Shestarteddrawingtheinjectionandsettingupwater…Iwasreallyscaredtoseethis…she

askedformyhand.Isaid‘whatareyoudoing?’…howcouldIaskherwhatshewasdoing?We

don’task.Wedon’thavethehabitofasking…IgotscaredthatprobablyIshouldnothaveasked

anything,shouldnothaveinterfered.”(Sujata)

“Shesaid‘liedown,Iwillseeifthemouthisopen’.Sheinsertedherfingers.Shedidnotsay

anything.Iwasscaredandstartedscreamingveryloudly.Thedoctorsaid,‘shehasnopain

threshold,shecannothaveanormalbirth.’”(Pairo)

“Sheinsertedherfingersinsidemewithouttellingme.Theydidn’taskmeorinformme.”(Urmila)

Thelackofcommunicationwasn’tjustlimitedtoexaminationsandinterventions,thatmost

womenwentthrough.ThemostharrowingaccountcamefromPairowhowasdraggedtothe

operationtheatrebyanurseandontheoperatingtableshefiguredoutsheisgoingtobe

operatedaftershewasgivenaninjectionwhichmadeherlegsgonumbwhileshewasalso

blindfolded.HernarrationhasbeencapturedinherI-poemtitled‘Doll’inBox6.4.

Womenfeltlikeanobject,apassiveparticipantintheprocessandisolatedevenwhentheywere

surroundedbypeoplewhoweretheretotakecareofthem.Theyoftenfoundthatpeoplewere

talkingoverthemandnottothem.

“Ineverhadanyconversationwiththecareproviders.Theyweretalkingaboutme,aroundme,

butnottome…Afterdoingmycheckup,theyweretellingmyparents,notme,andIwasalsonot

talkingtothem.”(Urmila)

Someacceptedthislackofcommunicationanddisplayedanunquestioningbehaviornotbecause

thatistheirnature,asseeninsomeoftheearlierquotes.Itwasoftenledbythefearofinviting

obstetricviolenceandthefearofconsequences.Theyarriveatthehealthcarefacilityhaving

discountedonalltheirrightsandgivenuponalltheirchoiceswithanacceptancethatthereis

nothingtheycandoorsay,theyareexpectedtofollowinstructionstoleavethebirthingroom

withtheleastharmdone,evenwithsomeawarenessoftheirrightsinthebirthingroom.

“IfeelangrybutIamadmittedunderyourcare,soIwillhavetodowhatyousay.IfIdonotdoas

peryourorder,thenyouwillagaindosomethingtoharmme.Mymotherwasaskingmenotto

talkback,orargue,becausethesepeoplemightdosomethingulta-pulta(inappropriatetoharm

you)!”(Ria)

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Box6.4 Pairo’sI-poem-Doll

Doll

Ihadnoguardiansaccompanyingme.

Iwasscreaming,Mummy!Mummy!

Iwastakeninside.

Ifeltliketheygavemeaninjection.

Ifeltmylegsweregettingcoldandnumb.

Icouldnotseewhogaveittome.

Ithinkaspecialisthadcomeforthat.

Iguesshewasananaesthesiadoctor.

Iguesshehasonlygivenmethatinjection.

Itrustthematleastthatmuch,thatanyrandompersonwon’tstickinjectionsinme.

Iwaswearingthesamenightie.

Ihadnotchanged,itwasdirty.

Iwouldhavefeltfreshiftheyhadallowedmetotakeabath.

TheymademeliedownonOTtable.

Iwassitting.

Iwasputtosleep.

Iwasblindfoldedwithcottonballsonmyeyeandthentherewasacloththeytiedontopofthat.

SoIwouldn’tseeanything.

Ifelt,thereweresomanymen.

Iwouldhavefeltuncomfortablebecausethereweremen.

Iaskedhim‘whereismadam(ladydoctor)?’

Iwasblindfolded.

Iheardavoicethatmadamhadarrived.

Ifelttheyremovedmyclothes,mylegshadnosensation.

Theydidnotconsidermeasahuman.

Theyweretreatingmelikeadoll!

Doingwhatevertheywanttodowithme.

Theywerenotaskingformypermission.

Ifeltsomeoneraisedmynightie.

Ifeltthisbecauseofthelossofsensationbelowmywaist.

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Ifeltlikethis.

Iwaslyingdown.

Iwaslyingonthisadjustablething,theycouldturnitaroundastheywanted,totheir

convenience.

Theycouldjustoperatemelikethat.

Iremember,clotheswereremoved.

Ifeltso!

IfeltmylegsgettingcoldsoIthoughtmypetticoatwasremovedbysomeone.

Theydidnothaveanythingtodowithme.

Alotofmachinesandwireswereconnectedtome,onetomyheartandoneonmyfinger.

Myeyeswerekeptshut.

Idon’tknow.

Icouldnottellwhatwashappeningaroundme,orwhatwasgoingtohappennext.

Iwasconsciousbutnobodywastalkingtome.

Ijustlaythere.

Iwasnotsleeping.

Ikeptmyeyesclosed.

Iwashearingeveryone’svoices.

Icouldfeelthatsomeoneiscuttingmybelly.

Iwashearingthesoundofmachinesandinstruments.

Idid.

Iheardmybellybeingcut.

Icouldhearsomebodycuttingme,likecuttingajuterag.

Theycutme,tookmydaughterout,stitchedmeandsentmebacktomyroomimmediately.

IrememberprayingtoGod,sothateverythinggoeswell.

Idon’tknowwhostitchedmeorcutme.

Ididnotknowanything,nordidIfeelanything.

Myeyeswereclosed.

Ihaveadaughter.

Istartedimagining.

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Iwillmaketwoponytailsandtakehertoschoolwithme.

Iwashappy.

Ihaveagirl.

IwasfeelinglikeIamadoll.

Ididn’tknowwhatwillbedonetomenext.

Mymothersaid,‘Theyweretreatingyoulikeananimal’.

Idofeelonething,thebadexperienceswerewithmybody.

Ilovemydaughteralotmorethanmyson.

Thosethingsdon’tmattertomeanymore.

Whathappened,happenedtomybody,myspiritisuntouched.

Mybabycameintothisworldthroughthatexperience.

Iamhappyaboutthat.

Ifeelthatthebadexperienceswerewithmybody.

IfeeltheythoughtofmelikeIamacoworabuffalooradoll.

Therewereacoupleofinstanceswherethewomensaidthatthenurseorthedoctorwastalking

tohernicely.Thiswasoftenararepersonamongstallthepeopletheparticipantswouldhave

comeincontactwith,whichmadethemsuspiciousovertheunusualnicety.Aparticipantalso

sharedhowthecareproviderdidnotproceedwiththevaginalexaminationaftersherequested

hernotto.

“ThenursewasthefirstpersonImetthatmorning.Shewascallingmedearone,dearone!She

wastalkingtomeproperly.”(Sujata)

“Mymaternaluncle,anMBBSdoctor,gavemearecommendationletter.She(therecommended

doctor)usedtogivemetimeandtalktomenicely.Iusedtowonderifshetalksnicelyonlywith

meorwitheveryone.”(Pairo)

“Theladydoctorandonesisterweregoodwhowerecaringforme.Thereweretwosisterswho

werealwaysfrowning,shoutingandscreamingatme.Sheabusedmesomanytimes.”(Urmila)

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6.5.6 Respectful,disrespectfulandabusivepeoplearoundchildbirth

Fourtypesofpeoplehaveplayedarolearoundchildbirthinthehospitalsandhomes:1)qualified

healthcareprovidersinthehospital(nurse-midwife,doctor);2)women’scompanionsfrom

family/neighbourhood(husband,mother,mother-in-lawandothers);3)unqualifiedcare

providers(cleaners,Mamtas,dais)and4)mobilisers(ASHA).

Thequalifiedhealthcareprovidersincludednurse-midwives(mostlyreferredtoasnurseorsister

bywomen)anddoctors.Allthewomenwereexaminedandcaredforbydoctorsandnursesat

somepointduringtheirchildbirth(s)exceptinhomebirths.Theirinteractionswiththedoctorsand

nurseswererespectful,disrespectfulandabusivewhichalsoshapedtheirperceptionsfortheir

prospectivechildbirthandtheirexpectationfromcareingeneral.

Doctor’sroleduringchildbirth

Thedoctor’sroleduringchildbirthislimitedtovaginalexaminationsingovernmenthospitals,

aftertheinitialexamination.Intheprivatehospital,theyarealsoseenconductingcesarean

sectionandalsoperformingepisiotomyrepair.Participantshaduniqueinteractionswiththeir

doctors.Amritacameincontactwithtwodoctorsoverthecourseoftwochildbirths.She

experiencedobstetricviolenceintheformofdisrespectfulcommunicationfrombothofthem.

Thefirstdoctorinherfirstchildbirthrefusedtoassistherbirthbecauseshewasanaemicandthe

doctordidnotwanttotakearisk.Theseconddoctorshoutedatallherfamilymembersbecause

shevisitedthehealthcentreinlabourveryearlyinthemorningandthedoctorwantedtosleep

in.Afterrepeatedrequeststhedoctorarrivedinthelastminutetocatchthebaby.Pairocamein

contactwithfivedoctorsincludingonepaediatrician.Thefifthdoctorshemet,whowastheonly

doctorinhersecondcesareansection,wasrespectfultoher.Threeofthefourdoctorsshecame

incontactwithinherfirstchildbirthweredisrespectfulandabusive.Shewasn’tsureifthethird

doctor(seconddoctor’sson)wasadoctor,heronlycontactwithhimwasintheoperation

theatre,whilebeingblindfolded.Sheassumedhewasadoctorbecausehewasthereandhe

calledPairo’sdoctor,hismother.Shedidnothaveanyinteractionswiththefirstdoctorshesaw

inthegovernmenthospital.Shesawhimperformingvaginalexaminationwearingthesame

‘polythenegloves’,forwomenwhoqueuedoutsidehisclinic,soshelefttheplacedisgusted.

“TheyheldmedownbecauseIwasinpain…Iliftedmywaistandshe(doctor)pusheditdown

sayingthebabywillgetinjured.Then,Ineverlifteditup.”(Amrita)

“Theformerdoctor’sbehaviorwasnotgoodwithme.Ididnotlikeherbecauseshedidnottalkto

menicely.Sheusedtothinkveryhighlyofherselfasifsheisageniusandaknow-it-all!Sheused

tojustprescribewithoutexplainingwhatthemedicinesarefor.ShewasoverconfidentandIdon’t

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knowwhatshethoughtofherself?ShethoughtverylittleofmeorthatIamworthnothing

comparedtoher.Didn’teventalktomemuch.Iusedtothinkthatitsmewhowillhavethisbaby,

atleasttalktome,saysomething!”(Pairo)

BothPratimaandUrmilacameincontactwithjustonedoctorwhilegivingbirthinaprivate

hospital.Urmilafoundherdoctortobeabusive.Pratimafoundherdoctortoberespectful.Urmila

wascaredforbytwodoctorsandshewenttothesamehospitalforallherbirths.Urmila’s

experiencewithherdoctorissharedthroughherI-poem‘Theladydoctorwasreallynice’,inBox

6.5.Whilethedoctorwasdisrespectfulandabusive,shetookcomfortinthefactthatitwasa

femaledoctor.

“Thenthepoorlady(doctor)searchedformyveinandgavemeaninjection.Shewasinnocentand

nicelady.Thewayshetookcareofme,Ifeltlikeherowndaughter.Ifeltgood.Iwasfeelinggood

becausethosepeopleweregoodpeople.Wewerehappy!”(Pratima)

“Onlyfemaledoctorcheckedmethroughoutmydelivery…IwasfeelingsomanythingswhichI

couldnotsharewithanyoneelse.Idon’tknowwhy.Iwassoangrywiththedoctorbecauseshe

calledmesomanytimesforvaginalcheck-ups…Ididnotlikeit.Thedoctorinthedeliveryroom

wasgood.Sheencouragedmewithherwords,‘Don’tworry,everythingwillbealright!’shesaid.”

(Urmila)

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Box6.5 Urmila’sI-poem-Theladydoctorwasreallynice!

Theladydoctorwasreallynice!

Itoldhernottodoit,butsheforcedherhandinsideme.

Itoldherdon’tputyourhandin,itwashurting,butshecontinuedtodoso,didn’tlistentome.

Iwassoangrywiththedoctor,shecalledmesomanytimesforvaginalcheck-ups,everytime

shetoldmethepassagedidnotopen.

Ididn’tlikeit.

Iwasshoutingandcryingduetopainbutstilldoctorkeptonsuturing.

Iaskedthemfor‘behoshikidawa’(anesthesia),buttheywerenotlisteningtomeandkeptdoing

it.

Ithoughtmyproblemswereoveraftergivingbirth,buttherealchallengewaspostbirth.

Iwasscreaming,thedoctorandsisterswereholdingmedownfromallsidesandkeptstitching

me.

Ifeltallofit.

Ikeptscreamingandaskingforanesthesia.

Ifeltallofit!

Ididn’thavesuchpaininmyfirstdeliverywhilestitching.

Ilikedthebehaviourofmydoctorandoneofthenurses.

Ididn’tlikethosetwofrowningsisterswhoshoutedatme.

RiaandSujatahadalmostnointeractionwithanydoctorafteradmission,wheretheyhadonly

seenonedoctorlookingatlaboringwomenfromadistance.Bothofthembirthedingovernment

tertiarylevelhospitalsatthestatecapital,inabigroomwithfourtofivewomenbirthing

together.DoctorsappearedinSujata’sstorywhenshetalkedaboutbribes.Thedoctorwasseen

walkingaroundinbothcases,oftenjustatthefoot-endofthelabourtablewhilethewomen

birthedandnevercommunicatingwiththewomeninlabour.

“Therewasadoctor.Shegaveadvicetoeveryoneandwentaway.”(Ria)

“Myhusbandgaverupees1001tothedoctorand500tonurses.”(Sujata)

“Ifshe(doctor)hastoaskanything,thenshecanaskfromthere(foot-end)that‘areyouhaving

painornot?’or‘whatistheproblem?’…theydon’tcomeclose,theydon’tfeeltheneedforthat.

Thereisonlysomuchspacebetweenthelabourtablessothereisnoneedforthataswell.”

(Sujata)

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Thelackofcommunicationwasacommonthemewithalltheparticipants.Thedoctorsdidnot

explaintheiractionsorproceduresanddidnotseekconsentfromthewomenforanything.When

theydidcommunicate,itwaswiththefamilymembers,ofteninthecareseekingwoman’s

absenceorintheformofinstructionstothenurseoraideforsomethingtheconsciousparticipant

iscapableofdoing.ThesamescenarioplayedoutinacompletelydifferentwayinPratima’scase

whereshefoundthedoctorwastalkingtohernicely.InPairo’scase,shewasnottoldthatshe

wouldundergoacesareansection,herparentsalsodidnotinformher,shefoundoutafterspinal

anesthesiawasgivenintheoperationtheatre.

“She(doctor)askedtothenursetobendmyleg.”(Pairo)

“Shesaid‘liedownandholdyourlegswithbothhandsandIamcheckingyou’.Sheaskedmeto

liftup(mysaree)andIdidthesame.Thenshecheckedme.Noonewasthere.Justmeandher

(doctor).”(Pratima)

“Thedoctorhadalreadyspokenwithmymotheraboutthis(cesareansection).Theydidnottell

meanything.Theyjustkepttalkingamongstthemselves,noinformationhadcometome.”(Pairo)

TwopediatricianswerementionedinPairoandSujata’snarrative.Inprivatehospitalsthey

seemedtohavemoreresponsibilities,whichincludedgivingmedicineandinjectionsandstarting

theintravenousline,alongwiththeirinitialroleinsendingthewomenforadmissionandsigning

fordischarge.

Nurse’sroleduringchildbirth

Womencouldconfidentlyidentifythedoctors,bytitleorbysensingthepowerdynamics.Any

womancaringforthemwasconsideredanurseandeventhoughtheyconfidentlysharedan

interactionaboutthenursetheyweren’tsure.Therewasnointroductionabouteachother’srole

betweencareproviderandcareseekerduringtheirstayatthehospital.

“Yestheywerenursesonly.Shewasgivinginjectionandhelpinginthebirth.”(Pratima)

“Shegavehertwotightslapsonherface.Iguessshewasasister(nurse).Yes,theyweresisters

only.”(Ria)

“Nursemeansdai!”(Sujata)

“Iwasinthewaitingareawhennursesapproachedme…theladieswhodoallthecleaningwork

aroundbirth…theytookmeinsidethelabourroom.”(Urmila)

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Nursesareusuallyreferredtoas‘sister’.Nursesatthetertiarygovernmenthealthfacilitieswere

seengivinginjections,runningIVfluids,augmentingandperformingepisiotomyrepairs.Atthe

secondaryorprimarylevelofcareprovisiontheywerementionedwithsimilarrolesbutnotfor

episiotomyrepair.

“…nursesdon’tgetinvolvedincleaningworkusually.”(Amrita)

Intheprivatehospitalitwasnotclearwhetherthepeople,participantswerereferringtoasa

nurseorsister,wereactuallylicensednurses.Theywereoftenonlyseeninthebirthingarea.In

bigprivatehospitals,theywereseendoingmultiplevaginalexaminations.Onenursewas

mentionedasperforminganabdominalpalpation.Butmostwereseenfollowingdoctor’s

instructionstoparttheparticipant’slegsortorestrainherforvaginalexaminationorduring

episiotomyrepair.Itseemslikebeinganaideinobstetricviolencebyphysician’sorder.

“Therewasjustoneoldnurse.Sheshiftedmetothatroomforbirth.Shecheckedmefromupon

theabdomen,notbelow.Thentookmeinsidetheroomandgavemeaninjection.”(Sita)

Mostparticipantscameincontactwithnursesandoftenmorethanone.Theysharedhownurses

workedinshiftsintertiaryhospitals,oraboutanurseataPHCwhomtheyhadknownforyears,

whohadpassedaway.Thischangeinrelationshiporinknowingthecareprovider,wasseen

betweenurbanandruralareas.Itdidnotnecessarilyhaveanyeffectontherespectfulnessofcare

thesewomenreceived.Therewerecontrastingopinionsonwhetherthenurseswereinvolvedin

extortion.Sujatafelttheywere,thoughothersfelttheywerenot.Inprivatehospitals,theywere

seenaskingforhappinessmoney.

Communicationwithnurseswaslimited,although,oneconversationwithPairo’smotherstands

out.Theabsenceofanydisrespectfullanguageandactionsoftencountedasbeingrespectfuland

insomecasesitinvolvedspecificactionsthatconveyedrespect.

“Anurse…toldmymotherthattheclothesofpatientareremovedatthetimeofoperationinthe

OT.Butshedidnotlikethatatall…thereareladiesandgentseveryone.Shesaidshetriestokeep

thepatientsascoveredaspossibleinthatsituation.”(Pairo)

“Outofthosethreenursesonewasverygoodbecausesheusedtoholdmyhandinbetween

labourpains.”(Urmila)

“Shewastalkingnicely.Shewassayingnottopanicandthateverythingwillgowell.”(Sita)

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Dai’sroleduringchildbirth

Daiwasoftenconfusedwithanurse,MamtaandASHA.Daiwasmentionedbywomenwhogave

birthatalllevelsofgovernmenthealthcaredeliverysystemandathome.Withthewomen

interviewedintheruralarea,Sita,AmritaandAnjumentionedthepresenceofadaiaroundtheir

birth.Intheurbanareainterview,Ria,SujataandPratimawereaidedbydaisintheirchildbirthas

well.SitaandAmrita’snarrativeshedslightontheirroleintheprimarycarehospitalwherethey

cleanthebirthingarea,callthedoctorswhenneededandrestrainwomenwhenrequired.Dai

oftenaccompaniedwomenfromtheirhomestothehospital,iftheyarefromthesame

neighbourhoodorvillage.

SujataandRiahadsimilarnarrativesofdai’spresenceinthelabourroomandtheirroleduring

childbirth,eventhoughtheygavebirthindifferenttertiarylevelhospitalsinthestatecapitalof

Bihar.Theycameincontactwithmanydais.Twotothreedaiswereseenassistingtheirbirthsand

thatofthewomenbirthingonthefourtofivelabourtablesnexttothem.Daisreportedlyworked

indifferentshiftsandwereattheforefrontofaskingformoneyateverylevelofpublichospital.

Peoplepaidalottodaisatthetertiarylevel,especiallybecausethereweresomanyofthem.

“Thedaiaskedfor5000rupees,1000rupeeseach…‘areyougivingmealms?AmIabeggar?You

keepit,youaretreatingmelikeabeggar…’Therewerethreedaisinoneshift.Theyusedtocome

forcleaningandmopping.Thedaiswhosweepthefloorarenotthesamedais.”(Ria)

Sita’s50-year-oldmother-in-lawhasbeenadagarin(dai)forover20years,assistingbirthsinher

villageandnearbyvillages,yetSitainsistedongivingbirthatthehospital.Sita’smother-in-law

goestowomen’shousesandputsherhandinsidetoknowhowmuch‘themouth’isopen‘one

phinter,twophinter’.Shegivestheinjectionssothefoetuscancomeoutquickly.Shealsostocks

IVfluidsathome.Herworkisinlessdemandbecausethehospitalsarefunctioningbetter.Sita

sharedthatdagarin/daisfromthevillageareelectedtoworkinthehospitalsometimesbuther

mother-in-lawwasnotselected.

Atthehospital,thedaiswereseendoingeverythingfromgivinginjections,vaginalexaminations,

episiotomy,assistingbirths,weighingbabies,conductinguterineexplorationandcleaningthe

labourtablethereafter.Thedoctorornurse’sroleinthelabourroomwasthebareminimum.

Theywerealsomentionedinrelationtomuchoftheabuse.

“Theyweresaying‘youarescreamingunnecessarilywhilejustproducingonechild.Howmuchwill

youscreamwhenyouproducemore!Wehaveallbirthed15childreneachandneverbehavedlike

you.’Daisweresaying.Onewasstandingnearmyfeet.Shewasanoldlady,keptsayingrubbish

anddisgustingthings.”(Ria)

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“Mydeliverywasdonebydais.Daigavemeaninjectiontoo…sheworeagloveandcheckedme

byputtingherhandinside…threedaiswerethere…saying‘push,push’…theywereconductingthe

delivery…Iwasnotabletofigureoutwhowasdoingwhat.Whenthebaby’sheadwasout,all

threewerebusyremovingthebaby…oncethebabywasouttheycleanedeverything.Theytorea

clothandwipedthebabyandcutthecordlater.Theyremovedtheplacentabyapplyingpressure

ontheabdomen.Shetookitoutbyputtingherwholehandinsideandcheckedsothereisnodirt

leftinsidetheuterus…sheheldmyhandandgotmyclotheschanged.Askedaboutmypainand

gavememedicine.Theywerenotlettinganyone(fromfamily)goinsideatthetimeofbirth

becausetheywerethere.”(Sujata)

DaiassistedAnju’sthreehomebirths.Pratima’ssecondbirthwasassistedbyadai,asshownin

herbodymap(Figure6.17).Shewantedherfirstbirthathomeaswell,butthedaisentthemto

hospitalaftershethoughtthelabourhadlastedtoolong.Thisissimilartothepatternwithbirths

inpublicsectorhospitals,beittertiarylevelhospitalorathome.Birthsassistedbydaisareseen

withPratima(Figure6.12)andSujata(Figure6.13).

“Shedidallthedeliveries.Dagarincameat12atnight.Shewasmassagingmyhandsandlegs.

Shecutthecordwithblade.Shemassagedthebabywithoil.”(Anju)

“Myfather-in-lawwentandbroughtthedaihome…wheneveryougotocallher,shecomes.Poor

thing!Eveninthemiddleofthenight.Sheisanoldwidow.”(Pratima)

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Figure6.12 Pratima’sbodymap

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Figure6.13 Sujata’sbodymap

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ASHA’sroleduringchildbirth

ASHAswerementionedinAmritaandSita’sstory.Herroleistocalltheambulanceandhelpthe

womanreachthenearbyinstitutionforbirth.ShealsoaidsingettingtheJSYincentive.Butin

bothcasesthewomenhadnotreceivedtheirJSYincentivesfortheirrecentbirths.On

complainingaboutthistotheASHAs,theyblamedthecomplainants,sayingthattheyprobably

receivedthemoneyandspentit.ASHAswerealsoseenhelpingtogetthebirthcertificate,but

theychargedafeesof300rupees.Inthelabourroom,theyweresometimesseenrestraining

womenwhoaregivingbirth.OneparticipanthadanASHAwhowasafamilymember.Participants

oftenfounditdifficulttodifferentiatebetweenwomenaroundbirthandcouldnottellASHAand

mamtaapart.ASHA’srolewasthatofamediatorofservicesandamotivatorforthewomenand

familytoseekhealthcareservices.

“Sheisinmymaternalhousehold.Sheisourfamilymember,soshehaddonealltheproceedings.”

(Sita)

“Igavehermypassbookandtoldherifyoudon’tbelievemethenwhydon’tyoucheckit.Itoldher

‘youthinkIwillgrowricherby1400rupees?’Thenshetookandupdatedthepassbookbutshedid

notfindoutanything.ShesaidnowIwillnotgetthemoney.”(Amrita)

Mothersandmother-in-law’sroleduringchildbirth

Motherandmother-in-lawwerenotmentionedtobetogetheraroundbirth.Amrita,Sitaand

Pratimahadtheirmother-in-law’spresence,whilePairo,Ria,UrmilaandAmritahadtheirmother

besidethem.Sister-in-lawswerepresentatSujataandPratima’sbirths.Theirrolewasthatofa

femalefromfamilywhowasaroundtocallthecareproviderswhentheyfelttheneedand

facilitatecommunicationfromthefamily.Womenwereaskingquestionssuchas,howlongwillit

taketogivebirth.Theydidnotnecessarilyconveytheinformationtothebirthingwomen,asis

seenwithPairowhowasn’tinformedbyhermotherthatshewasgoingtobeoperatedthenext

day.Theycommunicatedtheinformationtorestofthefamilymembers,includingthehusband/

fatherofthechild.Theymadesomedecisionsaroundbirthtoo.Mother,mother-in-lawand

sisters-in-lawswereamongstthefamilymemberswhorestrainedthebirthingwomen.Sita’s

mother-in-lawinterruptedtheinterviewafewtimesandalsotookovertheconversation,untilwe

couldtalkprivatelyagain.

“She(mother)washoldingmyclothesandkeepingmylegsdown.”(Amrita)

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Womensaidtheypreferredtheirmother’scompany,exceptUrmilawhofeltveryangrywithher

mother’spresence.Riafeelshermothersavedherbaby’slife,aftershemadealotofnoise

becausethedaisannouncedastillbirthand‘threw’thebabyunderthetable.Thisiscapturedin

herIpoem(Box6.6).Pairohasasimilarstorywherehermotherfoundthenewborn’scordstump

bleeding,hoursafterbirthandreportedtothedoctors.

Box6.6 Ria’sI-poem-Thedeadbaby

Thedeadbaby

Mybabywasbornwithgreatdifficulty.

Mybabywasmovinginmywomb,butafterbirtheveryonesaidthatthebabyisdeadandtheythrewmybabyunderthetable.

Mymothershoutedatthem,‘Howcanthebabybedead?’

Mymothertoldmethebabyisdead.

Iwasnotawareofitwhileitwashappening.

Mymotherwentthereandquestionedeveryonebecausethebabygetsexchangedoften.

Ididn’tknowanythingafterthat.

Iwasjustlyingdown.

Iwasinalotofpain.

Iwasdrowsy.

Iwasrestlesstooandmymotherwenttothebaby.

Iaskedmymother,‘howisshe?’

Irepeatedlyaskedmymotherhowthebabywas.

Iwouldhavebecomefamiliarwiththem.

Iwouldthinkthat‘Yes,Ihavesomeonehere’.

Iwillfeellessafraidandnotpanic.

Mymotherwouldhavebeenthere.

Ihadthebaby,afterhalfanhourtheystitchedmeupandIwasalmostunconscious.

Iwasunconsciousandtheyshiftedmetoanotherroom.

Iwouldhavenotknownaboutthebaby.

Mymothersavedmybaby!

Iwasupstairs,mybabywasinNICU.

Ihadtopaytoseemybaby,whomIgavebirth!

IusedtosaythatIamgoingtotellthistohigherauthority.

Iwassaying,‘letusseethebabyonce’.

Irequested,‘showmefromafaratleast.Howismybaby?’

Mybabyfinallycameinmylapafter8days.

Mybabywascoveredinherstoolafter8days.

Iexpressedmilkinaglassandgaveittothem.

Iwasnothappyfortwentydaysatleast.

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Iusedtobeveryrestless.

Istartedspendingmoretimewithmybaby,Iusedtofeelmuchbetter,satisfied.

Womendidnotchoosetheirbirthcompanion.Womenoftenfelttheyhadnochoiceinmaking

thatdecisionandfoundthathavingtheirmotheroranywomenamongstrelatives,wasthemost

acceptableoption.Sujatawastheonlyparticipantwhofreelyexpressedherwishtohaveher

husbandbyhersideoveranyoneelse,butshedidnotvoicethatchoiceduetosocietalbarriers.

Shealsohadtofollowtraditionalnorms,suchaswearingsignsofmarriage,becauseherin-laws

werepresentduringchildbirth.Theyalsohadaroleinconvincingwomentoacceptinterventions

thattheydidnotagreewithandfelttheyhadnochoicetodeny.

“Iwaswearingbindiandvermillion,becausemyin-lawswerethere.”(Sujata)

“Mymothersaidtolether(nurse)checkonce.”(Sita)

“Ididnotwantanyonetotouchme.EvenwhenmymothercametoholdmeIfeltlikeIwillhit

her…itwasnotcomfortingme…mostofthetimeshewasjustsittinginthelabourroom.WhenI

waswalkingshewastryingtoholdmyhand,Ididnotlikethat.Iwantedtodoitonmyown.

What’sthepointofholdinghand?Itmakesmelookweak!”(Urmila)

6.5.7 Respect,disrespectandabuseinpersonalspaceandrelationships:householdand

husband

Therewerenodirectquestionsaboutwomen’shouseholdenvironmentotherthanhousehold

incomeandsourceofincome.Womensharedabouttheirrelationshipwiththeirhusband,while

talkingaboutthebirthcompanion,theirhusband’soccupation,themainsourceofhousehold

incomeandtheirhusband’sroleduringchildbirth.Womenoftenworkeduntiltheywentinto

labour(pleaseseePratima’spoem‘Bornathome’inBox6.3andAmrita’spoem‘I’inBox7.2).

Thisincludedtheirpaidworkandunpaiddomesticwork.Thisworkwasoftendescribedasa

burdenthatwasrarelyshared.Oftheeightwomeninterviewed,fourdidnotengageinpaidwork.

Anjuisalaboureronothersfarms;Riaworksasacleanerandrearedcowstosellmilk;Amritaran

asmallgroceryshopandPairoisagovernmentschoolteacher.RiaandAnjuarethesoleearners

ofthefamily.AmritaandPairo’sincomewassupplementedbytheirhusband’s,buttheyranthe

household.Anjuhadthelowesthouseholdincome(1000rupeespermonth),forafive-member

familyandPairohadthehighesthouseholdincome(65,000rupeespermonth)forafour-member

family.Womenwhoengagedinpaidwork,managedallthedomesticworkaswell.Womenin

jointfamiliesordomiciledattheirmother’splace,wereabletorestforthefirstfourtosixweeks

aftergivingbirth,thiswasfoundtobeacommonnorm.Thiswasnotpossibleinnuclearfamilies.

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“Nooneistheretolookaftermykidsandfamily.Ionlygotothemarkettopurchasegroceryfor

theshop.Ileavethechildrenforafewhoursattheanganwadi.Iwas8monthspregnantandhad

tolift25kgjutesacks.”(Amrita)

“Afterthefirst3monthswhenmymotherwenthome,IusedtowashclothesandIusedtositand

feeltiredandthinkhowwillIgobacktoschool,howwillItakecareofmybabyandhowwillIdo

everything?TwomonthslaterIstartedtakingbauua(daughter)toschool…itwasquite

troublesomebutImanaged.”(Pairo)

“AtleastinthefirstmonthandahalfIdidnothavetodoanything.Usedtojustroamaround.

Cookedfoodwasbroughttome…Iwasatmyin-law’shouse.”(Pratima)

Womenfeltshytalkingaboutpregnancyandbirthwiththeirhusband,andthenarrativesdepict

thatthiskindofconversationwasnotnecessarilyencouragedbetweenthem.Box6.7showsRia’s

communicationwithherhusbandwhensheannouncedherpregnancytohim.Hernarrative

showshowherpregnancyledtoherseparationfromhim,whicheventuallyledtoadivorce.She

recountedexperiencingintimate-partnerviolencefromherhusbandandoflivinginaviolent

domesticenvironment.

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Box6.7 Ria’sI-poem-Ithasstayed

Ithasstayed!

Iusedtoaskwhatthedoctorsaidexactly.

Myfriendsaid,doctorusedtosaythat,‘whenyoudon’thavethestrengthtogivebirthandbearthepain,thenwhydidyoukeepthebaby?’

Myhusbandtoldmethathewantsason.

Itoldhim,‘Myperiodshavestopped,IguessIampregnant.’Hecurledhislipsinangerandsaid,‘Idon’twantababyrightnow’.

Igotpregnant.

Ididnoteatordrinkmuch,IusedtoliftheavyweightandIusedtocarrytwobucketsofwater,atatime.

Ihavebeenmarriedfor6years.

Myhusbanddoesnotstaywithme.

Iamdivorced.

Iwaspregnant,hedidnotgivemeanymoney.

Ialsosaid,‘Don’tgive!’

Iwentforthedelivery;hedidnotgivemoney.

Iwenttohospitalwithmymother.

Icalledhimfrommymother’sphonebuthedidnottakemycall.

Ialsoleftitlikethat.

Iwasscared.

Iwasnothappy.

Itoldhim,evenifIampregnant,Iwillnottakeapill.

Iwillnottakethatpill.

Ialsotoldhim,‘don’tdo,Iwillmanage’.

Isaidtomymotherto‘helpme.Idon’thaveanythingtodayandIdon’tearn,Ihavenoonetospreadmyhandsinfrontofformoney.Yougivemetoeat’.

Ialsosaidthendon’targuewithme,whotoldyoutoarguewithme…abuseme.

Urmiladisclosedaboutherhusbandbeinganalcoholicandabusive,whichledtohercallingthe

police,followedbyhisimprisonment,asseeninherI-poeminBox6.8.Nothavingaproductive,

respectfuldialoguewithhusbandwasacommontheme.ThiswasseenwithSujataaswell,who

wasotherwisequitefrankwithherhusbandabouteverything.Husbandsoftenconveyedtheir

opinionaboutthefamilysize,andtheirwordwasusuallythefinaldecision.

“Myguardian(husband)didnotletme…saysourchild(son)remainsverysick.That’swhyIdid

notgetitdone.They(in-laws)saidyouhaveonlytwochildren.Operation(tubectomy)wasmy

thought.”(Amrita)

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“Icouldnotaskhim‘howwillitcomeout’.ButhewishedIwoulddelivernormally…hesometimes

says‘doyouwantmorechildrenthatyoudidnotgetfamilyplanningoperationdone?’.Inthe

secondtimehesaidregardlessofboyorgirl,gettheoperationdone…ifthebabyishealthythen

onlyIwillgetitdone.NeitherIhavedonetheoperationnorhehas.Itellhimwhydon’tyougetit

done.Hesays‘Iwillhavetositandworkallday,Iwillgetweak!’.Sonowwheneverweget

intimate,Itellhim‘mylifeisinyourhands!’.Hegetsscared!(laughs)”(Pairo)

“Ifeeltwokidsareenoughbutmyhusbandkeepssayinghewantsonemore.Asin,ason!Isay

see,asonisbornoutofgod’sgrace…howwilloneoperate(Vasectomy)onhusband?!(shocked)

No,no,no…ahowcanamangetoperated!”(Sita)

Box6.8 Urmila’sI-poem-Inevermadeadecisionaboutmyself

Inevermadeadecisionformyself

IleftmyeducationwhenIwas13.

Igotmarriedveryyoung.

Ihavenoideaaboutmoney,myhusbandtakescareofmoney.

Idon’tknowwhatheearns.

WhatdoIhavetodoaskingaboutmoneyanyway!

Iputmyhusbandinjailbecauseofhisaddiction.

Ishouldnothavedonethat.

Idon’tknowwhenmyhusbandwillbereleased.

Iwasbetteroffalone.

Iwouldhavedonesomething,earnedsomemoney.

Ijustdon’tlikewhenhecomeshomedrunk.

Ifeellikelockingmyselfinanotherroom.

Ididnotlikethesmell.

Myhusbandhadmoneytodrinkalcoholbutnomoneyformychildren’seducation.

Ifeel,Ishouldjusttakecareofmychildren.

Iwillfindthemoneytofeedthem,evenifIdivorcedhim.

Hedrinksandhitsme.

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Iputhiminjail.

Noneofthehusbandswereallowedintothebirthingenvironmentinthehospitalsettings.The

husband’srolewaslimitedtocallingforthedaiorambulance.Inthehospitalsettinghusbands

paidthebills,paidthebribestocareworkers,boughtthesuppliesinstructedfromthehospital

andwaitedoutsidethelabourroomoroperationtheatre,asseeninthecaseofSujataandPairo.

Amrita,SitaandPratima’shusbandscouldnotmakeittothehospital.Amrita’shusbandwas

workinginanotherstate,asheisamigrantworker,andanothertimehedidnotwanttogotothe

hospitalbecausethebabywasgoingtobebroughthomeanyway.Pratima’shusbandisarag

pickerandcouldnotmissaday’sworkashewasearningadailywageof250rupeesthatensured

foodfor22householdmemberseveryday.Pairo’shusbandworksinabankandwasawayduring

thetimeofherpregnancybutarrivedrightbeforechildbirthfromanothercity.

Thehusband’spresencearoundchildbirthwasn’talwaysdesired,asnarratedinAmrita’sIPoem

inBox6.9andshowninherbirthmapinFigure6.14.Sujatawastheonlyparticipantwhowanted

herhusbandtobethereduringherbirthsasmentionedintheprevioussection.Anju’shusband

playedakeyroleinallherbirths,fromcallingtheambulancetoaccompanyherforfirsttwobirths

whichwerestillbirths,followedbycallingthedaiforhomebirthinhernextthreebirths.Heeven

assistedherfirsthomebirthasthedaiarrivedlateandhewaitedoutsidetheroomfortherestof

thetwobirths.

“Nonono…whywillIcallmyhusbandtoholdme!Iwasinsomuchpain!Ididnotthinkof

husbandandall.”(Sita)

“Tofranklytellyou,itwouldhavebeenmostencouragingifmyhusbandwastherewithme,but

mencannotbethere.Theyarenotallowed.So,ifheisn’tthere,itdoesn’tmatterwhois!All

othersaresame!Husband’spresenceissomethingentirelydifferent.Inthisconditiononly

husbandisneededmore.”(Sujata)

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Figure6.14 Amrita’sbirthmap

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Box6.9 Amrita’sIpoem-Becauseofhim,Iaminthissituation!

Becauseofhim,Iaminthissituation!

Ifeltgood!

Iaminpain,obviouslyIgetveryangrywhenIwilllookathim.

IalsogetangrywheneverIwasinpain.

Iamthere,justbecauseofhim,Iamhereinthissituation.

Ifeelheshouldbeaway.

Ididn’twanthimtobetherewithme.

Idon’tknowaboutitexactly,guardianspaidthatbutthepeoplewhowerecleaningthere,theyallhaveaskedformoneytoeatsweets.

Idon’tknowhowmuchtheypaid.

Ididn’taskanythingtoanyone.

IwasjustprayingtoGodsoIdon’thaveanymorebabies.

Iwascrying.

Ididnotfeelliketalkingtoanyone.

Iwasthinkingabouttheoperation(tubectomy).

Ithinkthereisnopointofhavingmorethantwochildren.

Iwantedtogivethemagoodlife.

Iwantedtosendthemtoschoolforeducation,whichIhavenotreceived.

I[could]gothereforoperation.

Ididnotgetitdone.

Myguardian(husband)didnotletme.

6.5.8 Birthinginformation,birthpreparednessandmythsaroundbirth

Womendidnottalktoothersaboutpregnancyandchildbirth.Theyoftenhadnoinformation

whengivingbirthforthefirsttime.Noneofthewomenhadanydiscussionaboutpregnancyor

childbirthwiththeirhusbands.Anycommunicationwaslimitedtosomeconversationswithother

womenintheneighbourhood,whichwaslessoften.Oneparticipantdiscusseditwithhergrand-

mothertoo.Theinformationsharedamongstwomenwerenotalwayscorrectandfullofmyths.

Womenwereaskedtoeat,drinkandrestwhiletheyarepregnantandleaveeverythingtoGod.

Nobodytalkedabouthowthebabyisbornorotherdetailsofitforvariousreasonsincluding

shame,asSujatashared.

“Inwinterstheydon’trunwater(IVfluids)becauseitissocold…myneighbourhoodsistertoldme

theyranwaterandthebabycameoutquicklyafterthat.”(Amrita)

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“It’sasayingthatiftheenvironmentishotter,thebabywillcomeoutquicker.Likeifsomeone

doesnotwanttohavethebabywhensheispregnant,everyoneadvisestoeatanddrinkhot,like

cardamom,whichhasheat.Thatheatsupthebodyandthebabygetsspoiled/wasted.Thesame

waywhengivingbirth,heatwillcausethebabytocomeout.Womenwhoseexpecteddateof

deliveryisupwillhaveasafedeliveryandthosewhoseduedateisfarwillgetitaborted.

Definitelyitwillgetspoiled!”(Sujata)

“Babywaspoisonedinsidethebellyfor3monthsanditstayedinthebellyandmotheralsodied

becauseofthatpoison.(Aladyfromthenearbyvillage)”(Anju)

“Mymotherinlawusedtosayifyouwanttoeatsourthenyouwillhavedaughterandifyouwant

toeatsweetyouwillhaveason.ItoldherIlikeboth.ShesaidthenIwillhaveadaughter.”(Ria)

Womenwereshytotalkaboutbirthwiththewomenaroundthem,withtheirhusbandsandwith

healthcareproviders.ThestigmatotalkaboutbirthcanbeseeninPairo’sI-poemtitled‘Itwas

myinnocence!’inBox6.10.

“Iwasveryanxiousduringmyfirstbirth.Ididnotaskaboutittoanybody.Iwasfeelingvery

ashamedandnotunderstandinganythingsinceIwasveryyoung.Iwasveryashamed.Howwill

theydoit,whattodo,forallthatIwasnervous.”(Sita)

“Ididnotknowbeforehand.IneverwenttohospitalsohowwouldIknow?Idon’ttalktoanyone.

Therewasafairwomaninthenexthouse...Iusedtodiscusswithhersometime.Idon’tgooutof

thehouseatall…whatwillhappenwillbeGod’swill,whenGodwillwantittohappen.It’snotin

ourhands.”(Pratima)

“Youknowhowwomentalkaboutthesethings…theyusedtoshareithappenedlikethisandlike

that.Oneofmyfriendssaidthatdoctorsaid,‘whenyouyoudon’thavethestrengthtobearthe

painandgivebirth,thenwhydidyoukeepthebaby.’Everyonegetstohearthis.Thisisvery

normalconversationaroundchildbirth.”(Ria)

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Box6.10 Pairo’sIpoemaboutconversationaboutbirthingandpreparedness

‘Itwasmyinnocence!’

Iwasbornin1990.

Iamaschoolteacher.

IampursuingmyMAdegree.

Icallmymothertotakecareofmykidsandfamily.

Ikeepaskinghertocomehere.

Iamtheeldest.

Imusthavebeen10yearsold.

Ihadtomindhim.

Ihadtotakehim.

Iusedtobeathimalot.

Iremember,whenIwasunabletotakecareofhimasachild,sowheneverhecried,Iwouldbeathim.

Ididnotknowwhattodowithhim.

ItoldthistohimthatIusedtobeatyoualotwhenyouweresmall.

ItoldhimthatIusedtodothiswithyou.

Isometimesthinkthatit’snotpossibleforamothertotackletoomanychildren,sosheputsthatburdenofresponsibilityonhereldestchild.

Idothattoo.

Itellmydaughter“youmusttakecareofyourbrother”.

Icompareitwithmychildhoodwhenmymotherdidthesame.

Ithinkthisisagiventhingtodo.

Igotmyjobhere,sowestayedhere.

Ihavealsostudiedfrommymaternalgrandmother’shouse,notevenfrommyownmaternalhouse.

Iusedtolivethere.

Ididnotunderstandsomuchaboutthesethings.

Ihavealwaysjustkeptmyfocusonmyeducation,thensuddenlyIgotmarriedandhadchildrenquitequicklyafterthat.

Igenerallydidnotpayattentiontothesethings.

Ididnottalkaboutthiswithanyonemuch,didnothavemuchinformationaboutthis.

Ihadneverheardaboutit.

Iusedtothinkthatthebabyhasgotteninsidemywomboneway,buthowwillitcomeoutnow(laughs).

Itoothoughtsinceitwalkedlate(inthewomb)thenitwouldbeason.

Iwascarefreeaboutit.

Ithoughtit’sfineandIampregnant.

Ijusthavetokeepeatingandgotowork.

Ikeptgoingtillthelastmonth.

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IwaswaitinginmyhousethatIwillhavepainanymoment.

Iwasthinking,howwillitcomeout?

IusedtolivealonewhenIhadthesethoughts.

IwasnotsayinganythingtoanyonebecauseIwasthinkingthatthesepeoplewouldthinkaboutmywellbeingonly.

Ibelievethatthesepeopleshouldhavetoldmethis.

Iwasjustapatient.

Ineverdiscussedaboutitwithanyone.

IknewthatIwouldhavenormalbirth.

Iwashappythatmysecondbirthwillbenormal.

Iwantedtoexperiencenormalbirth.

Iwillcometoknowhowwomengivebirthnormally.

IneverevenwatchedavideoonYoutubeabouthowbabycomesoutofthemother’swomb.

Ineveraskedthesethingstomymotheroraunt.

Ineversharedthesethingswithmymotheroraunt.

Ithoughtitwillhappensomehow.

Iwasthinkinghowwillithappen.

IusedtomeetmydoctorforUSG.

Iusedtoaskherpleasetellmewhatisinsideotherwisemyhusbandwillfeelangryeventhoughhewon’ttellmeanything.

IassumedIhaveadaughter,ithadtobeagirlsinceshewasnottellingme.

Iusedtothinkthatitwouldbeason.

Ithinkbecauseofmymindsetwhenwassheborn,shewaslookinglikeaboy.

IthoughtsecondtimeIwillhaveagirlbutitwasaboy.

Ilovehermore.

IusedtotellmybrotherandsisterthatIdon’tlikehimmuch.

Withnoonetotalkto,SujatalookedintoYoutubeforinformationonbirthingandcareduring

pregnancy.Womencarriedmanythingswiththemwhentheywenttotheinstitutiontogive

birth.Wearinganightiewasacommoninstructionthateithercamefromthecareprovidersoras

asuggestionfromwomenintheneighbourhood.Womenoftendidnotwearanyjewellrywhen

theyweregoingtogivebirth.Theycarriedaseparatesetofclothestochangeafterandoldcloths

tobeusedduringbirthinthehospitaltocleanthebaby,thewomanandthelabourtable.

“Wecarriedeverything.Petticoat,nightie,bedsheet.Notpads,theygaveusthere.Theclothes

whichonewearsatthetimeofbirth,theythrowitbecausetheybecomedirtygivingbirth.That’s

whywecarryextraclothes.Theyremovedallmyclothesandaskedmetowearanightie.”(Sita)

“ItshowsonYoutuberight,whatisgoodtoeatandwhatnot.Iusedtowatchit.Myhusbandhas

amobilephone,Iusedtosearchinthat…Iwouldengageinthesemischiefsaftermyhusband

wouldsleepoff.Iusedtolookforallthesesecretly.”(Sujata)

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Womenfounditdifficulttodeterminewhoisgivingtherightinformationandoftentheywillonly

getthatclarityaftergivingbirthforthefirsttime.Womendidnotfeeltheneedtotalktoanyone

aboutit,asUrmilashared.

“Ihavenevertalkedaboutmybirthswithanyone.Ididnotfeeltheneedtotalkaboutthiswith

anybody.Wedonothavethecultureoftalkingaboutbirth,beforeorafter.Iwasnotabletotalk

aboutthistomymother,husbandanybody.IdidnotknowIneededit,aftertalkingtoyouI

realised,Ilikedtalkingaboutmybirth.”(Urmila)

6.6 Discussion

Breakingthesilencethroughbirthmapping

Womenweresurprisedtofindsomeoneknockattheirdoorwiththepropositionofhearingtheir

birthingstories.Birthisatabooedtopicofconversationamongwomenbecauseitiscommonly

ascribedtoanoutcomeofsexualintercourse(Chawla,2006;Chawla,2019).Womenareoften

verballyabusedwithjudgmentalcommentsusingthisfact,asisseeninRia’snarrative.Thisisnot

justaboutnarrativesoftraumaticbirth,theliteraturesuggeststhatwomensharinggoodbirthing

experiencesareshamedfor‘showingoff’(Hill,2019).Giventheutilityofbodymapsin

understandingwomen’sexperienceofcruciallifeeventssuchaschildbirth,myadaptationcanbe

named‘birthmaps’andtheprocess‘birthmapping’.Birthmappinghelpedtobreakwomen’s

silenceabouttheirbirthingexperiences,wheretheirsisthecrucialvoicedrivingthe

improvementsinsexual,reproductiveandmaternalhealthcare(Oakley,1984;hooks,1989;

Kitzinger2005;Chawla,2006).Birthmappinghasproventobeanexcellentchoiceforamethod

ofdatacollectiontounderstandwomen’sexperienceswhicharesensitiveinnature,suchas

childbirth,andrequiresmoretimeandwillingnessfromparticipantstoshareinatrusting

environment.Itisaneconomicandflexiblemethod(Devine,2008)whichrequiresrelativelylow

costsuppliesfortheartwork(Gubriumetal.,2016).

Theuniqueapplicationofbirthmapshelpedtoaddressthelanguageandpower-basedbarriers

andhelpedwomentobreaktheirsilence,especiallyabouttheirexperiencesofobstetricviolence,

andsharetheirbirthingexperienceindetailwithcomfort.Birthmappingensuredthat

participantswereattentiveandfocusedthroughouttheexercise.Womenhadbetterrecall,more

thantheyexpectedthemselvestoremember.Somewomenwereinterviewedthreetofourtimes

andallthroughtheconversationstheyremainedintriguedandweredeterminedtofindtimeout

oftheirbusyscheduleandcontinuetheirparticipation.Participantsweredeeplyengagedinthe

process.Theirattentivenessreflectsintherichnessofthedatacollectedthroughtheirnarratives

ofbirth(Lysetal.,2018).Thebirthmapsenabledtheconversationtomovefromonepartofthe

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bodytoanother,fromtheexperiencesthatwomenfeltontheirbodytotheirexperiencesofthe

birthingenvironment.Itwaseasierfortheparticipantstoarticulatetheirfeelingsthroughthe

map.Specificaspectssuchasthecolours,cut-outs,facialexpressionsandpeoplethewomen

chosetoputonthemap,openedthewayforrelevantprobesandgaveoptionsforwomento

choosefromwhattoshareoftheirstory.Thismadeiteasyfortheparticipantstoreflecton

certainprobesandtheirperceptionfromtheirexperience.Thiswasakeyrationaleforusingthis

methodtounderstandwomen’sexperiencesofchildbirth.Birthmappingmadethedata

comprehensiveandrich.

Listeningtothecontrapuntalvoices

Withthechoiceoffeministembodiedmethods,Ihaveensuredthatthewomen’svoiceisprimary

andtheauthor’sinterpretationissecondary.Thishasbeenensuredduringdatacollection,

analysisandinthepresentationofthefindingsthroughthebirthmaps,birthingstoriesandthe

generousinclusionofquotes.Feministmethodsreducethepower-basedimbalancebetweenthe

researcherandparticipant.Feministrelationaldiscourseanalysisandvoice-centeredrelational

analysisarenovelmethodsthatensurewomen’svoicesareprioritisedandareatthecentre.This

multilayeredanalysisisakeystrengthofthisstudywhichguidedmylisteningtothecontrapuntal

voicesthroughoutthedifferentformsofdata.Figure6.15presentsarangeofcontrapuntalvoices

heardinwomen’spoemsinthisstudythroughthelanguageofmusic.

Figure6.15 Rangeofwomen’scontrapuntalvoicesaboutselfdecision-makingandsurrogate

decisionmakingduringchildbirthandinlife(Author’sown)

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Therangeshows‘discord’ofthenegativeend,wherewomenexperienceextremeformsof

obstetricviolenceanditsconsequences.Ittransitionsthroughthe‘harmonicprogressions’,which

expresswomen’sstruggleandresistance,extendingtotheextremepositiveendof‘concord’fora

satisfyingandpositivebirthingexperience.Women’sexperiencesarenotlinearoronedirectional

butrathercomplexandlayered.Thedominantdiscourseofthecontrapuntalvoicesisofdiscord

andsuspension,ratherthanofconcord.Someofthevoicesprevailmorethanothers.Oneof

thesefigurescanbecreatedforeachparticipant,focusingonjusthercontrapuntalvoices.Even

withinthepoems,themapsandquotes(andthebirthingstoriespresentedinChapter7)show

thatthevoicesdepictingconcordwerelimited,whereasthelengthordurationofthevoicesof

discordwerelongerforallfourwomen’sexperiences.Forinstance,Pairo’spoem‘Doll’hadthe

voiceofdeterminationandhappiness,onceeach,whensheishappythatshehasgivenbirthtoa

girlanddeterminedtotakehertoschoolwithher.Theothervoiceswerethoseofshame,

powerlessness,trauma,fear,silence,isolation,sadness,detachmentandstruggle.Thetwopoems

fromUrmila’sexperiencehaveanalignednarrativeaboutdecision-makinginthebirthing

environmentandaboutherlife.Thesevoicescanbenoticednotjustinthebirth-relatedpoems

butintheirroutinelife-relatedpoemsaswell,allowingthereadertoseeconnectionsemerging

betweenbothaspectsoflives,withbirthingbeinganextensionofhowtheyexperiencelifeand

theoppressionthatcomeswithitinroutinelives.Thevoicesofsilence,powerlessness,isolation,

pain,fear,anger,resistanceandstrugglecanbenoticedinbothdomainsandsimilarlyonthe

positiveside,thelessfrequentvoiceoftriumphcanbeheardwhenshedescribessendingher

husbandtojail.

Complex,richanduniqueexperiencesofrespectfulbirthsandobstetricviolence

Thisstudyhasopeneduptherich,complexandmultilayeredbirthingexperiencesthatarenot

unidirectionalandhaveaspectsofbothrespectfulcareandobstetricviolence,takingitastep

furtherfromthequantitativeanalysisof2194women’sbirthingexperiencesthatIpresentedin

thepreviouschapter.Thischaptershinesalightoneachparticipant’sembodiedexperience,

enablingreflectionbyunderstandingthemasaholisticbeingalongwithadeeperunderstanding

ofthehealthcareinfrastructure,birthingenvironment,policies,normsandmuchmorefromthe

women’sperspectiveandexperience.Thehospitalbirthsettinginaprivatehospitalwasnot

necessarilyverydifferentfromthepublicsettingsatdifferentlevels.Womenreportedthatthe

privatehospitalsdiscussedinthisstudywereadvantageouswhencomparedwiththepublic

hospitalintermsofgettingabedoraseparateroom,andtoreceivequickerattentionfromthe

careproviders.RiaandPairohavebirthedinverycrowdedenvironments,butthisisquitethe

oppositetothecomfortingexperienceofcommunalbirthing,whereeveryonearoundthewoman

isthereforher,supportingherandencouragingher(Chadwick,2018;Shabot,2020).

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Inhospitalbirths,respectfulcarebeginswiththereceptionofwomen.Anabsenceofbasichuman

interactionisthemostcommonformofdisrespectthatwomenexperience(Vedametal.,2019).

Thereisscopeforcareprovidersandhealthsystemstoembedrespectfulnessateverypointof

interactionwithwomenthroughouttheirsexual,reproductiveandmaternalhealthneeds.

Respectfulcarecouldbeensuredviabetterinterpersonalcommunication,appropriatebirthing

environments,effectiveteamcommunications,avoidingunnecessaryinterventionsand

conductingtheessentialinterventionwithconsentandsensitivity,ensuringcleanbirthingspaces,

accesstocleanwater,hygieneandsanitationandbirthcompanionsofchoice(UnitedNations,

1947;WHO,2018).

Over-medicalisationmakesthebirthworldimpossibleforwomentounderstandanddescribe.

Studiessuggestthatthecultureofsilence,leadingtoacclimatisationtotolerateviolencein

personallives,oftenasaresultofapatriarchalculture,maykeepthemfromreportingtheir

experienceofdisrespectandabuseinthebirthingenvironment,astheymaybeconditionedto

feellessvalued(Chawla,2006;Hill,2019;Oakley,1984;Mayra&Hazard,2020;Jejeebhoy&

Santhya,2018).Thisisconfirmedwhenmedicalinterventionsareprioritisedoverwomen’s

comfort,dignityandchoice(Chawla,2006;Madhiwalaetal.,2018;Dinizetal.,2018;Kapoor,

2006).Womenreportedbeingthelastpriorityinthebirthingenvironment.Thisisasadreality

thatissystemicandapartoftheculturalconditioningofwomenthatmakesthemaccept

unnecessaryunwantedinterventions,includingcesareansections(Dinizetal.,2018),andsothat

birthingbecomesanexperiencethatneedstobeendured.Lambertetal.(2018)arguessaying

‘youbarteryourchoiceinreturnforskilledcare’.

Whileotherstudiessuggestthat“beingpresentwiththewoman”iscrucialforapositivebirthing

experience(Kapoor,2006),inwomen’sopinionthecareproviderswouldrankthefoetus/baby

andtheirownconvenienceastopconcernsintheorderofpreferenceforcare.Thisisreflectedin

careproviderscoercingandcompellingwomenandrestrictingwomen’schoicesabouttheirbody.

Itisimperativetounderstandthedifferencebetweenhavingbirthcompanionschosenbythe

familyandhealthcareproviders,againsthavingasupportivepresenceofsomeonechosenbythe

woman.Acompanionwhoisfocusedonthecareseeker’sneedsandthebirthingprocess

(Chawla,2019).Thecontinuouspresenceofahealth-careproviderwitheverywomanisnot

reportedinthesestoriesfromBihar,apartfromadagarininonecase,whowaswiththewoman

throughoutherhomebirths.Goodtouch,thatissoothing,ishighlightedasessentialinthegood

birthingnarratives(Chadwick,2019)ascouldbeseeninSujata’sexpectations.Thistactilecomfort

isusuallysoughtinanatmosphereandrelationshipthatwomentrust(Shabot,2020;Scotland,

2020).Mystudypredominantlyreportsbadtouch,becausemosttouchwomenreportedduring

childbirthwasuninvited,unconsentedandtraumatising.Thecurrentnarrativesofthebirthworld

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arehostileandharrowing.Theyincludewomen’sexchangesaboutbirthwiththeirfemalefamily

membersorfriends,whichleadthemtoexpectobstetricviolence.Thatisunlesstheybehaveor

abidebythecareprovidersorletthemdothingsanddonotcomeinthewayofcareandactasa

passiveparticipantinasignificantexperienceoftheirlife.

Fromendurancetoadaptation

WomeninBiharrequest‘dardkidava’(augmentationbyun-prescribeduterotonicstohasten

uterinecontractions).Theyareoftenaugmentedbeforegoingtothehospital,toreducethe

durationoftheirstayinthehospital.Theydonotconsideritasabuse,aswomeninhigher-income

countriesoftendo.Thedifferenceisintheperceptionofbeingabusedandtheextentof

acceptabilityandreporting,whichisdifferentinhigh-incomecountriesbecauseofabetter

understandingbywomenofpoorqualityanddisrespectfulcare.Women’schoicesaremoulded

bytheirpreviousbirthingexperience,andwomenoftenfactorinmemoriesoftherespectfulness

oftheircare,especiallywhentheyhavepreviouslyexperiencedobstetricviolence.Womenoften

recoverfromtheirprevioustraumaticexperienceintheirsubsequentbirthbytryingtodo

everythingpossibletomakeitapositiveexperience,asawaytohealfromtheirprevious

traumaticbirth(Beck,Driscoll&Watson,2013;Kapoor,2006;Shakibazadehetal.,2018;Keedleet

al.,2019).Thiswastrueforwomengivingbirthforthefirsttime,basedonwhattheyhadheard

fromwomenintheirneighbourhood.Womeninlowandmiddle-incomecountriesendureand

oftendonotknowthattheirexperiencecanbebetter,theypreparethemselvesforanalarming

experience.Sometimestheawarenessofchoiceoverwhathappenstotheirbodyandhowthey

willbetreated,comesasarevelation(McAra-Couperetal.,2011).Thiscouldbeattributedto

intersectionalityofthewomen’sbackgroundcharacteristicssuchaseducation,socio-economic

status,gender,maritalstatus,religion,age,gravida,caste,classetc.andthedifferencebetween

hercharacteristicsfromthatofhercareproviderandeveryonewhoplaysaroleduringchildbirth

(Sen,Reddy&Iyer,2018;Chattopadhyay,2018;Sen&Iyer,2012).Intersectionalityisbetter

explainedintermsofraceandgenderbutcouldbeusedtounderstandwhatdrivesobstetric

violenceduringchildbirth(Chadwick,2018).IncountriessuchasIndia,careprovidersneedto

workhardertoensurerespectfulperson-centeredcare,astheyareupagainstwomen’slow

expectationsfromcare(Roder-DeWanetal.,2019).Eventhoughsomeinstancesofabuseare

unintentionaloraparticularcareprovider’sfault,buttheyneedtobeawarethatabusivecare

duringbirthisthedominantdiscourseintheIndianbirthingculture,andonlytheycanchangethis

narrative.Measuresarerequiredtoalsoaddressthestructuralandpolicyrelateddriversthat

makethewomenvulnerabletoobstetricviolencebutthatwillonlybepossiblethroughthe

understandingofwhywomenexperienceobstetricviolence,andarenottreatedinarespectful

anddignifiedmannerduringchildbirth.Idiscussthisinthenextchapterfromthefourimportant

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constructsofgender,power,cultureandstructurethatemergedfromtheseeightinterviewswith

women.

6.7 Strengthsandlimitations

Thischapterpresentswomen’sexperienceofrespect,disrespectandabuseduringchildbirth

usingthevisualarts-basedparticipatorymethodofbodymapping.Adaptingthismethodtobirth

narrativesbyproducingnovelbirthmapsisakeystrengthofthestudy.Theresultantrich

accountsofwomen’snarrativeshelptoenlightentounderstandtheircontextualsituations

(throughthemapsandtheirbirthingstories)helpthereadertoappreciatetheirperspectives.

Womeninmystudyexperiencedrespect,disrespectandabuseinthehomeenvironmentaswell

asinprivateandpublicfacilities,thoughexploringtheseperspectivesfurtherwasbeyondthe

scopeofthisstudy.Therewereaspectsofdisrespectfulorabusivebehaviourlinkedtofamily

membersorathomethatwomennarratedinregardtobirthingexperiencethathadaninfluence

on,oraddedcontexttotheirperspectives.Childhoodsexualabuseincreaseswomen’s

vulnerabilitytoabuseduringchildbirth,butthiscouldnotbeexploredinthisstudyduetoadded

sensitivitiestothealreadysensitivenatureoftheissuebeingexplored.Women’sexperienceof

respect,disrespectandabusechangeswithcontextandwomen’schangingperspectives

dependingontheirsociodemographicbackground.Itisessentialtounderstandthisthroughthe

intersectionallenstoinvestigatetheroleofdifferentcultures,religionsandsocio-economic

backgrounds,tounderstandhowitinfluencescareduringchildbirth.

6.8 Conclusion

Women’smissingvoicesinresearchaboutdeeplyfeminineissuesconstituteaglobal

phenomenon.Obstetricviolencerelatedresearchisdominatedbysurveysandperspectivesof

everyonebutthewomenwhogivebirth,especiallyinthediverseIndiancontext.Women

rememberthetraumaofanabusivebirththroughouttheirlife,oftenwithoutanopportunityto

shareitwithanyone.Thisresearchmakesanimportantnovelcontributionthroughthecreation

anduseofthebirthingmapsasaparticipatoryandculturally-appropriatevisualarts-based

methodproveusefulforaccuratelyportrayingwomen’srespectful,disrespectfulandabusive

birthsinlowresourcesettings.Ithelpswomentobreaktheirsilenceaboutobstetricviolenceand

expresstheirexperienceofrespectfulmaternitycare.Thisisimportanttounderstand,asevenin

theeightcasestudiesweobserveddiversityinwomen’sexpectationsalongwithsome

similarities.Thisdiversitycanbewellunderstoodthroughbirthingmapsascareneedstoadaptto

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thesechangingcircumstances,toensurerespectfulperson-centeredcareduringpregnancy,

labourandchildbirth(Afulanietal.,2019).

ThesystemofcareduringchildbirthisverymedicalisedinBihar,asseeninthenarrativesof

womenfromthisstudyandtherampant,oftenunethicaluseofinterventionsperformedsothat

thecareprovidersdonothavetobeatthemercyofthephysiologicalbirthingprocess.They

createsomethingthatcanfittheirscheduleandcalendars.Pairo’sstoryclearlyshowshow

“Docsplanation”hastakenoverthebirthworldbecausethemedicalmodelhaschangedtosuit

theneedsofobstetricians,especiallymale(Mayra,2020a).Remnantsofthiscanbeseenin

hospitalbirthingenvironmentsinIndiawherewomenarerestrainedwhengivingbirth.The

presenceofeightmenintheoperationtheatreforPairo,noneofwhomshehadmetbefore,isa

severeviolationofherprivacy.Insteadofkeepinghercomfortinmind,Pairowasnon-

consensuallyblindfolded,whichperfectlysignifiestheoppressionofwomenintheobstetric

settings.Allwomenhaveauniversalrighttorespectfulmaternitycare,regardlessofthecontext

anddiversebackgrounds.Thismakesitimportanttosystematicallyunderstandwomen’schoices,

experiencesandexpectationsthroughinnovativemethodslikebirthmappingtoinformchanges

inpracticesandpoliciesaroundchildbirth,whicharediverseacrossculturesandcontexts.

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Chapter7 “Ihavetolistentothemortheymightharm

me”:Whydowomenendureobstetric

violence?

Thepreviouschapterpresentedthenatureofrespect,disrespectandabuseduringchildbirth

fromwomen’snarratives.Thiscouldbeconsideredtheirfirststepinbreakingthesilenceabout

theirexperiencesofobstetricviolenceduringchildbirthandstatetheirexpectationsofrespectful

maternitycare.Women’snarrativesarerichandtheyoftenmentionedtheirperspectiveofwhy

theyexperiencerespect,disrespectandabuseentangledintheirresponsestothenatureoftheir

experience.Iutilisedtheadditionalinformationwomenprovided,byanalysingittounderstand

theunderlyingreasonsbehindrespect,disrespectandabuseduringchildbirth.Thiswas

thematicallydifferentfromtheplannedobjectiveofthepreviouschapter,soIampresentingitin

thisnewchapter.Womenwentastepaheadfromsharingwhattheirexperienceand

expectationsare,byalsostatingwhytheyexpecttobetreatedwithrespect,disrespectandabuse

andwhatdrivesit.Thischapterismorethanbreakingthesilence,itpresentswhatcausedthe

silenceinthefirstplace.

7.1 Background

Silenceisacommonthemewhenexploringwomen’ssexual,reproductiveandmaternalhealth.

Silenceisnoticedathomeandinthehospital,whichpointsatwomen’sunquestioningattitude

whichstartsathomeandextendstotheobstetricsetting.Womenhardlycomplainaboutpain,be

itpainduringintercourseorpainwhengivingbirth(McAra-Couper,2014).

InthepreviouschapterIpresentedevidencethatwomeninBiharraiseconcernsreferringto

aspectsofthecarethattheyconsideredrespectfulordisrespectful.Thelanguagewomenuse

whentheyreferredtobeing‘allowedto’or‘madeto’or‘forcedto’isamanifestationofthe

imbalanceofpowerdeep-rootedingender-baseddiscriminationsandhasbecomepartofthe

structureandculturewhichensuresthisconditioningisperpetuated.Women’snarratives

exemplifyhowpower,gender,cultureandstructureinfluencethecaretheyreceiveandhowthat

isrelatedtowhatshapestheirperceptionofrespect,disrespectandabuseduringchildbirth.

Thesethemeswerenotincludedinthepreviouschapterbecausetheyrelatetothefactorsdriving

respect,disrespectandabusethatemergedfromthedata.Butthisisanimportantpieceofthe

puzzlewhichprovidestheperspectivesofthekeystakeholderofchildbirth,thewomen.Hence

theimpactofgender,power,cultureandstructurearepresentedseparatelyinthischapterI

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choseadifferentsetofquestionsusingthesamedatafromthebodymappingaidedin-depth

interviewsandfollowingthesamemethodsofanalysisaspresentedinthepreviouschapter.

Thischapterandthenextchapterexploreswhywomenexperienceobstetricviolence.Thishas

thepotentialforpositiveimpactonprovidingrespectfulmaternitycare.Themethodshavebeen

describedinChapter6,butitisimportanttomentionthatIacknowledgethepower-based

inequalityintheinterviewenvironmentbetweenmeandtheparticipant.Iemployedmeasuresin

termsofusingthelanguageofparticipants,dressinglocallyandbeingatthesamelevelinterms

ofpositioningoneselfphysicallytotrytoreducethisinequality.Theseeffortsmaynotgoallthe

wayinbalancingthepowerdynamics,thereforetheresearchteamensuredthatall

communicationandinteractionwiththeparticipantandpeopleinthecommunitiesare

respectful,theinterviewsandthebirthmappingexerciseareconductedwithutmostsensitivity

andtheparticipantsaremadeawarethattheycanrefusetobeapartoftheexerciseoranswer

anyparticularquestions.

Aresearchrelationshipoftenputstheresearcherinapositionofauthorityofpowerascreatorof

knowledgethattheyseektocreate(Sprague,2016).Studieshaveshownthatarts-basedresearch

methods,suchasbodymapping,tendtominimizepower-basedimbalancesbetweenresearcher

andparticipant.Researchmethodsshiftsthepowerdynamicswheretheparticipantistheexpert

knowledgeproducer,andtheresearcherbecomesafacilitatorandco-creatoroftheoutcomeof

thearts-basedresearch(KlienandMilner,2019;Lys2018;Boydell2018;Sweet&Escalante2015;

Boydelletal.,2020).Ifollowedthecourseofdiscussionoftheparticipant,probingonlywhen

required,andnoticedmanyinstancesthatcouldindicateashiftinpowerimbalanceduringthe

courseoftheinteractions,suchasparticipant’scomfortaboutcallingusatoddhours,haltingthe

interviewtoattendtothehouseholdchoreswhenrequiredandwiththeirfrankness,humour,

honestyandopennesswhensharingsensitivedetailsoftheirexperienceofbirthingandother

aspectsoftheirlife.Thistrustwasgrowing,itcouldbeseenmorestronglyinsubsequent

interactionsandinthenatureofthecontentwediscussed,thatoftenwentofftrack,butwomen

sharedwhattheyfoundrelevanttothecontextofmyresearch.Thischapterisaresultofsuch

off-trackconversationsthatprovidedarichunderstandingoftheparticipant’sunique

perspectivesofwhywomenexperiencerespect,disrespectandabuseduringchildbirth.

7.2 Researchquestion

Whatarewomen’sperceptionsoftheunderlyingfactorsdrivingrespect,disrespectandabuse

duringchildbirthinBihar?

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7.3 Objective

Tounderstandthedriversofrespect,disrespectandabuseduringchildbirth,fromqualitative

participatoryarts-baseddataaboutwomen’sexperienceofgivingbirthinBihar,India.

7.4 Findings

7.4.1 Powerinfluencescareduringchildbirth

Powerwasevidentinthewaywomeninteractedamongstthemselvesandwithothersintheir

homeortheirsocialenvironmentandtheobstetricenvironment.Twokindsofhierarchiescould

benotedfromtheseinteractions;1)socialhierarchyand2)medicalhierarchy(whichisembedded

withinthesocialhierarchy).Powerinrelationshipswithpeopleincreasesasonegoesupwards

andwomenareatthebottomofboththehierarchies,asshowninFigure7.1.Allkindsofpeople

(especiallyasmentionedinsection6.5.6aboutpeopleinthebirthingenvironment)andtheir

relationstowomenmentionedbythemintheirinterviews,areshownhere.Thehierarchyis

createdafteranalysisofwomen’snarrativesabouttheseactorsinthehouseholds,

neighbourhoods,communityandobstetricenvironments.

Figure7.1 Hierarchyofpowerrelations(Author’sown)

Inthehospitalenvironment,thedoctorcouldbeseenatthetopofthehierarchy,asobserved

fromwomen’sresponses.Whenaskedtorankallthepeopleinthebirthingroomintheorderof

theirimportance,Sujatamentionsthatthedoctoristhemostimportantpersoninthebirthing

room,andevenforthecareprovidersaroundherlikethenurseanddai,thedoctorwaspriority.

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Sujataforgetsherselfwhenrankingeveryoneintheorderofimportanceandpower;andwhen

sheisremindedofherself,shesharesconfidently,withalaugh,thatwhilesheshouldbethemost

importantpersoninthebirthingroomalongsideherbaby,thatisnotthereality.Theinferiority

canbenoticedinthelanguageusedbywomenindescribingthemselvesassomeonewhowill

needtofollowthecareprovider’sordersandthattheyhavenochoiceorrighttoconsentinthe

situation.Thiswasobviousinwomen’snarrativesofbeingtreatedlikeanobject,apassive

participantandoftenbeingatthereceivingendofthecareprovider’sanger.

“‘Ifyouaresoafraidwhydidyouconceive?Whatistheneedofhavingchildren?’Theysaysuch

things,whatcanwesay!Ifeelangry.ButIamadmittedunderyourcare,so,Iwillhavetodowhat

yousay.IfIdonotdoasperyourorder,thenyouwillagaindosomethingtoharmme.SoIhaveto

listentothem….Ortheymightharmmeinsomeway.”(Ria)

“Theydecidedontheirown…Iwasinthedeliveryroom.Weallwanttohaveanormalbirthbutit

dependsonthedoctorwhattheywanttodo.Whatisbest!”(Sujata)

“Thenursewasverysadbecausewewerecreatinginconveniencesforthemearlyinthemorning.”

(Amrita)

Thiswasmanifestedinthewaycommunicationbetweentheseactorsplayedout.Doctorsand

nursesdidnotdirectlycommunicatewiththewomen,nordidtheyexplaintheproceduresto

themorseekconsent.Theytreatedwomenasapassiveparticipant,asanobject.Themost

extremecasewasseeninPairo’sfirstcesareanbirthwhichisalsoshowninherbirthingstory(Box

7.1)12.Pairofeltthatthedoctorwasover-confidentanddidnotcarewhatherpatientsmightbe

thinkingofher,asshewasprescribingmedicineswithoutdescribingwhattheyareforandjust

expectingherprescriptiontobefollowedwithoutanyexplanation.Shealsofeltthatthe

pediatrician,whoscoldedherhusbandafterhavingbeenatfaulthimself,justmadeamistake.

Shefeltshehadnorighttofeelangryorconcernedaboutitbecausehewastreatingherbaby,so

wasonlyexercisingthepowerhehadoverher,andherfamily.Adisplayofphysicaloverpowering

wasalsoseenintermsofrestrainingwomenduringvariousinterventionswherepeoplearound

birthfromhomeandhospitalparticipatedinrestrainingthebirthingwoman.Womendidnotlike

this,butconsidereditnormalandhencedidnotreportgrievance.Powerwasdisplayedby

completelyignoringthebirthingwoman’spresenceintheroom,andnotgivingheranychoiceor

voicebycuttingallcommunicationswithher.ThecommunicationtookplacewithwhatIcallthe

‘surrogatedecisionmakers’whoconverseonbehalfofthebirthingwomanwhoiscapableof

makingherowndecisions.

12For better impact please look at Pairo’s birth map in Figure 6.11 while reading her birthing story in Box 7.1.

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“Theyweretalkingaboutme,aroundme,butnottome.Theywereonlytalkingtomyparents.

Theywereinformingthemaftercheckingme.Ididnotaskthemanything.Whatisthepointofme

askingthemthingsunnecessarily,theeldersarethereforthat.Theyneedtoknowanddecide

things.”(Urmila)

“Shedidnotneedtoaskmyname.Shewascallingmeyou,you.”(Sujata)

“Iwantedtostraightenmylegforawhilebuteveryonewasholdingmedown,mylegsandhands

fromallfoursidestightly.Icouldnotbearthat,thetouchofanyone.”(Urmila)

Athomewomenfollowthedecisionsoftheirguardianswithoutquestioning.Fatheratmayka

(maternalhome)andhusbandatsasuraal(in-lawsplace)arethepeoplewiththehighest

authority.Inthebirthingenvironmentthefatherandhusbandhavealimitedrolebuttheelderly

womensuchasthemother-in-lawandthemotheroftenmakethedecisionsaboutpregnancyand

childbirthandalsonegotiatedthatwomennotfussabouttheinterventionswiththeclassic

‘womenhavetoendurethisexperience’.Thisisseeninsomeofthequotesingender,cultureand

structureaswell.DaiandASHAshaveadualroletoplayaswell,whichisevidentfromASHA’s

placementinbridgingthegapbetweenhomeandhospital.Daiisoftenseenprovidingcarein

boththeseenvironments.

“She(ASHA)toldme‘youmighthavewithdrawnthemoneyfromyouraccount.’…Igavehermy

passbookandtoldhertocheckifshedoesnotbelieveme”(Amrita)

Participantsoftendidnotquestiontheauthorityofanyoneandfollowedalltheinstructions

withoutresistance.Theywouldgobacktothesamecareproviderwhohaveabusedthem,

avoidinganyconfrontation.Therearenoconsequencesforhealthcareprovidersforviolence

againstwomenandthenewbornintheobstetricenvironment.

“Hewasagooddoctorandweknewthathemadeamistake…hescoldedmyhusband…Ijustfeel

heprobablydidnotdoitintentionally.ItrusthimenoughthatIstillgothereformychild.ButI

neverconfronthim(doctor).Didnotwanttohurthisfeelings.”(Pairo)

“Theyaredoingtheirwork,theyarenotatfault.Theyweredoingastheyshoulddo.Accordingto

mylevelofpain,Iwasalsobehavingacertainway.Atthetimeofbirth,theyusedtoremovethe

clothesandliftitup,butthatisnecessary.”(Sujata)

Thefactthatthe‘surrogatedecisionmakers’donotfeeltheneedtoconveythecommunication

theyhadwiththecareprovidersaboutthecourseoftreatmentordecisionsandchoicesmade

aboutthewoman,isastounding.

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“Iwasthinkingthesepeoplewouldthinkaboutmywellbeingonly.They’llhavemybestinterestin

heart,mymotherandhusband.Ibelievetheyshouldhavetoldmeaboutitbuttheydidnot.What

shouldIsay,Iwasjustapatient.Butthesethingsshouldhavebeenexplainedtome.”(Pairo)

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Box7.1 Pairo’sbirthingstory

Pairo’sBirthingStory

Myheartwasbeatingoutofmychest,becauseIknewwhatwasgoingtohappennext.Heheldmyhand

tightly,astranger,butitfeltgood.Asifsomeonemyowniskeepingmecalm.Scared,Iaskedhimtopress

hishandonmychest,onmyheart.Iama29yearsold,governmentschoolteacherandthiswasmy

secondchildbirthayearago.

Memoriesofmy1stbirthhadtraumatizedme.Everythingisstillfreshinmymind.EvennowwhenIthink

aboutit,Ijustknow,neveragain.Iwasn’tinpainbutIwasleakingsomefluid.Soeveryonetookmetothe

governmenthospitalthatmorning.Thereweremanywomenallwaitingfortheirturn,andthenIsawthat

doctorwearingaplasticglovecheckingeveryoneinthatdirtyenvironment.Iranfromthere!Iwastakento

aprivatehospitalnext.Theladydoctorjustmadethenurseliftmypetticoatandnightieup;andforcedher

handinsidemewithoutanyexplanation.Istartedscreamingandcryingoutofpain.“Youcanneverhaveanormalbirth,ifyoucannotbearthispain.”ThenextthreedaysIwasinobservationwhenIwasgivennineteenbottlesoffluids,manyinjectionstoincreasethelabourpainandnumerousvaginalexaminations.

Thenurseswouldjustcomeandinserttheirhand,notevenmindingthecrowdandhowmanypeopleare

aroundme.Iwasfrustratedandcomplainedtothedoctor,“whydoeseveryonehastofirstinsertahandinsideme,withouteventalkingtome.Istherenootherwaytocheck?”.Shesaidnothing.Mymothersays,

“womenhavetoendurethat,tohaveachild”.EvennowsometimesItellmummy,“thatwasn’tright!”

Iwasinthecafeteriawithmyfamilywhenthenursecameandjustdraggedmebymyhandtothe

operationtheatre.Noexplanationgiven!MyfamilystayedoutsidetheOT.Therewere8menintheroom

allinregularclothes,liketheyareonapicnic!Oneofthemsaid,“getup!”.Gavemeaninjectiononmy

backandmademeliedown.Noexplanationgivenagain!That’swhenIrealizedIamgoingtogetoperated,

noonetoldme.Myonlysolacewasthattherewon’tbeanylabourpain.Anothermanblindfoldedme

becausethelessIsee,thelessuncomfortableIwillbe.Ifeltsomeonetalkingmypetticoatoffandlifting

mynightietomychest.Theyweretreatingmelikeadoll…orlikeananimal…doingwhatevertheywant…

notcaringaboutmeatall.LikeIdidnotexist!Iwasfilthyandmyhairtangledwithoutashowerin4days

myclothesgettingdrenchedinmyfluidanddryingonme.Ididnotknowanyoneinthatroom.Iasked

aboutmyladydoctortothisotherguywhowasapparentlyherson.Shearrivedlater.

Theyplayedmusic.Itwascalming.Therewereothersoundstoo,ofinstrumentsandscissorscutting

throughmeliketheyarecuttingajuterag.Everyonewastalkingamongstthemselveswhiletheytookthe

girloutofmybody.It’sagirl,theydiscussedandIthought,“Iwilltieherhairintwopig-tailsandtakehertoschoolwithme.”Istayedinhospitalfor10daysafterthatbecauseIhadfeverandchillsandwasrecoveringfromsurgery.Meanwhilethebaby’sdoctordidnottiemybaby’scordproperlywhichkept

bleeding.Shegotinfectionthesamenightandmyhusbandhadtotakehertoanotherhospital,3

kilometersaway,everydayforinjections.Istruggledtobreastfeedmybabyandevenholdherproperly.

IcriedwhenIcouldnothaveanormalbirththe2ndtimewithmyson,2yearslater.Thedoctorpressedon

theincisionandithurt.“itcangettornandyoumightgetacutdownthereanyways.You’llneedabigoperation.”Shesaid.Thenormalbirth’spainlasts4daysbutthemiseryofCSlastsforyearsandbreaks

yourbody.InthebeginningsometimestheincisionusedtohurtlikesomeonerubbedchillipowderonitforthemedicineIwasprescribedtoapplyonittogetridofpainandrednessinthefirstplace.Thiswasa

quackinourvillagewhoconsidershimselfourarea’sMBBS!

Myhusbandasks,“whydidyounotgetsterilizedifyoudon’twantanotherchild?”.“Yougetsterilized”,Itellhim.Hemakesexcusesthathe’llgetweak.Sowebothdon’tgetitdone.ButIdoteasehimsaying,“mylifeisinyourhands”whenwegetintimate.IfeelIneededtosharethesewithsomeone,itallneededto

comeoutasIcouldnottalkaboutitwithanyone.Thatdaysomehowgotover,butthosehaunting

memorieshavestayedwithme.

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7.4.2 Genderinfluencescareduringchildbirth

Gendermanifestedinmanywaysandisakeyfactorinfluencingtheimbalanceofpowerbetween

differentactors,asshowninFigure7.1.Sonpreferenceisshownindifferentwaysbypeoplefrom

homeandhospitalinthebirthingenvironment.ThisseemedtobeapartoftheBihariculture,

thatbeginsatbirthandinfluenceseverypartoftheparticipant’slifeincludingtheireducation,

financialstability,occupation,marriageandeveryroletheyplay.Careprovidersdemandmore

moneywhenasonisbornandofferadiscountonthebirthofagirl,tomakeupforthesorrow

thatdescendedonthehousehold.Thefamiliesavailthediscount.

“Nobodywasplayingwithmygirl.Noonewastakingherintheirlap(whenshewasborn).Then

slowlypeoplestartedwarminguptoher…mymother-in-lawwasveryhappywhenitwasaboy.”

(Amrita)

“Ifitisagirlbabytheyaskforlessmoney,it’smoreforaboy.Ifsomeonegivesbirthto2-3girls,

thentheydon’taskforhappinessmoneybecauseit’samatterofgreatsorrowforthefamily.They

(careproviders)understandthesituation,whentoask(formoney)andwhennotto.”(Sujata)

Womenoftenhavenosayinthemajordecisionsoftheirlife,regardlessofeducation.Thisreflects

intheirdecisionsaboutpregnancy,birthandfamilysize.Adoptingfamilyplanningmethodsis

treatedaswomen’sbusinessandwomenacceptitastheyacceptthatdomesticworkiswomen’s

domain.Thiscouldbeseeninthehugedifferenceinthefemaleandmalesterilisationratein

BiharandIndia,indicatingthatifonehastogetsterilisedbetweenthecouple,itwillbethe

woman,andallthefamilymembersweighinonthatdecision.Womendidnotknowmuchabout

money-relatedmatters,theyhadnosayinexpensesandoftendidnotknowhowtomanagea

bankaccount,eventhoughmostwomenhadabankaccountwhichismandatorytoreceivethe

JSYincentive.

“Myworkistojustcookandtakecareofthehouse.SoIdon’tknowmuch.”(Sita)

Womenarenotaccustomedtothesegenderrolesforthemselvesandforothers.Forinstance,

theyassumeawomaninthebirthingareaisanurseandamanisoftenadoctor.Theyalso

assumemenintheOTtobenurses,toensureoneselfthattheirpresencetherewasnecessary.

“WhatwillIcallthem,gentsnurse?Aretheynurse?Imeancompoundermaybe?”(Pairo)

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“Thedoctorplayedmusiconhismobile…Iaskedwhereismadam?Hesaid‘mummyiscoming!’

ThedoctorwhomIusedtoshowwasaladybuthersoncameintheoperationroom…hehada

degree…Ididnotknow,heisadoctor.”(Pairo)

ThepersonwhoPairoreferredtoasdoctor,mayhavementionedthatthedoctorwashismother

toindicateandexercisethesamelevelofpoweroverPairo.Womencitemanyreasonsforthe

obstetricviolence.Theyfeelthatrespectisfortherichandifonehasthefinancialmeanstopay

the‘happinessmoney’,apartfrombearingthecostofcare,their‘patient’willbecaredforwell.A

‘guardian’accompanyingthemindicatetherearepeoplewhowillpay.Anexperienceofprevious

birthmatters,becausethewomenwouldhavegonethroughthepainbeforeandexperienced

obstetricviolence,andwouldbehaveaccordingly.Povertyandalackofeducationinviteabuse,

accordingtoparticipants.

“Whenpoorcomeforcare,theygetscolded.Wearepoor,uneducated,weakanditisourneed

thatwewent,sowecannotsayanythingandhavetolistentoeverythingtheysay.Aneducated

personknowshowtotalktothem…aneducatedpersonwillbeabletoreasonwellwiththembut

wecan’t.Wehavetobearthebruntoftheiranger.”(Amrita)

“Theonewhoscreamsgetsabused!Theyarenotusingtheirstrengthtopushbuttoscream.

They’llhavetolistentoabusivelanguage.Thosewhohaveahabitofbirthing,donothaveto

listentosuchthings.Newmothersdon’thaveahabitofbirthing,sotheydon’tknowmuch,they

havetolistentosuchthings.So,theywereabusingme.”(Ria)

“IwasblindfoldedbecauseIwouldhavefeltuncomfortablebecausethereweremen.Therewere

noladies.Thedoctorwhowasgoingtoperformtheoperationwasalsoaman.”(Pairo)

Pairoassumesthistobethereasonwhyshewasblindfolded.Therewasnoexplanation.When

womenaskforanexplanationorquestionaboutaprocedureormedicationorthedurationof

labour,itoftenfallsondeafearsandisnotrespondedtobythecareproviders.Treatingwomen

asapassiveparticipantintheirbirthisgender-based.Womenunderstandthis,andthatas

womentheyhavelittlesay.Women’spainisnotaddressedorevenacknowledgedinmost

scenariosasIdiscussinthepreviouschapter.

“Ikeptaskingforanesthesiabuttheywerenotevenlisteningtomeandkeptdoingit(episiotomy

repair)…Ikeptscreamingandeveryonewasholdingandstitchingme.Ididn’thaveasmuchpain

duringdeliveryasIdidwhentheystitchedme.”(Urmila)

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“Idofeelthatthebadexperienceswerewithmybody.So,thosethingsdon’tmattertome

anymore.Whathappened,happenedwithmybodybutmyspiritisuntouched.”(Pairo)

Themanifestationofgenderindifferentaspectsofawoman’slifecanbeseeninthepoemfrom

Amrita’snarrationtitled‘I’.

Box7.2 Amrita’sI-poem-‘I’

I

Imighthavebeen18or19yearsold.

Ihaveahusband.

Irunmyshop,takecareofmychildrenandmyhouse.

IgotothenearbyPHC.

Igothereformedicinesandall.

Igothere.

Iwenttheretogetchecked.

Ihadmyboythere.

…Ifallsick,mychildfallssick.

Iamfinenow.

Ihavetakenmedicineatnight.

Igetheadachesatnight,Igetfever.

Idon’tknowwhetheritisduetotirednessorsomethingelse.

Iwasveryhealthybefore.

Ihadnofever,nothing.

ItakemedicineandstaywellforaweekandthenagainIfallsick.

Iamallalone.

…Ifallill,thereisnoonetolookafterme.

Ionlylookafterthem.

Igotothemarketforpurchasingthethingsformygroceryshop.

Isellit.

Ileavemychildrenatthenearbycentre.

Ileavemychildrenwiththem.

Igethelp.

Ileavethechildrenwiththewomeninmyneighbourhood.

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Iwasalone.

Iusedtodoallthehouseholdworkalongwithtakingcareofgroceryshop.

Icarriedbagsofrice,veryheavy.

Iusedtolift25kgjuterags.

Iusedtositatthegroceryshop.

Iwasalmost8monthspregnant.

Iusedtocallmysisterforhouseholdwork…cookingandall.

Itookrestthen.

Ihadatwo-year-olddaughter.

Iusedtotakecareofher,likewashingclothes,cleaningher,bathingher.

Iusedtokeepherwithme.

Iusedtogetalotofrest.

Ijusthadtoeat.

Itook3daystogivebirthtomyfirstchild.

Iwasolder(18years)whengivingbirth.

Iusedtobeverysickwiththesecondchildinmywomb.

Ididnotlikeanyonetalkingtome.

Iusedtoalwaysfeeltired.

Iusedtobelethargic.

Icouldnoteveneatmuchfoodorwater.

Ididn’tlikeanything.

Irelaxed.

Ialsohadnauseaandvomitingduringmyantenatalperiod.

Imeanmylipsandtonguebecameredandblisteredandmouthwasdry.

Iworeasareeforbothmybirths.

Ihadababyboy,theyallweresohappyandtheystartedtalkingwithmepolitely.

Ihadthegirlchild,everyonewashappyatmymothers’side.

Ididn’thavemuchtroubleinmyfirstbaby.

Ibirthedagirl.

Iusedtodoeverythingforher,putakala-tika13onherforeheadandputhertosleep.

13Blackkohldotontheforeheadwithwithculturalsignificanceofprotectionfromevileye.

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Iwasalsohappy.

Iwashappybothtimes.

Iusedtofeelalotofpainwhilepassingurine.

ImightbedarkskinnedbutIamveryneatandclean.

ItelleveryonehowIgavebirth.

Ihadnormalbirth.

ItoldthemwhatproblemIhad.

Iwillfeelrespectfulwhentheywilldomydeliveryontimewithoutmuchdelay,whentheywill

speaktomepolitely,withasmile.

Iambirthingaboyorgirl,Ishouldbetreatedwell.

Iwantsisters(nurses)tocheckmenicely.

7.4.3 Structureinfluencescarearoundchildbirth

Systemsaroundbirthfollowstructuresthatincludecertainnormsanddeep-rootedcultures,and

areinfluencedbygenderandpower.Women,couples,familiesandcommunitiesareconditioned

tocarryonthesestructureswhichrelatetotheirhome,extendingtothebirthingenvironment

andbeyond.Thisisnoticedintheirnarrativeswheretheywanttofollowaritualbecauseitis

normalized.Thestructureofbirthingmayincludemanygoodandbadaspectswhichmay

encouragewomenandpeopletomakebirthingchoices.Thisstructureencouragespeopleto

strengthenthe‘doctor-knows-best’culturewhichmakesthemfollowcareproviders

unquestioningly.Questioningcanalsobeconsideredoffensivebetweenpeoplewithsuchhuge

hierarchicaldifferences.

“Weallthinkweshouldhaveanormalbirth.That’sthebest!Butaftergoingtothedoctor,it

dependsonherwhatshewillsay.”(Sujata)

“Mymother-in-lawsaidifshedoesn’tcheckyoudowntherehowwillthebabycomeout?’We

don’tunderstandthisbuttheydo.”(Sita)

Sujatafeelswhatthedoctorandothercareprovidersdoinabirthingenvironmentisinthebest

interestofthebirthingwomen.Itmightnotbecomfortable,butthewomenhavetogothroughit

anywaybecausetheydonothaveachoicetodenycare.Participantsbelievethatthecare

providersknowwhatisbestforthemandhopedthattheirrespect,dignityandcomfortwouldbe

consideredwhenmakingchoicesforthem,andthattheyshouldbegivenachoice.Forinstance,

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Urmilasharedthatbabiesareexchangedatgovernmenthospitalsbasedonsex.Riafeelsherbaby

couldhavebeenexchangedwhenshewasinitiallyinformedaboutastillbirth.Womenhave

assumptionsaboutthequalityofcaretheycanexpectatgovernmentandprivatesectorsandalso

atdifferentlevelsofcareprovisionwhichhelpsthemtodecideandplanaboutchildbirth,starting

withwearingapetticoattoensurealittleprivacybykeepingthelowerhalfofthebodycovered,

inanobstetricstructurethatprovidesbareminimumlogisticsupport,tochoosingwherethey

wanttogivebirth,basedonhowmuchagencytheyhaveinthesematters.

“Ingovernmenthospitaltheydonotcutopenthebellyunnecessarily.”(Amrita)

“Peoplesayaboutgovernmenthospitalthatyougetthefacilitythatyoucanaffordtopayfor.The

moneywegiveascertainstheconvenienceweget.Ifyougotoaprivatehospital,theywillrobyou.

Youhavetobringeverythingyourselfingovernmentbutdon’tneedtopaythedoctor.”(Ria)

“Thosewhoareaccompaniedbytheirguardianaretreatedwell…iftheyfeelthattheywontmake

moneyafterbirthfromguardians,thentheydonottreatwell...theydonotgiveanyattention.”

(Sujata)

CallinganambulanceandASHAwheninlabour,ispartofthestructure,soisexpectingtheJSY

incentiveafterbirthinginagovernmenthospital.

“Weusedit(JSYincentive)uptobuyknickknacksforhome.Forvegetablesandotherimportant

things.Ifyouhavemoneyinyourhands,somanythingscomeup.Weusedupthemoneyfor

householdrelatedthings.”(Sita)

Obstetricviolenceisstructuralandnormalised.Womenexpectsomeextentofdisrespect,abuse

ortheabsenceofrespectfulcare.Theyacceptittoacertainextent,anddonotobjecttowhat

theycanendure,complainingandconfrontingisnotdesirable.Theyseekcare,knowingmany

aspectsofbirthingpracticesthattheydonotnecessarilylike,buttheconsensusisthattheyhave

toendureittogivebirth,everywomanenduresit.Theysharemanyargumentsthatsupportthis

beliefwhichincludestheirlowerstatus,lowlevelofeducationincomparisontothecare

providersandthefactthattheyarecareseekers,sothecareproviderhaspoweroverthemasis

thenatureofthestructure.

“Hesaid,‘getup’andinjectedinmywaist,takingmyclothesoff…theyweretreatingmelikea

doll.Theywerenottakingpermissionfromme…Noexplanation!”(Pairo)

“Iquicklydrankit(soda)asIhadorderedit,butthosepeople(hospitalstaff)wantedittoo.It

happensinthegovernmenthospital,peopleaskyoutofeedthem.”(Sujata)

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“IleftmyeducationwhenIwas13.Butit’stheir(parents)responsibilitytosendmeforfurther

studieswhichtheydidnotdo.Theyshouldhavebeenstricter.”(Urmila)

Thestructureofsocietyshapespeople’sattitudesandbehaviourabouthowwomenshouldbe

treatedingeneral.Theireducation,mobility,financialindependenceanddecisionmakingright

andchoicesareallpartofthesocietalstructure.Thishasaninfluenceonhowwomenaretreated

inthehospitalandalltheactorsarepartofandactingaccordingtothestructure.Urmila’s

birthingstoryinBox7.3andherbirthmapinFigure7.2,showsthisaboutherlife.

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Figure7.2 Urmila’sbirthmap

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Box7.3 Urmila’sbirthingstory

Urmila’sBirthingStory

Iam25years’old.Ihavethreechildren,allunder5years.Igavebirthtoalloftheminaprivatehospital

nearmymaternalhouse.Ihadheardfrommysisterinlawaboutherhorribleexperienceofgivingbirthin

themostreputedgovernmenthospitalinBihar.Shewasalwaysaloneandhadtoshoutforattentionevery

time,astheywerealwaysbusychatting.Also,nomatterwhichbabyyougavebirthto,agirlorboy,you

canbringababyofanysex,ifyouhavethemoney.Peopleingovernmenthospitalwaitforyourdeath.In

privatehospitalwepay20,000rupeesforbirth,butatleastwecanaskforthingsasourright,sincewe

paidforit.Allmybabieswerebornfromdownunderthroughtinyoperation(episiotomy),exceptthelast

one.

Mygrandmotherhadtoldmeduringmy1stchildbirth,thatyou’llleaksomethingfromwhereyoupass

urineandthefirstthreepainswillbewrong.Youmustgotothehospitalthe4thtimeyougettheright

pain.Mysecondbirthingexperiencewastheworstamongthethree.Thesamepeopledeliveredmy

babies,thesamedoctor,onegoodnurseandtwobadnurses.Theykeptshoutingatme,whereasthe

othernursecalmlyinstructedeverything.Theykepttalkingaboutmychildbirthtomyparentsandothers

andamongstthemselves,nottome.Thedoctorwasnicetoo.Shekeptmecoveredandexposedonlyas

muchasneeded.Thedoctordideverythingfromcheckinginmyvaginaifmybabyiscoming,togiving

injections,fluids,andstitchingmeafterbirth.Thenursesjustcleanedeverythingaroundme.Thenurses

weretherethroughoutthough.Thedoctorhadjustinstructedthemto‘callmewhenit’stime’.Iwasgiventwoinjections,atabletandtherewasaninjectioninthebottlewhichincreasedmylabourpains.Ikept

screamingafterthat,asmypainsincreasedsomuch.Myfathertoldmymothertobeinside,becauseI

mightbescared.IdidnotwanthertotouchmesinceIwasinsomuchpain.Iwantedtohiteveryone.Her

too!

Mythirdbirthwasthebest!Itwastheshortestindurationwithverylesspain.Iwaswaitingtobecut,but

thedoctordidnot.Iwassohappy!Inthepreviousbirththeysaiditwonthurtwhilecuttingandstitching

me.Theysaiditwasjust2-3stiches,butIknowitwasmuchmore.IknewwhenshecutmedownthereandIfelteverystitch.Ifelteverything.Theyheldmedowntightly!Twoofthemheldmylegsandoneof

themtightlyheldbothmyhandsabovemyheadasIscreamedthroughthepainandthedoctorignored

mypleasandkeptstitching.Theysaiddon’tyouwanttogiveussomethingoutofhappiness?Theyfinallybroughtmybabytomehourslater,aftermyfathergavethem2000rupees.

Haveyoudoneanyresearchonalcoholism?Alcoholruinedmyfamilyyouknow!Iamlivingformychildren

andIwanttostartearningtoraisethemtobeawayfrommyalcoholichusband.Hedrivesataxi,drinks

andbeatsme,butItookhimtocourtandheisnowinjail.Iprobablyshouldn’thavedonethat.Hehas

moneyforalcoholbutnotforchildren’seducation.Idon’tknowanythingtogetajob,Istoppedgoingto

schoolwhenIwas13andwasmarriedveryyoung.Iwasveryhappywithoutacareintheworld,but

marriageruinedeverything.Myparent’sshouldhaveforcedmetostayinschool,itwastheirjob.Ihavean

accountinbankbutnomoney.Idon’tknowanythingaboutmoney,Ineverdid.Ineveraskforanythingfor

me,butIcanfightwithanyonewhenitcomestomychildren’swellbeing.

Ineversharedthesethingswithmymotherormyhusband.Wedon’ttalkaboutbirthinfamilyorwith

friends,youjustdon’tdoit.IdidnotknowthatIhadtheneedtotalkaboutmybirth.Youareclosertome

thanmyfamilynow.

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7.4.4 Cultureinfluencescarearoundchildbirth

Cultureguidesmanyactionsduringbirthingthatfunctionatdifferentlevels.Familiesusuallyhave

someculturalnorms,mythsandtraditionswhichcouldbelimitedtothefamilyorsharedbythe

communityoreventhestateorcountry.Thisisbasedontheaspectsthatbindthemtogether

whichcouldbefamilyties,gender,caste,religionetc.Whowillbepresentaroundthewoman

givingbirthisculturalandsoisthepresenceofdai,asnoticedinallthehomebirthsinruralor

urbaninterviewsandeveninthehospitalbirths,althoughthereisnoformalroleforadaiinthe

hospitalbirthingenvironment,andyetsheseemstobeoneofthekeycareproviders.

“Everyonewantedittobenormalbecausenobodyhadgivenbirthbycaesareaninmyfamily

before.Nobodywantedmetohaveacaesarean.That’swhyeveryonewassad,mymotherwas

sadandcryingandsaying‘whathashappenedtomydarlinggirl!’.”(Pairo)

Culturedrivesmanysmallandbigactionsaroundchildbirth.It’sinwomen’sculturetowearsaree

ingeneralandwhentheygivebirth.Wearingasareeand/orpetticoatunderit,helpstoavoid

overexposurewhengivingbirth,beitathomeorhospital.Manycareprovidersrecommend

womentowearanightiewhentheygoinlabour,fortheeaseofwearingandremoving.Notall

theculturesareappropriate,somearequitedamagingforthecommunityandhaveadrastic

impact.SonpreferenceisonesuchdangerousanddominantcultureinBiharthatturnsthebirth

ofagirlintoanatmosphereofsorrow.Eventhoughsexdeterminationinpregnancyisillegalin

India,peopleoftentrytodeterminethesexofthebaby.Ondenial,theymayfeelthattheyare

notbeingtoldbecauseitsnotthe‘preferredsex’.

“For9monthsIassumedIhadadaughterbecauseshe(doctor)won’trevealittome.SoIthought

it’sagirlbecauseshewasn’ttellingme…Thedoctorsaidthatthisisagirl.Peoplewanttheirfirst

childtobeaboy.Theyalsosayifitstartswalkinglateitwillbeaboy.”(Pairo)

“IthoughtIwillhavetwoboysandagirlandthenIwillgetoperated.Butthisisalsoagirl.I

usuallystayunwellsoIdon’twantanymorechildren.”(Sita)

Itisessentialtounderstandhowthecultureofabuseseapsintopeople’sliveswhentheyare

growingupintheirhomeandsurroundings.Thisaidsinnormalisingviolenceagainstwomen,

wherewomenadapttoitaspartoftheircultureanddonotresistviolenceduringpregnancyor

childbirth.Extortionisalsoobstetricviolenceduringchildbirth,whichiscalled‘happinessmoney’

especiallyofferedgenerouslyfollowingbirthofamalebaby.ItisaculturalcharacteristicofBihar.

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Oppressionofwomen,givingwomenasecondarystatusinsocietyandwomen’soveralllackof

importance,iscultural.Thisisevidentinwomenenduringpain.Womenaresupposedtoendure

painandtheydothataslongastheycan.Theirsilenceaboutanythingthathappensinthe

birthingenvironmentispartcultural.Womenunderstandthattheyarenotsupposedtoconverse

inthebirthingenvironment,theyarenotsupposedtoquestionordoanythingtodrawattention.

“IwasfeelingbadbutIcouldnotsayanythingbecausewewereinthehospital.IfIsayanythingto

themthentheywillsay‘youarenottheonlyonehavingababyhere.Thereareotherpeopletoo

whodon’thaveanyproblem.Youdon’thavesomethingspecialdownthere’.”(Ria)

“EverythingwashappeninginfrontofmebutIcouldnotsayanything.Youarenotsupposedto

talkaboutoperation…youloosealotofbloodandthebodybecomesweak.”(Pairo)

“Ifirsttriedtobearthepainbutwhenitwasunbearableforme,thenItoldmymother.”(Sita)

Birthingisconsideredwomen’sbusiness,butironicallythewomangivingbirthhasnosayinit.

Thewomenaroundthebirthingwomanmanagemostthings.Womenoftengototheirmother’s

housetogivebirth,mainlyexpectingsomerestduringthelatestageofpregnancyand

immediatelyafterbirth.

“Wedon’tdoanyheavyworkjustcookfoodafterbirth.Noliftingheavythings.”(Sita)

“Iwasatmymother’shouse…therewasnoonetotakecareofmeheresoIwenthome.”(Sita)

Womendonottalkaboutbirth,regardlessoftheircuriosity.Theyaresurroundedbywomenwho

havegivenbirthbutdonotsharethegorydetailsofthebirthingprocess,andwomenacceptit

withoutquestioning.Theydonotdiscussitwiththeirhusbandsasitistooshameful.Theculture

istonottalkaboutbirthingandbirthsinBihar,itisstigmatised.

“Atthetimeofbirtheverybodykeepssearchingforallthis(information).Everyoneiscuriousto

knowallthis.”(Sujata)

“HowcouldIaskhim(Husband)‘howwillitcomeout?’”(Pairo)

“WhatwillhappenisGod’swill.WhenGodwillwantittohappen,itwillhappen.”(Pratima)

Thelackofimportanceaccordedtowomenbeginsatbirthandiscultivatedthroughlivingalife

thatisnotvaluedmakingwomenawareofthateveryday.Theirdateofbirthisofless

importance;itwasnotcelebratedorremembered.Decisionsaremadeforthemandtheyare

supposedtofollow.UrmilaandRia’sIpoem(Box7.5)presentthisaspectoftheirupbringing

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whichmentionshowimportantitistobeafair(lightskinned)girltobemarriageableandtogive

birthtoasonthereafter,assoonaspossible.

“HowoldamI?Idon’tknow.”(Sita)

“Inevertookanydecisionformyselfneitherformychildbirth.”(Urmila)

Box7.4 Ria’sIpoem-HadIbeenfairerandhadbirthedaboy

HadIbeenfairerandhadbirthedaboy…

IwouldhavebeenhappierifIhadason.

Ihavenosonsorbrotheratmyhome.

Ihadonesister,shepassedawayatanearlyage.

Ihaveneverseenmyfather.

Iwas1½yearsold,whenmyfatherpassedaway,hewasmurdered!

Iwasallaloneatmyhome.

MymothertookcareofmeasIgrewup.

IthoughtifIhadason,thenhewouldcarrymyfamily’snameforanothergeneration.

Iwasexpectingason,butIhadadaughter.

Iwassad.

Iswear,Iwassad!

IwonderwhyIdidnothaveason,whyIhaveadaughter.

IliveinthishouseandnooneasksmewhereIwork.

Igotowork,butpeoplesayIamgoingtodowrongthings.

Ifeellikecrying.

Ithink,ifIhadason,hecouldsupportme.

Ishouldhavehadason!

Iwasmarriedwithgreatdifficulty.

Iusedtotellmother,‘Idon’twanttomarryhim.’

Myfamilyruinedmymarriage.

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MyunclesaidIworkinaboutique,inaparlour.

Iusedtoworkverylate,11amto8or9pm.

Idon’tworkthereanymore.

Myhusbandstarteddoubtingme.

IsaidIwillnotstaywithhim.

IfIhadbeenfair14,Iwouldbebeautiful,mymotherwouldhavemarriedmeofftosomeonenice.

Iwouldhavebeeneducated,Iwouldhavebeenbetteroff.

Myluckwasbad!

7.5 Discussionandconclusion

Gender,power,structureandcultureinfluencethedecisionsmadeforwomenbywomen,by

theirfamilymembersandcareprovidersabouttheirlives,includingpregnancyandchildbirth.

Figure7.4summarisesvariousaspectsofthesefourdomainsthatarecross-cuttingandoverlap

acrossdomains.Forinstance,women’slackofchoiceisgender-based,culturallydeep-rootedand

womenareconditionedintoit,inapatriarchalsocietalstructure.Itmaintainspowerlessnessby

keepingwomeninalowerpositioninthesociety.Similarly,theotheraspectshavebeenputin

onedomaineach,basedontheresearcher’sunderstandingofwhichdomaineachofthese

aspectsrepresentbest.Theircross-cuttingnaturecanbenoticedinthefindingsaswell.Idecided

tokeeptheminaparticulardomainbasedonwhatmademostanalyticsensetome,butthisis

subjectiveandthereadermayfeelthatanaspectbelongstoadifferentdomain.

14Lighterskincolour

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Figure7.3 Impactofgender,power,culture&structureonwomen(Author’sown)

Womenreportalackofagencyinmakinganydecisionsaboutthemselvesandtheirbody

includingduringpregnancyandchildbirth(McAraCooper,2011).Thisbeginswiththeuncertainty

ofwhetherwomenwillbeallowedtobebornowingtotheunwantednessofafemalechild

(Hawkesetal.,2020).Thisisfollowedbyalifecoursethatincludesnotbeingallowedtomakeany

decisionsabouttheireducation;nothavingfinancialindependence;havingnosayinconception

andcontraception;notbeingabletodecidetheirfamilysize;nosayinageofmarriageorpartner

ofmarriage;notallowedtodecidewheretogivebirth;whomtohaveasabirthcompanion;not

beingaskedtoconsentforthemedicalinterventionsandbeingtreatedlikeanobject;enduring

obstetricviolencewithoutgrievancewhichincludesnotbeingallowedtoscreamduringlabour

painsandnotgettingaresponsetoquestionsandbeinginformed,evenwhenbeingoperated,

andnotgivenasayinthecareoftheirnewborn.Thisoppressionofwomenaroundchildbirthand

alackofagencyindecision-makingisinlinewiththeliteraturefromIndiaandothercountries

(Menon,2012;Chawla2006;Chalwa2019;Senetal.,2018).

Villarmea(2020)explainsthatthereasonbehindalackofwomen’sagency,autonomyandthe

frequentdisregardoftheirrefusaltointerventionsisbecauseofthe‘uterineinfluence’.Women

areconsideredincapableofmakingrationaldecisionsduetopain,andwomen’schoiceand

consentisoftensupersededbecausetheyaremerethe‘container’forthe‘foetus’,whois

consideredthekeystakeholderinchildbirth.Thisisacharacteristicofapatriarchalmedicalmodel

ofcare(Oakley1982;Hill2019)evidentalsointhefailureofthedoctortostoponUrmila’sstrong

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resistancetounanesthetisedepisiotomyrepair.Urmila’sanxietyoverherdecisiontoputher

husbandinprison,isasignofthepatriarchy-drivenmindsetwhichcomesfromadeep-rooted

conditioningintothatculture.Heranxietyisaboutbreakingthenormsandtherealisationofthe

repercussionsofthisactofresistanceonherandherchildrenfromherhusband’sfamily,society

andfromherhusbandwhenheisreleasedfromprison.Women’snarrativesdisplayapatriarchal

culturewheretheirvoicesandchoiceshavelimitedscope.Whenpatriarchypermeatesthe

birthingenvironment,medicalinterventionsareprioritisedoverwomen’scomfort,dignityand

choice(Villarmea2020;Mayra,Matthews&Padmadas2021).Urmilapraisedherdoctorduring

herinterview,regardlessofthetraumaticexperienceshenarrated.Thisisindicativeofa

structuralissueandapartoftheculturalconditioningofwomen.Wenoticethisinwomen’s

expectations,acceptance,enduranceandtheirreactiontotheviolenceandalackofdecision-

makingroleduringchildbirthinanobstetricenvironmentandintheirroutinelife,intheirsocial

environment.

Women’sresiliencetoendureviolenceinthehospitalenvironmentisinaccordancetotheir

intimatepartnerviolenceanddomesticviolenceintheirhomeenvironmentinBihar(Jeejebhoy,

2018;Koskietal.,2011).Justaswomenoftendonotexpectrepercussionsforviolenceintermsof

intimatepartnerviolenceanddomesticviolenceinthehomeenvironment,theymaynotexpect

anyrepercussionsforobstetricviolenceintheobstetricenvironmentbecauseviolenceagainst

womenisnormalised.Repercussionsareonself,notontheperpetrator.Therearefewexamples

inthisstudyofwomenwhobrokethisnarrativeandshowedresistance,suchasthatofUrmila.

Sitarefusingtoletherdagarinmother-in-lawdoavaginalexaminationanddecidingtogivebirth

atthehospital,inanareawheremostofthebirthsintheneighbourhoodweretraditionally

assistedbyhermother-in-law.InanotherscenarioUrmilawantingtohithermotherwhenshe

washerbirthcompanion,goesagainstthecommoncultureandstructureofbirthinginBihar.In

thepersonallives,bothRiaandUrmilashareaboutintimatepartnerviolenceandbothhavetaken

astandagainstit,Urmilabysendingheralcoholichusbandtojail,andRiabydivorcingher

husbandwithoutalimony,whichisquiteunheardofinIndiawheretherateofdivorceis0.24%of

themarriedpopulation(Thadathil&Sriram,2019).Receivingrespectfulcare,alongwiththebasic

gestureofbeingspokentorespectfully,changesthatpowerdynamicsandindicatesan

equalisationofthepower-basedimbalancewhereinwomenfeeltheyarereceivingwayabove

theirgrade,whichmayleadtoarelationshipoftrustbetweenthecareproviderandcareseeker.

Womenareconstantlynegotiatingpowerathomeandhospitalandeveryotherenvironmentshe

engageswith.Sheknowssheisatthebottomofthehierarchybystructure,moresoinan

obstetricenvironment,soshediscountsthegoodbehaviouranddoeswhatisbeneficialforher

baby,followsorders,enduresobstetricviolenceandshegoeshomewithalivebaby.

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Thepowerdynamicismoreleveledinhomebirths.Educationorfinancialindependencedidnot

influenceitmuchforPairo,whowantedtobetoldabouttheinterventionsanddenyvaginal

examinations,andatleastrequestforprivacy,butshecouldnotstateanyofthesetoherfamily

membersorthecareproviders.However,theimpactofhereducationandfinancial

independencecouldbeseeninherdecisiontonotgivebirthinagovernmenthospitalandgotoa

privatehospital.Thecultureofsilenceisseeninmostaspectsofwomen’sexperienceswhichthey

acceptandendureintheirusuallivesthatreflectsinthebirthingenvironmentaswell(Shabot,

2020a).Thenormaroundbirthingisthatwomenaresupposedtoendureit,asthatistheusual

courseofinstitutionalbirthanddoesnotfallinthecategoryofviolenceorvictimisationtobe

grieved(Shabot,2020a).

Obstetricviolenceisgender-basedviolence.Theintersectionalityofawoman’sotherbackground

characteristicssuchaseducation,socio-economicstatus,gender,marriage,religion,age,parity,

caste,class,stateandnationmaydeterminehervulnerabilitytoobstetricviolence(Pateletal.,

2018;Jeffery&Jeffery,2010;Senetal.,2018).Thishasalsobeenreportedelsewherewhere

scheduledcastewomenwereseentoreceivetreatmentafterhighercastewomenaretreatedin

Bihar(Pateletal.,2018).Literaturealsosuggeststhataccesstomedicaleducationhas

traditionallybeenlimitedtomostlymenofhighercasteandricherfamilies,whichincreasesthe

socialdistancebetweenthewomanandherdoctor(Prakashetat.,1993).Inmystudywefound

womenbeingabusedduetosomeofthesefactors,whichwerealsoidentifiedbytheparticipants

suchaspoverty,lackofeducation,beingawomanandstateofmarriage.

Structuralintersectionalityexplainswhythewomenareatadisadvantageinapatriarchalculture,

inamale-ledmedicalmodelofcareandthroughthevariousfactorsthatmaintainthedominant

poweroverwomen.Thecurrentstructureofbirthinghaschangedtoinstitutionalbirthsasa

dominantculture,eveninlow-economicsettingswiththeimplementationofJSYaspartofNRHM

(nowNHM).Anjuchallengedthisstatusquowhenshedecidedtofreebirthinherthree

subsequentbirthsfollowedbytwostillbirthsatapublichospital.Freebirthingor‘handsoffbirths’

havebeenontheriseandarebeingincreasinglyreportedincountriessuchasAustralia,

Netherlands,UKandUSforexpressingwomen’sdesiretohaveaninterventionfree,vaginaland

respectfulbirth(Freeze&Tanner,2020;Jackson,2020;Feely&Thomson,2020;Hollander,2020).

Therearemanyaspectsinthestructureofbirthingthatareviolenttowomen,thatviolate

women.Mostwomenstronglyexpressedtheirdisapprovaltowardsvaginalexaminations,when

theywereoftengivennoprivacyandwererestrainedbyothers.Thiscanbeconsideredadisplay

ofphysicaloverpowering.Chawlaconsidersroutineepisiotomyandfemalegenitalmutilationas

violenceagainstwomenassexualbeingstargetedattheirgenitals,women’s‘siteofpower’

(Chawla,2019).Regardlessofthelackofagencyandchoice,thelossofpowerispartofthe

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culture.Respectfulmaternitycarewasseenwherethefamilyhadsomeinfluence,suchasfor

Pairoinhersecondcesareansectionduetotheinfluenceofherdoctormaternaluncle.The

interplayofthesefourdiscourses,gender,power,cultureandstructure,areessentialto

understandtoensurerespectfulcaretowomen(Figure7.4)(Hutter,1994).

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Chapter8 “It’seasytoabuseobesewomen!”:Whydo

somecareprovidersengageinobstetric

violence?

Thepreviousfindingschaptersfocussedonwomen’svoiceandembodiedexperiencesof

respectfulmaternitycareandobstetricviolenceduringchildbirthasprimarycare-seeker.Nurse-

midwivesaretheprimarycareproviderstowomen,whentheyseekreproductiveandmaternal

healthcare.Nurse-midwives’standpointaboutobstetricviolenceisessentialtoensurerespectful

maternitycareandtounderstandthebarrierstheyfaceincareprovision,inlowresource

settings.AsisdiscussedintheFreedmanetal.’sdefinition,thedeterminantsofobstetricviolence

needtobeexploredandaddressedatallthreelevels,individual,structuralandpolicylevels.

Nursingandmidwiferyleadershaveservedatthefrontlineofcareprovisionandexperiencedthe

challengesintheircareersspanningdecades.Theyarenowatthehighestdecisionandpolicy

makingpositionsintheirdomain.Theyarebestplacedtosharethedeterminantsofobstetric

violencefromthecareprovidersside,atallthesethreelevels.Thischapterpresentsnurse-

midwives’perspectivefromdifferentpolicy-makingpositions,tounderstandhowtomake

respectfulmaternitycareareality.Somenursingandmidwiferyleadersreflectontheissueand

thesolutionfromtheirownbirthingexperiences.

8.1 Background

Obstetricviolenceisahumanrightsviolationandarecognisedglobalphenomenonthatmayvary

acrossdifferentculturalandsocio-economicsettings.Ihavedescribedthenatureofobstetric

violencefrompreviousstudiesandfromwomen’sownexperiencesandperceptionsinthe

previouschapters.Thisincludesthecommonlyheardabusiveandsexistcommentsthathealth

workersdirectatwomenduringchildbirthandIhavepresentedhowthisisnormalised,endured

andtoleratedresultinginloweringofwomen’sexpectationsfromcareduringchildbirth.Studies

oftenreflectonintentionalityasakeyconstructinthecontextofhealthcareworkersengagingin

obstetricviolence.Intentionalactionstoharmwomen’shealthandwellbeingaredisrespectful

andabusive.Studiesreportevidenceofseveralformsofdisrespectandabuseglobally,which

beginswithanabsenceofgreetingonarrival,acommondisrespectthatmanywomen

experience,toextremeformsofabuseincludingphysicalviolence,reportedfromdevelopingand

developedcountriesalike(Abuyaetal.,2015;Miltenburgetal.,2018).

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Despitegrowingevidenceontheextentofdisrespectandabuseduringchildbirth,theunderlying

reasonsfromaprovider’sperspectivehavenotbeensystematicallyunderstoodintheIndian

context.Thesecouldbecultural,socialorhealthsystem-relatedfactorsthatmayexplainwhy

womenaredisrespectedandabusedduringchildbirthbytheircareproviders.Between2005and

2016,Indiahasseenanunprecedentedincreaseininstitutionalbirthsfrom39%to79%,yetthere

hasbeenlittleimprovementintheprovisionofqualitymaternalcareservices(NFHS-3;NFHS-4).

Positioningnurse-midwives15inanindependentmidwiferyrolehasbecomemoreimportantin

suchcircumstances,becausetheyaretheclosestcareproviderthatwomencomeincontactwith

duringpregnancyandchildbirth.InIndia,everyyear,approximately27millionbirthsare

reported,andofthese,nurse-midwivesattendoneinfourinruralareasandoneinsixinurban

areas,asprimarycaregivers(Radhakrishnan,Vasanthakumari&Babu,2017).

Studiesshowthat,globally,midwivesfacesignificantprofessionalbarriersbecausetheyarepart

ofaprofessiondominatedbywomen.Midwiveshavehistoricallybeencomparedwith‘witches’

(Ehrenreich&English,1970)andlabelled‘halftaught’,‘totallyignorant’(Oakley,1997)and

blamedfornegativebirthoutcomes.Fromafeministperspective,thisrepresentsadouble

contextofpowerlessnessattributedtosocialhierarchiesforbothwomenintheirsocially

prescribedrolesandnurse-midwivesatalowlevelinthemedicalhierarchy(Sheikh,Raman&

Mayra,2012;Filby,McConville&Portella,2016;Mayra,2020a).Furthermore,alackofleadership

opportunitiesamongnurse-midwivesindecision-makingpreventthemfromadvocating

effectivelyforwomenintheprovisionofquality,respectfulanddignifiedmaternitycare(Maslach

&Leiter,2016;Steege&Rainbow,2016).Midwivesarguethattheirroleincareprovisionis

unrecognisedandtheyareoftendiscriminatedagainstandsuppressedbyphysicians.Such

challengescanleadtoburnout,workplaceharassmentandbullying,causingcareprovidersto

showreducedempathyandcompassion(Maslach&Leiter,2016;Steege&Rainbow,2016)

therebyincreasingthecareseekers’vulnerabilitytodisrespectandabuse.

Theliteraturesuggeststhatpoorworkingconditionsleadingtoburnoutincareprovidersmay

leadtopoormaternalhealthoutcomes(Maslach&Leiter,2016;Steege&Rainbow,2016;Hunter,

2009).Midwives’workhasbeendescribedasemotionalwork(Hunter,2009).Theresulting

depersonalisation,cynicismanddetachmentareusedascopingmechanismstodealwith

workloadandjobstress(Maslach&Leiter,2016;Steege&Rainbow,2016).Thisisevidentin

15IndiadoesnothaveanindependentmidwiferycadreasperthestandardsofInternationalConfederationofMidwives.TheIndiansystemofeducationenablespracticingmidwiferywithnursingthroughadualregistrationofregisteredmidwivesandregisterednurses.Hencetheyarereferredtoasnurse-midwivesinthisstudytoacknowledgetheirdualroleandabsenceofindependentmidwivesinIndia.

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manyaspectsofcareduringchildbirththatincludesaddressingwomenbythecolouroftheir

attireorbednumber;thatdisplaysalackofempathywhenintentionallymistreatingwomen

duringchildbirth.Midwivesreport‘switchingoff’andputtingontheir‘masks’or‘happyfaces’to

appeardignified,whichleadstoemotionalwithdrawalandphysicaldistancingfromwomenthey

arecaringfor(Hunter,2009).Theyfeeltheneedto‘dontheiremotionalarmour’whichsome

refertoas‘surfaceaction’or‘impressionmanagement’,tobeabletoperformwhatthejob

requires(Hunter,2009;Deery,2009)whileinsidetheymightbefeelinglikea‘foodmixer’

(Edwards,2009).Potentialabuseofthemidwifeandalackofopportunityforthemtoprocessthe

emotionsinajobthatinvolvesdealingwithvitalevents,suchasbirthsanddeathsregularly,may

addtowomen’svulnerabilitytomistreatment.

The‘WhatWomenWant’campaignisveryrelevant,asitaskedwomenandgirlsgloballytheirone

keydemandforimprovementinmaternalandreproductivehealthservicesandthetopranking

demandfrom1.2millionparticipantsin114countrieswasrespectfulmaternitycare(WRA,2019).

Theneedforrespectfulcarecanbebetterunderstoodbyunravellingtheunderlyingcausesof

obstetricviolenceduringchildbirth,whichremainsakeygapintheobstetricviolenceliterature.

Clearly,midwifery,nursingandmedicalstudentsshouldbeprovidedwitheducationfreeof

hierarchy,genderandstatusbaseddifferences,andtheyshouldbesufficientlymentoredto

providecarewithoutanyformofbiasordiscrimination.Theabuseofhierarchyinmedical

educationisasignificantbarriertorespectfulmaternitycare(Madhiwallaetal.,2018;Dinizetal.,

2018).ArecentstudyconductedintwotertiarylevelhospitalsinMaharashtra,Indialooked

specificallyatstructuralviolencethroughinterviewswithcareprovidersandfoundnormalisation

ofdisrespectandabuseduringchildbirthandmedicalstudentsengaginginsuchpractices

(Madhiwallaetal.,2018).Furthermore,respectfuleducation,studentsobservingrespectfulcare

andpracticingitintheirpre-serviceeducationiscrucial,sothattheyarenotconditionedto

providecarethatisdisrespectfulandabusive(Moridietal.,2020;Dzomekuetal.,2020).

Evidently,theseunderlyingcausesmaybeperceiveddifferentlybywomen(ascareseekers)

comparedwiththeperceptionsofmidwives,nurses,doctorsandother(ascareproviders)(Beck,

Driscoll&Watson,2013).Ipresentedwomen’sperceptionofthefactorsbehindobstetric

violenceinthepreviouschapter.Thischapterbridgesthegapbyexploringthenurse-midwives’

perspectiveofthereasonsbehindobstetricviolenceofwomenduringchildbirthinthecontextof

India.

8.2 Researchquestion

Whydosomehealthcareprovidersdisrespectandabusewomenduringchildbirthinindia?

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8.3 Objectives

1. Toinvestigatemidwiferyandnursingleader’sperceptionsandexperiencesofrespect,

disrespectandabuseduringchildbirthinIndia.

2. Tounderstandthedeterminantsofobstetricviolencefrommidwiferyandnursing

leader’sperspectiveinIndia.

3. Todocumentmidwiferyandnursingleader’srecommendationsforrespectfulmaternity

careprovisionduringchildbirthinIndia.

8.4 Methods

ThestudyparticipantsarethemidwiferyandnursingleadersinIndiaholdingkey,formaland

informalleadershiprolesinthedomainsofeducation,regulation,administration,advocacyand

serviceprovisionaspresentedinTable8.1.Someoftheparticipantsrepresentmorethanone

domain.Itiscrucialtoexplorethestandpointofprimaryhealthcareprovidersandthestudy

participantshavedecadesofexperienceatthefrontline,providingcaretowomenbeforetaking

onvariousleadershippositionstoinfluenceandmakepolicies.Theselectedleadershavereached

alevelofprominenceintermsoftheirofficialposition.Mostofthemhavereportedlimited

decisionandpolicy-makingpowerevenwhentheyareatthehighestattainablepostsfornurse-

midwives’.Theyunderstandthechallengesinherentincareprovisionandhowthesechallenges

maybetackled.Theperceptionsandexperiencesoftheseleadersareusefulindeveloping

practicalsolutionstoensurerespectfulcareduringchildbirthinIndia.

Table8.1 Participantbydomainofleadership

Domains State National Global Total

Administration 3 2 1 6

Advocacy 8 3 4 15

Education 9 4 2 15

Regulation 4 1 2 7

ServiceProvision 6 1 1 8

*someparticipantsrepresentmultipledomains

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Iusequalitativemethodstoinvestigatethereasonsunderlyingobstetricviolencefromthecare

providers’perceptions.Iselectedparticipantsthroughpurposiveandsnowballsamplinginfive

statesinIndia,namelyBihar(BH),Rajasthan(RJ),Odisha(OD),MadhyaPradesh(MP)andWest

Bengal(WB)andatthenationallevel(NL).Thesestatesrepresentdiversecontextswith

unfavourablematernalhealthindicatorsincludinghighmaternalmortality.Theleadersare

selectedinthreecategoriescomprisingthestatelevelandthenationallevelinIndiaandathird

categoryfromaninternationalperspectivewithparticipantsfromadvancedhealthcaresystems

participatinginglobalpolicymaking.

InIndia,healthisastatesubject,thereforepolicy-makingandgovernanceisdividedbetweenthe

statesandthecentre.Thestatesrepresentawiderangeofhealthcarecontextsthataredifferent

ingeography,cultureandhealthoutcomes,yettheysharethesimilarhealthsystem

infrastructureandfacesimilarchallenges.Theselectionofnurse-midwifeleadersatanational

levelfacilitatestheunderstandingofthelargerpictureofhealthpolicyandgovernancestructure

inIndia.Additionally,IinterviewedmidwiferyleadersintheUnitedKingdombecauseit

representsasuccessfulmodelofmidwiferycarethathasmadecommendableprogressin

respectfulcareprovisionandhascollaborationswithpartnersimplementingmidwiferyinIndia.I

alsointerviewedeightmidwiferyleadersforaglobalperspectivewithprofessionalsfromWHO

Headquarters,ICM,ICNandUNFPA,thatplayakeyroleinmakingandinfluencingpoliciesata

globallevelthathasanimpactoncountriessuchasIndia.

8.4.1 Studyinstrument

Ipreparedasemi-structuredguideforin-depthinterviews.Theinterviewguidehadthree

sections;1)backgroundinformation;2)participant’sroleandresponsibilities;and3)perception

ofrespect,disrespectandabuseincareduringchildbirth.Giventhesensitivityindiscussing

disrespectandabuseofwomenduringchildbirthbycareproviders,Iusedanillustratedpainting

ofawomangivingbirthtoinitiatetheconversation(Figure8.1).Thethemeandcontentsofthe

paintingreflectedtheleadresearcher’sexperienceandobservationsofchildbirthinapublic

hospitalsettinginIndia.

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Figure8.1 FlashcardshowingabirthingenvironmentinIndia

(Sourcecourtesy:ExclusiveimageproducedbyS.Karmakarforthisresearch)

Idevelopedaquestionnairebasedonliteraturereviewofdisrespectandabuseofwomenduring

childbirthinmultiplesettings(AnnexureC).Theopen-endedquestionsareaimedtounderstand

theparticipant’sreflectionandperspectiveonthepainting.Theinterviewguidehelpedtoexplore

participant’sperceptionsonwhywomenexperiencedisrespectandabuseduringchildbirth,how

thatchangeincareproviderbehaviourhappensandfinally,theparticipantrecommendationson

howrespectfulanddignifiedcarecanbesafeguardedduringchildbirth.

ResearchEthicsApproval:Respondentsprovidedwrittenconsenttoparticipateinthestudy.I

tookconsenttoaudiorecordtheinterviews,gavethemaparticipantinformationsheetanda

copyofthesignedconsentform.Outofalltheleadersapproached,fivedidnotgiveconsentfor

theinterview.Someparticipantsarereplacedbyothersmatchingthecriteria,althoughitwasnot

alwayspossiblegiventheleadersrepresentingparticulardomainsarefew.Ethicalclearanceis

providedbyInstitutionalReviewBoardofUniversityofSouthampton(Referencenumber41164).

Thestudyparticipantsholdkeypositionswhichcanbeidentifiable,thereforeIhavemaintained

anonymitythroughouttheprocessofdatacollection,analysisandpresentationofthefindings.

8.4.2 Datacollection

IconductedtheinterviewsbetweenJuly2018andJanuary2019.Iconductedthreeofthe

interviewsovervideocallsanddidtherestinpersonindifferentstatesinIndia,theUnited

KingdomandSwitzerland.IinterviewedleadersinSwitzerlandasmostoftheglobalhealththink

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tanksthatinfluenceglobalpoliciesarelocatedthere.LeadersfromUnitedKingdomhave

establishedamidwiferyledmodelandhavecollaboratedwithIndiancounterpartstoimplement

midwiferyinIndia.IcarriedouttheinterviewsinEnglish,afewinHindiandBengali.Iamfluentin

thesethreelanguagesandmynativelanguageisBengali.

Icontactedtheparticipantsbyemailinitially,witharequesttoparticipateinthestudy.I

conductedmostoftheinterviewsintheparticipant’sofficeorresidence.Mostwerefreefrom

anyinterruptions.Iconductedtheinterviewswithparticipantsrepresentingregulatorybodiesin

theiroffices,withquiteabitofinterruption.Mostinterviewslastedbetween30minutesto1.5

hours.Itookreflexivenoteswithdescriptionsoftheinterviewenvironment.Iinformedthe

participantsaboutthestudyobjectivespriortoschedulingtheinterview.Iintroducedmyselfto

theparticipantswithinformationaboutmyqualificationsandprofessionalbackground.Nine

prospectiveparticipantseitherdeclinedtoparticipateordroppedoutfromthestudyduetoalack

oftime.

8.4.3 Dataanalysis

Ianalysedthedatausingthematicanalysis(Green&Thorogood,2014).Theanalysisapproachisin

linewithreflexivethematicanalysiswhichhasthemesdrawnfromtheresearchquestionsandthe

semi-structuredinterviewguide(Braun&Clarke,2019).Thethemesareclustersofcodesthat

haveasharedmeaning(Braun&Clarke,2019).Isupplementeditwithemergingthemeswith

deductivecodingasanalysisprogressed.Idecidedtheinitialcodesbasedonwhatmadethemost

analyticsenseandappearedfrequentlyacrossdata.Furthercodesweregeneratedbasedoneach

code’spropertyandrefinedwithsubcodes.QualitativedataanalysissoftwareNVivo12isusedto

aidinanalysis.Icodedthedata,alongsidedatacollection,toidentifyandexploretheemerging

themesandintheupcominginterviews.

8.4.4 Positionalityandreflexivity

Mybackgroundandinvolvementinresearchingandinfluencingmidwiferyandnursingpoliciesin

Indiaandgloballyplayedakeyroleinparticipant’sagreementtotakepartintheresearch.Ihave

professionalacquaintancewith11outofthe34participants.Mysubjectivity,shapedbymy

experiences,hasbeenapotentialresourcethroughoutmydoctoralresearchandasBraunand

Clarke(2019)state‘itshouldnotbetreatedasathreattoknowledgeproduction’.Myexperience

ofreceivingeducationinnursingandmidwiferyingovernmenthospitalsinWestBengal,along

withoveradecade’sexperienceofresearchingonthechallengesinhealthcareprovision,helped

todesigntheinterviewguide,conducttheinterviews,analyseandinterpretthedata.

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8.5 Findings

Thefindingsarepresentedunderthreesections.First,Ipresentthemidwiferyandnursing

leader’sreactiontothepaintingofawomangivingbirth.Second,Iexaminetheirperceptions

towardschildbirthandthefactorsthatmakewomenvulnerabletoexperienceobstetricviolence

duringchildbirth.Third,Ipresenttherecommendationsofstudyparticipantsonensuring

respectfulcareduringchildbirth.

Participantprofile:Thirty-fourparticipantsareinterviewedagedbetween46and83yearswith

24to60yearsofgeneralexperience.Allparticipantshadpreviouslyreceivedmidwiferyeducation

exceptonewhoisaregisterednurse,and32participantsareregisteredasbothamidwifeanda

nurse.ElevenparticipantshavePhDlevelqualification.Fourmaleparticipantsareinterviewedin

Rajasthan,whichisoneofthefewstatesinIndiathatprovidesmidwiferyeducationtomale

candidates.Theremainingthirtyparticipantsarewomen.Moredetailsabouttheparticipant’s

profileispresentedinTable8.2.

Table8.2 Participantprofile

Indicator No.ofparticipants/Range Totalresponses(N)

AgeRange

40-60years 18 30

61-80years 11 30

>80years 1 30

Gender

Female 30 34

Male 4 34

Qualification

RN,RM 32 33

RM 1 33

MScNursingandMPH 22 33

PhD 11 33

Experience(years)

Urbanexperiencerange 5-46 17

Ruralexperiencerange 0-25 17

Totalexperiencerange 17-60 29

Midwiferyexperience(years)

<15years 19 25

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Indicator No.ofparticipants/Range Totalresponses(N)

15-30years 3 25

31-45years 3 25

Midwiferyexperiencerange 0-41 25

Birthsassistedrange(0-40,000)

<25 4 26

25-100 6 26

101-500 6 26

501-1000 4 26

>1000 6 26

Participant’smidwiferyexperiencerangedfrom0to41years.Theysharedthetotalnumberof

vaginalbirthsassisted,includingduringtheirnursing-midwiferyeducation.Theresponsesrange

from0toapproximately40,000births.Fourofthemassistedlessthan25vaginalbirths,even

thoughitisanessentialcriteriaofpre-servicecurriculumbeforeregisteringasamidwifeinIndia.

Fourrespondentscouldnotciteanumber.

8.5.1 Reactiontothepaintingofawomangivingbirth

TheparticipantsfromIndiausethewords‘terrible’,‘bad’,‘wrong’,‘notright’,‘familiar’,

‘uncomfortable’,‘stressful’,‘notconducive’,‘horrible’,‘extremedisrespectandabuse’and

‘concerning’todescribethepainting(Figure8.1).Oneparticipantsharedherperspectiveofthe

positiveaspectsinthepainting.

“…thepositionsheisin,thewomanisnotcomfortable.Peoplearoundherarestressful…lookat

thestrainedfacesaroundher.Theenvironmentisnotconduciveforher.Thislookslikearural

facility.Inahospitallabourroomsomanypeoplewillnotbearound.Theassistant,doctorand

maximumfourpeoplewillbearound.Studentswillbeallowed.Ascreenislacking,forprivacy.This

lookslikeaprivatefacilityassituationsaredeterioratingintheprivatesector.”(O03)

“She(careprovider)ismassagingtheuterusforcontractionandtoreducethechanceofPPH.This

lookslikePPH.She(labouringwoman)mustbeunconscious,thatiswhythestaffispinchingthe

thighwithforceps.”(R01)

Mostrespondentsacknowledgetheissueandmanyconfidetheyhavenotseenbuthaveheard

fromothersthatdisrespectandabuseduringchildbirthhappens.Afewparticipantsassumethat

thepaintingissetinaprivatehospital,whileothersrefertoapublictertiaryhospital,butdeny

thatnursesengageinsuchbehaviour.

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“Doctorsengageinthiskindoftreatment”(CL01)

“Staffnurses’don’tdothat,onlyuntraineddais(do).”(O02)

Participantsatthegloballevelreflectonhowsimilarthesituationseemedinmanyotherpartsof

theworldandsayitis‘horrifying’and‘shocking’.Aparticipantalsofoundithardtobelievethat

thelabouringwomanconsentedtohavesomanypeoplearoundherduringchildbirth.

“…thewomenarenotlookingatherbutatthebaby.Thiswomanisstruckwithhorror…blood

pouringfromher.Sheislyingonaflatbedwithnosheet…thefundalpressureisveryhard…Iseea

womanwhoisbeingtortured!Sheisingravepainandisscreaming…thereisonewomanwithher

armaroundherandshehasherhandonherheart.Itindicatessomekindofcompassionforthe

woman.Butbecauseofthesystemofthecareandplace,sheisflatonherback,intheworst

positionpossiblewithoutanycomfortatthetimeofherlife…thisisapictureofextreme

dehumanisation!”.(GL07)

8.5.2 Factorsbehinddisrespectandabuseofwomenduringchildbirth

Factorsaffectingdisrespectandabusethatarerelatedtocharacteristicsofwomen,areorganised

inathreelevelframeworkrangingfromindividualleveltosociallevelcharacteristics.Factors

emergingfromtheresearchthatrelatetonurse-midwives’disrespectfulandabusivetreatmentof

women,asidentifiedbythestudyparticipants,werecategorisedintoindividual,structuralor

policylevels,inlinewithFreedmanetal.(2014)definitionofmistreatmentduringchildbirth.

8.5.2.1 Woman-relatedfactors

Woman-relatedfactorsareorganisedintothreelevelstoo:(i)individual-whichincludespersonal

attributesofthewomanthatincreaseshervulnerability;(ii)communityenvironment-the

woman’simmediatecontextincludinghome,theplaceofbirth,neighbourhoodandcommunity;

and(iii)socialenvironment-includesthestatewomencomefrominIndiaandthecountry.The

differentiationbetweenthelevelsisnotjustgeographicbutalsointermsofimpactthatmaygo

acrosslevels.

Individualattributes

Women’sbackgroundandphysicalappearancecouldmakethemvulnerabletodisrespectand

abuseduringchildbirth.Ageandparityarefrequentlystatedreasonsforpredispositiontopoor

treatmentaswell.Onerespondentmentionedthatwomenwithfourormorechildrenareoften

verballyabused.

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“Whatdoyouplan,toscoreacentury?”(CL03)

Awomanhadcometogivebirthwithher16-year-olddaughter,whichmayhaveprovokedthe

conversationsuggestingthatthewomanshouldhavestoppedchildbearingafteracertainage.

“Amultigravidashouldnotcometoalabourroomsomanytimes.”(WB03)

Parityisassociatedwithreligiontoo.Onerespondentmentionedthatitiscommontohavemany

childreninsomereligionsandcultures.

“Muslimwomenaremultipara.”(RJ04)

Otherrespondentssaidthatolderwomeninevitablyhearjudgementalcommentsforhavingtoo

manychildrenorhavingthemtoolate.Younggirlshadtohearthemforgettingpregnanttoo

early.

Illiteracyincreaseswomen’svulnerability.Accordingtorespondents,judgementalcommentson

whyuneducatedwomenhavemorechildrenarecommon.Awoman’scooperationduringlabour

oftendependsonhoweducatedsheis.Thishasastronginfluenceonherknowledgeand

expectationsforcareduringchildbirth.Interestingly,manyrespondentsassumethattheonusis

onthewomantobeabletocommunicate,andnotthecareprovideronhowtotalktowomen

fromdifferentbackgrounds.Thedifferenceincareproviderandwomen’sbackgroundcanleadto

obstetricviolence,whichincludestheirlanguage,religionandcultures.

Thewayawomandresses,smells,weighs,maintainsherpersonalhygiene,includinghowher

genitalsarepresented,maydeterminehowshewillbetreatedduringchildbirth.Obesityattracts

judgementalcomments.Physicalappearanceisthefirstthingthatthecareprovidersnotice.

Womenwhopresentwithpoorpersonalhygiene,invisiblydirtyclothesandsmellingbad,are

consideredunpleasanttocarefor.

“Itiseasytoabuseobesewomen.Personalhygieneisafactortoo.Theycomewithskindiseases

attimes.Noonewantstotouchthem.Theyhavetohearalotofbadcommentslyingonthe

labourtable…theydonotbatheandwehavetocleaneverythingasthebabywillbebornthrough

theunhygienicpassage…woodsellers,coalsellers,Bihariwomenareverydirty.Wedonotcareif

onehasshavedornot.Manymotherscomeaftertrimming.Looksliketheyhavecomestraight

fromtheparlour,freshlywaxed.Theygetgoodcare,weliketouchingthem.”(WB03)

Communityattributes

Women’simmediateenvironmentincludesherhome,familyandneighbourhoodandthepeople

shecomesincontactwith,whomaysharethesamevaluesandcultureinthecommunity.

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Povertyincreaseswomen’svulnerabilitytoobstetricviolence.Itisacross-cuttingfactor,asitis

associatedwithcasteandeconomicstatus.Respondentsopinedthatpoorwomenhavenooption

buttoseekcareinpublichospitals.Manyrespondentscommentedthatstaffmembershavea

tendencytoaskforunofficialpaymentsfromthefamilyafterbirth.

“Shewillhavetolistentoalotofcommentsifsheispoor.Thereisalotofignorancetoo.If

someoneisrichorfrombetterincomebackground,theneverystaffbehavesverypatientlyand

respectfulmaternitycarepoursoutofthem.Theyknowhowtodoit,justdependsonwhetheryou

areworthyofrespect.”(RJ04)

“ThisistheculturalconstructofbirthinginIndiawhichtomeiswheretheissueis.Whenwomen

acceptthatthisisokay,thatiswhattheywillget.WomeninIndiapassonthisculturalconstruct

asbirthpreparedness.Whenwethinkaboutabuseofwomeninhealthcare,weneedtobevery

clearthatinsocietieswhereabuseisnormalit’sgoingtobeverydifficulttochangethatina

healthenvironment.Dothepeoplearoundherfeelthatitisnotokaytopinch,hitwomengiving

birth?”(GL02)

ThestereotypeofMuslimwomenhavingmorechildrenisalsoanormaboutbirthingand

contraceptioninsomecultures,fromthecareproviderspointofview.Thestereotypeabout

Bihariwomenisalsoprevalentandopensdoorstodiscriminationagainsttheminattracting

obstetricviolence.

Socialenvironment

Beingawomanincreasesvulnerabilityespeciallywhenthewomanisuneducated,poor,not

appearingacertainway,oldoryoung,marriedornot.Thewaysheistreatedbycareprovidersin

thelabourroomwhilegivingbirthisanindicationofhowsocietyandherfamilyvaluesher,and

treatsher.Thisshapesherexpectations,assheisconditionedtobetreatedinacertainway,with

acertainlevelofrespectfulness.Whethersheasksquestionsorcommunicateswithcare

providersandtheresponseshereceives,dependsonhowsheisconditionedtobetreated.In

fact,gender-baseddiscriminationbeginsatbirth.Thebirthofaboyoftenmeansmoremoneyfor

careproviders.Thebirthofagirlinvitesverbalabuseanddiscriminationforthenewmother.The

waysheexperiencesbeingvaluedornotingeneral,ishowsheexpectstobevaluedinthelabour

roombycareproviders.Genderisacross-cuttingissuewhichcanbeseenattheindividuallevel,

inthecommunityandinthesocialenvironment.

“Globallywomenareoflowstatus,nottreatedwithrespectorregardedasequalcitizens,not

valued.Littlegirlsgrowupthinkingsheisnotasimportantasherbrother,notlikelytoget

educated,notencouragedtoquestion.Womenaccepttheirlowerplaceinthesociety.Whenthey

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cometogivebirth,manyofthemdidnotchoosetobepregnant,theydidnothaveaccesstobirth

control,marriedoffveryyoung.Arrangedmarriages,childbrides.Thesealltakeawaytheir

empowerment.Youfinditdifficulttostandupforyourself.Whensheisinlabour,thelastthing

youwantisfightingforyourself.Youaresocaughtupinthepsychologicalprocessthatis

happening.Thatmakesyouvulnerableaswell.”(GL05)

8.5.2.2 Nurse-midwiferelatedfactors

Thenurse-midwiferelatedfactorshavebeenorganisedintothreelevelstoo:(i)individual-

includespersonalandprofessionalattributes;(ii)thebirthingenvironment-includesthebirthing

room(‘labourroom’);and(iii)thepolicyenvironment-thatdeterminesthequalityofcareand

serviceprovisionthroughpoliciesatstate,nationalandgloballevels.

Individualfactors

Participantsfeltthatworkloadoftenmadenurse-midwivesangryandfrustrated,astheyare

overburdened.Atatertiarylevelhealthfacility,forexample,birthshaveincreasedfrom400to

1000permonthoverthelastfewyears,thoughthenumberofstaffremainssame.

“Wehave1nursefor100patients,thatiswhythishappens.Workload!”(OD02)

“Staff’sconfidencebreaksassoonastheyseethecrowd.Theyworryhowtoprovidecaretoso

many.”(RJ06)

“Weusedtogivemorepsychologicalsupportbackthen.”(OD03)

Respondentsfeelthatthelackofpromotionsandstagnantsalaryisdemotivating.Theadded

workloadwithoutincentivesmakesthemfeelunder-appreciatedandunder-valued.

“Nurse-midwives’arenotgettingenoughsalary,recognition.Noonechecksonus.”(CL01)

“...theyarediscriminatedwithotherprofessions.Physiotherapistsandpharmacistsareallgoing

up(intheircareer)andnursing(andmidwifery)isgoingdown.”(O03).

“...sinceromantimes,womenwerenotrespectedandthenChristianitycameinandwomen

startedbeingdisrespected,whichincreasedasthemalemedicalmodelslowlyinstalleditselfinto

theprofession.Atonepoint,nursesandmidwiveswerebeingheldaswitches.Itslikeatrailof

under-representationthatleadstodisrespectandabuseofwomenandmidwives.Thisincreased

inthe80’sand90’sasthemalemedicalmodelmarginalisedmidwives.”(GL06)

Workingconditionsareoftendemotivatinginahierarchicalstructurewheredoctorshavebetter

facilitiesthannurse-midwives.Suchdiscriminationleavesnurse-midwivespowerlessandtaken

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forgranted.Onerespondentfeltthatthislearnedhelplessnessisanoutcomeofcontinued

oppression,whichmakesmidwives’powerlesstobringanychangesinthesystem.Beingvoiceless

inplanningcareprovisionleadstoassertionofpoweronthewomenwhoarefurtherdowninthe

socialhierarchy.

“Theytakethesewomenforgranted.TheyfeelIamtakingcareofyouandIhavethispowerover

youtoprovidecaretoyou,soyouhavetolistentome.Thisismyterritoryandyouareboundto

listentome.”(WB02)

Manystakeholdersmentionedthatnursesandmidwivesareoftenbulliedbydoctors.Withthe

lackofasupervisor,whoisanurse-midwife,thedoctorastheheadofanyinstitution,overpowers

everyoneleadingtomismanagementofmidwiferyandnursingservices.Nurse-midwivesareill-

treated;andtheirwelfareandworkingenvironmentisnotconsidered.

“Gynaewarddoesnothavetoilet,soifthenursesgotoadifferentwardtousethetoiletandthe

doctorcomesforaroundatthattime…marksherabsentfortheday.Sometimeswequietlyuse

thetoiletinthecabin(meantforwealthypatients)whennooneswatching.Wearenotrespected.

Themedicalsuperintendentdoesnotrespectus.”(BH01)

Stakeholdersexplainthatthenurse-midwives’workinvolvesdealingwithbirthsanddeaths.Due

toanincreasingworkload,theyhavelesstimetocommunicatewiththeirpatients.Thereis

frustrationfrombeingoverburdenedandnotimetoprocessemotionsrelatedtovitaleventslike

birthsanddeaths.

“Theydonotgetattached.Theycallthembybednumberorcolourofsaree.”(RJ04)

Birthingenvironment

Participantsmentionedthelackofinfrastructureasaninterveningfactorinthebirthing

environmentthatisdisrespectfultowomen.Screensareimportanttomaintainprivacyduring

childbirth.Lackofinjectableanaestheticsandanalgesicsaddstoadisrespectfulbirthing

experience.Itleadstowomenenduringmorepainwhentheyundergoanepisiotomyandrepair

withoutanaesthesia.Thecleanlinessofthelabourroomisanissue,resultinginwomenbirthingin

anunhygienicenvironment.

“Thedoctorsaretall,sotheirheightneedstobeconsidered,hencethelabourtableissotall.”

(B02)

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The‘teamculture’includeshowcareproviderscollectivelyperceiverespectfulcarebasedon

existingwork-placenorms.Thismakescertainpracticesandevenextentsofdisrespectandabuse

duringchildbirthacceptable,thusaddingtonormalisationofdisrespectandabuseduring

childbirth.

“Thereare12labourtablesinthelabourroom,separatedbycurtains.Wedon’tletmenenter,so

theirprivacyisprotected.Thenitisallwomen.”(RJ01)

Extortionisoftenpartofateamculture.Themoneygetsdividedbythewholeteameventhough

thenon-healthcareproviders,suchascleaners,areattheforefrontofaskingforit.Thereare

manyunethicalpracticesthatarepartofteamculture,includingaugmentationoflabour.

“Theywillscream‘push,push’iftheirdutyisendingat1:45pm.Theywillmakesurethewoman

givesbirthwithinone’sdutytimesothatcareprovidergetsthemoney…sotheywillinducewith

oxytocinsometimes.”(RJ04)

Taskshiftingbetweencareprovidersatdifferentlevelsofcareisbasedonthehierarchyofcare

providers,whichstemsfromthecentralisationofpowerandmismanagementoftheincreasing

workload.Respondentsshareexamplesofsystematicshiftingofdutiesfromdoctors,whichisnot

apartofnurse-midwives’role,followedbynurse-midwives’transferringtheirroleinassisting

births,tonon-healthcareworkerssuchasMamta16,ASHAandtraditionaldais.

“He(medicalsuperintendent)isrunningthehospitalinanywayhewants.Nurse-midwives’are

postedinnon-nursingrolesevenwithanexistingshortage.Therearenurse-midwives’postedin

thefireextinguishingdepartment.Sixnursesreadyintheiruniform,twoforeachshift.Theyare

notinvolvedinpatientcareanymore.Tennursesareworkinginpharmacydistributingdrugswhile

thepharmacistschillinaroom.Nursesareworkinginpathologywhiletechniciansareroaming

free.Thetelephonecontrolroomisrunbynursesandsoisthereceptionandhousekeeping.The

nursepatientratiois1:50-75.”(BH01)

Stakeholdersdescribethatwithincreasinglevelofcareprovision,disrespectandabuseofwomen

duringchildbirthincreases.Womenaremorevulnerabletobeabusedatatertiarylevelofcare

provisionthanaprimaryorsecondarylevel.Thisisrelatedtomanyfactors,forinstance,workload

increasesatahigherlevelofcare,reducingpatient-healthworkerinteractiontimeandincreasing

workloadrelatedfrustration.Manystakeholdersfeelthatdoctorsattertiarylevelareengagedin

16MamtaisanonhealthcareproviderwhoworksprovidessomecounselingtowomenonbreastfeedingandtheimportanceofcleanlinessafterwomengivebirthinaninstitutioninBihar.Shealsomaintainscleanlinessinthelabourroomandreceivesincentivesforherwork.

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moresevereformsofabuse.Beingfurtherupinthelevelofcareprovisionalsomeansthat

womenarenotknowntoanyoneintheteamofcare,whereexperiencesarefurtherover-

medicalisedthanatalowerlevelofcare.Thetertiarylevelincludesteachinghospitals,where

womenbecomesubjectsof‘casediscussion’aspartofthemedicaleducation.

“Everyonelooksatherassomeoneyoucanperformcaseson.Theyseethatthisisacaseinmy

logbook…theywanttogiveanepisiotomysoonecangetanepisiotomyrepairdoneandwrite

aboutitinlogbook.”(CL04)

Disrespectandabuseofwomenduringchildbirthoftenstemsfromalackofcompassionate

leadershipatthecentreofthemanagementsystemorhierarchy,whichalsoinfluencestheteam

culture.

“Itslikearippleinthepond.Youhavegotanabusivepersonatthecentreofthat.Thepersonwho

isabusiveinnature,maybeofpsychopathictendencies.Thepersonatthecentrebecomes

powerfulandinordertomaintainthatpower,buildsrelationships,andslowlypeoplechangetheir

behaviourtofitintothatwayofbeing.Thelongerthatpersonisabletostayinoneplace(centre),

theculture(ofabuse)growsstronger.”(GL06)

AparticipantinIndiacalledthisa‘dominoeffect’whereonecareproviderlearnstoabusefrom

another,establishinganabusiveteamcultureintheprocess,thispeerinfluenceslowlyturns

everyoneintoanabuser.

Policyenvironment

Somenationalpoliciesindirectlycontributetoadisrespectfulbirthingexperience.TheJSYpolicy

incentiviseswomenforgivingbirthinaninstitutionandincentivisesthecommunitybased

motivators,ASHAs.Thispolicyiscriticisedbyparticipantsasinsensitive,asitdoesnotuphold

women’srightsorfacilitatetheirchoicesanddecisionmakingaboutchildbirth.

“Itmakesnosensetohaveagovernmentpolicytomovewomentohospitalswhenthehospitals

treatthemsobadly.Theresponsewillbe‘ohbutyoushouldseehowtheyaretreated(athome)in

India,atleasttheygetfoodinthehospital’.”(GL07)

Participantsalsoidentifiedthatthedehumanisationofwomenbeginsinthepre-serviceeducation

asalearnedbehaviour,wherethemedical,nursingandmidwiferystudentsimbibehowthecare

providersdealwithwomen.Obstetricviolenceduringbirthhasbeenanorm,whichnormalisesit,

thusreducingtheimportanceofthisproblem.

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“IhaveseentheHeadoftheDepartmentverballyabuseinaround1977-78.Theyarenotproperly

educated.Thegovernmentdidnotcarebackthenaboutrespectfulnessastheyareenforcingit

now.”(WB01)

Birthingisexplainedas‘dirtywork’byaninternationalparticipant(GL03),whosharesthatsince

birthworkstemsfromunpaidwomen’swork,itmayhaveanegativeimpactontheprofession

whichfurtherentrenchesmedicaldominationofmidwifery,nursingandbirthing.

Theprovider-clientrationeedstobemaintainedtoensurerespectfulcare.Under-recruitmentis

anindicatoroflackofthewomen-centricpolicies.Itiscommoninhospitalstorotatenurse-

midwives,respondentsperceivethispracticeasdiscouraginganddeterrenttomaintaining

midwiferyandnursingskills.Theamountofdocumentationworkisanadditionalburdenthat

takesoverdirectcareprovision.

“Weareengagedinmultiplethings,astaffnurseinthelabourroomcannotmaintaincareand

qualityservice,theyjustcannot.Suchahugelogbooktheyhavetofill.Somanyrecordsto

maintain.Howwillsheconductsomanydeliveries?1:1ratioisrequiredforassistingbirths…

tertiarylevelstaffjustdoespaperwork.”(WB05)

8.5.3 Participant’srecommendationsforrespectfulmaternitycare

Participant’srecommendationsarecontext-specificandarebasedonbestpractices.Preventing

disrespectandabuseduringchildbirthandpromotingrespectfulmaternityisadeep-rooted,and

anage-oldproblem,whichrequiresaparadigmshiftinculturetoaddresschallengesatvarious

level.Participantssuggestinvolvingwomenandnurse-midwivesinpolicy-making,astwokey

stakeholdersinmaternalhealthcare.

“It’saboutreallystrongpartnerships.”(GL03)

Participantssuggestedamulti-sectorapproachtoinvolvestakeholdersfromcommunityand

healthsystemsforalastingimpact.Participantsfeeltheneedtodecentralisepower,fromthe

medicalmodelofcare,tomakecareprovisioninclusive.Collaborationswithwomen’srights

organisationsandnursingandmidwiferyassociationswillincreaseaccountability.Global

internationalorganisationshavearoleinadvocacy,settingstandardsandfundinginitiativeswith

asustainableapproach.Theserecommendationsaresummarisedinaframeworkformidwifery

modelforwomencentred-carewithchangessuggestedatdifferentlevels(Figure8.2),similarto

thelevelsdiscussedforthefactorsofdisrespectandabuseduringchildbirth.

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Figure8.2 RecommendationsforrespectfulmaternitycareinIndia(Author’sown)

Level1-Midwiferymodelforwomencentredcare-Itisimperativetohearwomen’sexpectations

andexperiencesofcaretounderstandwhatisrespectfulandgoodqualitycareforthemand

ensureapersoncentredpositivebirthingexperience.

“Thevoiceofpeopleisoneofthebiggestmotivesbehindchange…youcanregulatethattherehas

tobeawomaninthediscussionbuttheywillfindathousandwaysaroundtonotadheretothat.

Inchangingvaluesandnormsofsocieties,notmuchchanges.Womenneedtostandupandsay‘I

needrespectfulcare!’.Thosearethewaystomakechangehappen.”(GL01)

Participantsfeltthatsharinginformationandcounsellingshouldbeginintheantenatalperiod,to

helppregnantwomenunderstandtheprocessofbirthingandexplainproceduresbeforehand.

Theyalsofeltitisdifficulttocommunicatemanythingswhilethewomanisbearinglabourpain.

Proceduresneedtobeexplainedtogainthewomen’strust.Continuedcommunicationand

psychologicalsupportduringchildbirthisconsideredofutmostimportance.

“…tellthemhowmuchitwillhurt.Thenumberofhoursitwilltake.WeshouldtellthembeforePV

andwhenstartingabottletoincreasepain.”(R01)

Midwiferyandnursingisconsideredemotionalworkandparticipantsfeltitisimportantforcare

providerstotaketimeoutforthemselvesandtakecareoftheirwellbeing.

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“…takingtimetogetagoodworklifebalance.Doingwhattheyenjoy,switchingofffrom

workplace,gettingsupportfromcolleagues.Gettingaperspectiveandbeingawareofoneself.”

(GL03)

Theroleofnursesandmidwivesisrecommendedtobeenvisionedasadvocatesforwomen’s

rightforqualityandrespectfulcare.Thiswillincludestandingagainstdisrespectandabuseof

womenduringchildbirthintheirfacilityandfindinginnovativewaystopreventit.

Level2-Individualandteamculturefortheidealbirthingenvironmentcareprovider:

Perceptionsaroundqualityandrespectfulnessneedtoalignwithwomen’sperception.

“WelookatIndiaandseewomeninbeautifulsareesinruralareasandfeeleverythingisfine.One

hastolookbeyondthatandseewhattheyfeel,whattheyneed,whattheywantandservethem

well.”(GL02)

Toensureanappropriateteambehaviourtowardswomenundertheircare,itisnecessarythat

stepsbetakentoimprovetheteam’sattitude.Beingrespectfultowardseachotherintheteam

regardlessofgenderandprofessionisrecommended.

“Theteamneedstobetrainedtogether!”(WB04)

“Facilitiesneedtoimprovetheircollectivebehaviour.”(WB03)

Respectfulcommunicationisstronglyrecommended.Respondentsfeltthatcareproviderscould

beeducatedinwhattosay,whatnottosayandhowtocommunicatewithwomen,asthey

acknowledgethat‘theirwordscanhurt’.

Changesareneededattheprimary,secondaryandtertiarylevelofcare,whichcanbedifferent

basedontheissuesthatexistateachlevelofcare.Infrastructuralavailabilityandworkload

distributionneedtobeensuredateachlevelforanidealbirthingenvironment.

Homebirthwassuggestedbymanystakeholders,withscalingupofhome-basedcare.Theyfelt

thereisalesserculturaldifferencebetweenthecareproviderandwomenwhencareishome-

based,wherefamilymembersgetinvolvedasbirthcompanions,makingbirthingmoreculturally

acceptableandsatisfying.

“Let’sjustchangethephysicalenvironment,itsnotthatdifficulttodo.Itwillhaveprivacy.Does

notneedabed.Lotofwomendonotneedabed.Theywanttobirthstandingup,onamat,sitting

down,onalittlechair.Theywantitclean…andwarm…”(GL02)

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“Idealbirthingenvironmentistheenvironmentforlovemaking.Bothpsychologicalactivities

releaseoxytocinandendorphinonstimulationandobstructedwheninfear,embarrassedorin

doubt.”(WB03)

Level3-Compassionatenursingandmidwiferyleadership:Midwiferyandnursingleadershipis

consideredkeytoensurethatamidwiferymodelofcareisimplementedinIndia.Participants

stronglyfelttheneedforone-to-onemidwiferycareforwomen.Advancedcareisneededif

complicationsarise.Therefore,effortsareneededtoestablishamidwiferymodelofcare.

“Midwiferymodelofcareisinconflictbetweentryingtobalancecarebasedoninstitutional

hierarchies,whereyouareacceptedtointerveneandifyoudonot,thenyouareprofessionallyin

trouble.”(GL03)

Thetertiarylevelofcare,includingteachinghospitals,whichareresponsiblefortheeducationof

careproviders,needstoadoptmeasuresthatcompriserespectfulmaternitycarewhilestudents

canlearnandpractice.Theimportanceofstudentstoimbibevaluesofrespectfulnessintheir

behaviourneedstostartintheirpre-serviceeducation.Thestudentnurse-midwivesoftensuffer

theconsequencesofbeingatthebottomofthemedicalhierarchy.Medicalstudentswereoften

prioritisedintermsofpracticeinteachinghospital,whereasnursingandmidwiferystudentsdo

notgetachance.Thestudentnurse-midwivesareoftentreateddisrespectfully.Respectful

communicationisencouragedforeveryinteractionwiththestudents,evenwhentheymake

mistakes.Thewaytasksaredelegatedtostudentsneedtochange.

“...teachersshouldbecompassionatetothestudents.Iamshockedsometimestoseeintheglobal

workhowthemidwiferystudentsaretreated...thehierarchyisknockon.Everybodyisabusingthe

otherwhoislowerinstatusthanthem...weneeddeepculturalchange.”(GL05)

“Theactualrelationshipbetweentheclinicalinstructorandthestudentshouldberespectful.”

(CL02)

Midwivesandnursesneedtobeempoweredsothattheycantakeupleadershiprolesand

participateindecisionmakingateverylevel.Midwiferyandnursingsupervisorscanrealistically

plancareandmanagemidwivesandnurses.Aparticipantfeltthatcompassionateleadershipat

thecentrecouldpositivelyinfluencetheteamtowardsrespectfulbehaviour,asarippleeffect,but

thisdependsonthekindofleadershipatthecentre.

Level4-Policyreformsandregulation:Withincreasingevidenceofdisrespectandabuse,

midwiferyandnursingleaderssuggestedseveralrecommendationsforpolicychangesinhealth

serviceprovisionthatcanmakebirthingrespectfulanddignified.Theseincludeworkplacepolicies

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tohavecompassionateleadershipbyinfluencingnormsatworkplacethatcouldfosterrespectful

careandpoliciesthatgoverncareprovisionatthestatesandcountrylevel.Manyparticipants

recommendtoaddresstheincreasingworkloadbyimplementing1:1ratiofornurse-midwifeand

women,whichwilldirectlyinfluencecareprovisionforthebetter.Propermanagementof

workforceanddevelopmentofleadershipinnursingandmidwiferyisessential.

Regulatorybodieshaveakeyroletoplayineducation,practice,maintainingstandardsofcare

andupholdingprofessions.Regulatorybodiesneedtomakechangestodiscouragetheindividual

andinfrastructuraldisrespectandabuseofwomenduringchildbirthbysettingstandards.

“IndianNursingCouncilshouldprovidebestexamples,showcasingwhatitlooksliketohaveasafe

birth.SNCsaremembersofINCandcandoitintheirownstates.”(GL02)

Leadershavedividedopinionsonwhetherthereshouldberegulatoryreformstoaddress

disrespectandabuseduringchildbirth.Theyfeelthatpenalisingcareprovidersisnotasolution,

astheythemselvesaresubjectedtoharshworkingconditions.Theyalsomentiontheneedto

discourageanykindofintentionaldisrespectfulandabusivebehaviourwithinateamandtowards

thebirthingwomen.Thereshouldbezerotoleranceofintentionalabuseofwomenbyallhealth

careproviders,andnon-healthcareprovidersshouldnotbeallowedtoassistbirths.

8.5.4 Respectfulmaternitycareeducationforthenextgenerationofcareproviders

Respectstudent-Nursingandmidwiferyleadersfeelthatthestudentnurse-midwivesoftensuffer

theconsequenceofbeingatthebottomofthemedicalhierarchy.Medicalstudentsareoften

prioritisedtoallowpracticeinteachinghospital,whereas“nursesdonotgetachance”.Respectful

communicationisencouragedforeveryinteractiononehaswiththestudentsevenwhenthe

studentsmakemistakes.Aparticipantfeltthatthewaytasksaredelegatedtostudentsneedto

change.

“…theactualrelationshipbetweentheclinicalinstructorandthestudentshouldberespectful.”

(NL02)

Rolemodelling-Participantsconveytheimportanceofensuringthatthenextgenerationof

nurse-midwives’needtoberespectfulincareprovision.Someofthemfeelthatrespectfulness

cannotbetaughtthroughafewdaystraining.Theyunderstanditasaprocess,thatensurethat

thepersonalitytraitorvaluesystemisembeddedinthestudent,sothattheyarecapableof

respectfulcareandtostandagainstdisrespectandabuseduringchildbirthwhenrequired.Role

modellingismentionedafewtimestoachievethis.Participantsfeelthatteachershaveakeyrole

toplayinthis.Thisroleshouldbeginintheteachinginstitutionforthemtodemonstrate

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respectfulness,butitisalsoimportanttoshowintheinteractionswithwomenintheteaching

hospital.Theimportanceofgoodcommunication,addressingtheclientbyname,explainingevery

procedureandtakingconsentbeforeengaginginanycareprovisionismentioned.Itisimportant

tostandagainstdisrespectandabusetowardswomenwhenteachersseeanyoneintheteamof

careprovidersengaginginit,asNL03explains.

“…whentheyseedisrespectandabuse,teachersshouldpointoutandcallthestaffoutlaterand

discouragethisbehaviour.Theyshouldhelpthemtoperformbetterandbeanadvocateforthe

mother.”(NL03)

Thefirstchallengeistoletthenursingandmidwiferystudentspractice,whichisakeyhurdle

describedbyparticipants.

“Headofthedepartmentsaysmymedicalstudentswillpracticefirst.Thenursingstudentsobserve

casesandrequestthemtogiveachance.Hundredpercentcasesaredonebymedicalstudentsand

wehavecomplainedaboutthismanytimesbutwhowilllistentous.”(B02)

Thechallengeisgreaterformalestudentspersuingnursingandmidwifery,whotrytogetalittle

practicebyassistingdoctors.Thegapinwhatistaughtintheinstitutionfromthepractice

scenarioinlabourroomcanbereducedbypropersupervisionfromthenursingandmidwifery

supervisors.Participantsfeelitisimportantforcontinuityofcare,startingfromthepreservice

education,asNL06explains.

“Ineverallowedanystudenttopracticewithoutlearningproperly.Theyhadtoidentifythe

woman,giveantenatalcare,providecareduringchildbirthfollowedbyimmediatepostnatalcare

for48hours,ifpossible.Otherwise,Ididnotsigntheircasebook.”(NL06)

Clinicalinstructorsareusuallyassignedinthemorningshifttosupervisestudents,althougha

participantreportsencouragingresultsofassigningteachersinallthethreeshifts,wherestudents

practiced.

Properselection-Participantsfeelthatstudentswhojoinnursingandmidwiferyarenotalways

readyfortherole.Theyfeel,studentsshouldbecounselledonwhattheprofessionalcourse

entails.

“…somepeoplejoinmidwiferywhocannotfunctionindependently.Thereisalotofindependence

inthisareaandoneneedstomakedecisions.Everyonecannotdothat.Somepreferfollowing

orders,theyshouldworkinotherareaslikemedicalsurgicalnursing.Ifyoucannotfunction

independently,don’tworkinmidwifery.”(WB03)

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Theparticipantalsofeelsthatcandidatesshouldbeselectedbasedonanaptitudetestwhichwill

ensurewillingnessinthestudentsfromthebeginning.

8.5.5 Domidwiveshaverespectfulbirths?

Amongthenursingandmidwiferyleadersinterviewed,twelvehavesharedstoriesoftheirown

childbirth.Participantsnarratebothrespectfulanddisrespectfulbirthingexperiences.Someof

themsharethatbeinganurseandamidwifeisapositionofprivilege,becausetheyknowthe

processandhavetheknowledgeofbirth.Theseparticipantshavetheexperienceofbirthingin

publicandprivatehealthcarefacilitiesandathome.

Powerofmidwiferyknowledge-Manymidwivesfeeltheyhadabetterandrespectfulbirth

becausetheyaremidwives,evenwhentheydidnotgivebirthinthelabourroomtheyworkedin.

AsO03shares,sheguidedherownbirthwithanunderstandingofthecomplicationsinvolved.

“…myhusbandbroughtthemidwifeoncycleandItoldhertobringthecatheter.Herskillsandmy

knowledgeworkedtogether.Itoldhertoboilthecatheterfirst.Iwantedtogivebirthinsitting

position,soIdid…soskillfullyshedeliveredthatIwasveryimpressed.”(O03)

Nursemidwivesoftensharedabouttheirowndesignationthatensuredtheyhaveagoodbirth.

ParticipantB02’sbirthingexperienceisanexampleofthis.

“nursesdidnotbehaveproperly…shewaslisteningtofoetalheartsoundandIrefusedasking‘why

areyoulisteningtoFHSwhenIaminpain,can’tyouwaittillthecontractionisover?’.I

complainedtothenursingsuperintendent.ShesawmynameandrealisedwhoIam…shecalled

thestaffandsaid‘wherehaveyoulearntmidwifery,don’tyouknowsheisateacher?’She

apologisedandtheneveryonecooperated.”(B02)

Beinganurseandamidwifealsomeanstheysometimesknewthestaff,whichprovided

infrastructuralbenefitsandtheadvantageofhavingsomeoneassistingtheirbirthwhomthey

trustedasGL02describesit.

“…itsokaytofeeloutofcontrolbecauseyouarehavingacompletelyoutofbodyexperience,but

youneedtotrustthepeoplebirthingwithyou.”Beingacareprovideroftenhasextendedbenefits

fortheirfamilyandrelativesasWB03putsit,“thisisacommunalfeelingwhichwehave,where

wegetbettercarebecauseweprovidecareallourlivesandwefeelwehaveearnedit.”(GL02)

Birthingintheworkplace-Inonecasetheparticipantgivingbirthinherownplaceofwork

ensuredthateveryonewasveryrespectfultoher.Butshealsotriedtobe“inherbestbehaviour”

asshedidnotwanttobemadefunofthewayshewasscreamingorcryingduringchildbirth.She

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(NL04)furtheraddsthatherdoctorencouragedherbysaying‘sheisverybraveandwehavenot

seenanywomanwithsomuchpatience’butshehasalsoseenthesamedoctorsexuallyabusing

otherwomeninlaboursaying‘thisisallyoucandoathome,andthenyoucomehere.’Notall

experienceswereasgood,GL06sharedhowshewasbulliedinherworkplace,whichextendedto

herbirthingspace.Shefeelsthatherbirthcouldbemanagednormally,butduetoaugmentation

hercontractionsgrewstrongerandledto‘difficultforceps’withoutanyepiduralorpainrelief.

TheexperienceofbirthinginherownworkplacewastraumaticforGL08tooasshedescribesit.

“Iwasslappedonmybuttocksinmyfirstbirthcausemylabourmeantdelayinher(midwife’s)

leavingforhome.ShealsoforcedmetohaveanenemaevenafterIrefusedtohaveit.…Sheknew

Iamamidwife,weworkedtogether.…Iwaspowerlesstorefuseanything.SincethenIhavebeen

frightenedofmidwivesanddoctors.”(GL08)

Inthesubsequentbirths,theparticipantensuredtohaveamidwifeshetrusted,whoprovided

continuityofcare.Also,sheestablishedherownhomebirthpracticetoensurewomeninherarea

hadrespectfulbirths.

8.6 Discussion

Themidwiferyandnursingleadersperceivedthatthepainting(Figure8.1)depictedthewoman

beingabusedduringchildbirth.Theypointedoutmanyunacceptableactionsfromthepeople

aroundthebirthingwoman,intheobstetricenvironment.Thoughthereisadifferenceinthe

perceptionofparticipantsinIndiaandelsewhere,abouttheseverityofobstetricviolencethe

womaninthepaintingisbeingsubjectedto.Thisdifferenceinperspectivescouldbearesultof

theparticipant’scontext,thecultureofviolencetheyareexposedto,progressinthediscussions

aboutobstetricviolence,thelevelofeffortstoensurerespectfulcareandwomen’svaried

expectationofqualityandrespectfulcareindifferentcontextsandcountries.Participant’sown

contextofsharedoppressionsandpowerlessnessmayhaveanimpactontheirperceptionof

violenceaswell.Indianparticipant’sperspectiveconveysnormalisationofobstetricviolencetoan

extentwhereunlesstheactofabuseisextreme,itisunnoticeableandisside-lined.Aparticipant

fromIndiafeltthatthepictureshowsgoodqualityofcarewhileanotherbelievedthatsome

amountofshoutingatthewomanduringchildbirthiscompletelyjustifiable,aswomenareunable

tohearduetopainandfollowtheinstructionsduringchildbirth.Thiscouldbefuelledalsobythe

lowexpectationsofwomenandtheconditioningaboutbirthing,thatalivebabyandalive

womanareconsideredgoodenoughoutcomesofchildbirth(Shakibazadehetal.,2018).

Participantstouchedupondifferenttypesoffactorsassociatedwithobstetricviolenceand

increasewomen’svulnerability.Thesefactorsarenotlimitedtowomenbutalsothenurse-

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midwivesastheprimarycareprovider.Womenandnurse-midwivesareattheintersectionsof

differentindividual,structuralandpolicyrelatedattributesinthelargercontextofoppressionof

women(Sen,Reddy&Iyer,2018).Allthefactorsdiscussedinthispapershouldbeaddressedto

ensurethatcareisrespectfulandpersoncentred.Freedmanetal.(2014)discussedindividual,

structuralandpolicylevelsintheirunderstandingofmistreatmentofwomenduringchildbirth.I

createdaframeworkbasedonthepatternsIlearntfromthedifferentfactorsfromthemidwifery

andnursingleader’sstandpointforthecare-seekingwomanandthecareprovidersthemselves.

Someofthesefactors,suchasgender,arecross-cuttingforboththewomenandthenurse-

midwivesthatgoesagainstthemandleadstodisrespectedwomenanddisrespectedcare

provider.

Figure8.3 Midwiferyleaders’perceptionsofobstetricviolence(Author’sown)

Thenursingandmidwiferyworkforcefacesnumerousgender-basedandhierarchicalchallenges

thatimpedetheirleadershipanddecisionmakingpowers(Sheikh2012;Guptaetal.,2003;Langer

etal;2015).Thesocial,economicandprofessionalchallengesleadtomoraldistressandburnout

(Maslach&Leiter,2009;Steege&Rainbow,2009).Nurse-midwives’challengessuchasunsafe

workingconditions,alackofpromotions,pooranddelayedsalaries,longworkinghoursandalack

ofsupervisionarewelldocumented(Filbyetal.,2016;Mayra,2020b;Maslach&Leiter;2016).

However,usingnurse-midwivesforfireextinguishingservices,isadefinitenewlow.Itisclear

fromtheresponsesthatnursingandmidwiferyleadersunderstandthechallenge,andarecapable

ofmakingreformativechangeswithmulti-sectoralcollaborationthroughadministration,

regulation,advocacy,researchandserviceprovision(Ratcliffeetal.,2016).Currently,participants

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representingtheeducationsectorhavenoflexibilityandlittleinfluencewithoutasupportive

regulatoryframework.Theyalsohavelimitedpowertomakeanychangeinthehospitalswhere

themidwiferyandnursingstudentspractice.Inadifferentstudy,Ihavepublishedthesechanges

requiredineducationandregulationurgentlyinIndiawhichwillbeakeysteptowardsensuring

respectfulmaternitycare,inlinewiththerecommendationsthatparticipantssharedinthisstudy

(Mayra,Padmadas&Matthews,2021).Amidwiferymodelofcareiscrucialtoensuringrespectful

maternitycare,whichwillbeaculturalshiftfromthecurrentmedicalmodelofcare,thatledto

over-medicalisationofbirthandhasnormalisedobstetricviolenceduringchildbirth(Homeretal.,

2014;Renfrew,McFadden&Bastos,2014).Thisnowseemspossible,withIndiamakingstridesto

startmidwiferyinthecountry,whichwillincreaseaccountabilityforrespectfulmaternitycarefor

women(Ratcliffeetal.,2016;GOI,2018;Afulani&Moyer,2019).

Healthsystemmanagementexpectsnurse-midwivestobe‘supernurses’byprovidingthemless

thanidealworkconditionswhiledemandinggoodqualitycare.Policiescomewithanadditional

workloadwithoutincreasingworkforce,whichleadstounmanageablefatigue(Steege&Rainbow,

2016;Lui,Andres&Johnston,2018),asseeninthenarratives(insection3.2.2.3).Thenurse-

midwives’themselvesarevictimsofpoorworkforceandhealthsystempolicies,institutional

mismanagementandhierarchy(Moridietal.,2020).Thisisalsowhyitisveryimportanttolearn

fromthediscoursearoundintentionalityofhealthcareprovidersinobstetricviolencethatIhave

discussedatlengthintheliteraturereview(section2.3).

Thepolicyenvironmentiscrucialtoensurelongtermchanges.Thoughrespectfulmaternitycare

ismentionedintheLAQSHYAguidelinesinIndia,thecontentisnotenoughtoensurerespectful

caretowomen(GOI,2017).Studiessuggestthatexistingpoliciesorinitiativestargetedat

improvingmaternalhealthcaredelivery,suchastheJSY,arenotunderpinnedbytheessential

infrastructure(Randiveetal.,2014)toencouragerespectfulcareandcontinuityofcare.Itis

essentialtocalloutactionsofdisrespectandabuseandstaterespectfulcarespecificallytomake

itanorm(Morton&Simpkin,2019).Recentstudieshavepresentedknowledge,skillsand

behavioursforrespectfulcarewhichcanbecontextualisedandadaptedforIndia(Butleretal.,

2020;Shakibazadehetal.,29)whichcanbeimplementedwithcontinuedin-servicetraining,

birthinginfrastructureandpolicyreforms(Moridietal.,2020;Mselleetal.,2018).

Beingawomanincreasesone’svulnerabilitytoanykindofviolenceandvictimisation(Jejeebhoy

&Santhya,2018)inIndiaandapatriarchalcultureincreasesthisvulnerabilityespeciallyduring

childbirth.Women’sprioritiesareconsideredsecondary,whichensuresthatthelimitedreportsof

obstetricviolencesharedbythem,fallondeafears(Betronetal.,2018).Womenareoften

blamedforpoorbirthoutcomesandinsomeculturesthebirthofagirlchildisconsideredapoor

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outcome(Sacks,2017).Rulesandregulationsdeterminewhatwomenareallowedtodowith

theirbodiesandthiscontrolusuallytakesthepowerovertheirownbodies,awayfromthen

(Bradleyetal.,2016).Anyresistanceisconsidered‘misbehaviour’andmetwith‘punishment’.

Womenareexpectedtoquietlyendurethelabourpains,screamingorcryingviolatesthesocial

normsandcallsforpunishmentintermsofscoldingandmanyotherformsofobstetricviolence

duringchildbirth,todisciplineherbody(Bradleyetal.,2016;Sen,Reddy&Iyer,2018).Thecontrol

ofthefemalebodyduringchildbirthinahospitalsettingisareflectionofhowsocietyis

conditionedtotreatwomenathome,inthecommunityandingeneral(Sen,Reddy&Iyer,2018).

TheIndianparticipantsdidnotmentiongenderasafactor,thoughtherearesomereferencesto

poorstatusorlackofwomen’sawarenessdeterminingrespectfulcare.Respondentssharedthat

veryfewwomenaskanyquestion.Theyjustwanttoknowhowlongitwilltaketogivebirth,even

thatismetwitharuderesponseifthewomanaskstoomanytimes.

Itisclearfromthisstudythatmidwivesandnurseshaveanin-depthunderstandingofthefactors

underlyingdisrespectandabuseofwomenandcancollaborateinbringingchangesthrough

advocacy,administration,education,regulationandserviceprovision.Thisisthekeystrengthof

thisstudy.Thesefindingscanbestrengthenedbyunderstandingtheexperiencesofmidwifery

caretofurtherunderstandthechallengesthatcareprovidersfaceroutinelyindirectcare

provision,includinginthecurrenttimewherenewerformsofabuseandanincreaseofobstetric

violenceisbeingreportedinmediaasaresultoftheCOVID-19pandemic(Sadleretal.,2020;

Kumarietal.,2020).Thisisanaddeddisadvantagealongwiththeintersectionalityofwomen’s

manyattributesthatgivesrisetogender-basedinequalities,therebyincreasingwomen’s

vulnerabilitiestoabusivebehaviour(Betronetal.,2018).However,collaborativeeffortsare

requiredtoensurethatallthefactorsareaddressedatthethreelevels,forlastingchanges,while

keepingwomenandtheirnurse-midwivesatthecentreoftheeffortsandaskeystakeholders.

8.7 Limitations

Thisstudycouldbenefitfromtheexperiencesofdirectmidwiferycareproviderstofurther

understandthechallengesthatcareprovidersfaceroutinelyindirectcareprovisionatpresent.

Giventhestudyparticipantsareallnursesandmidwives,itmayhavesomebiasedopinions

againstothermembersoftheteamofcareproviders.Indiadoesnothaveaseparatecadreof

midwivesyet,hencetherespondentshavebeenaddressedasnurse-midwivesinthechapter.Asa

result,theresponsesareamixoftherespondentsnursingandmidwiferyroles,butthatisa

challengeinitself.Solongasthesetwostreamsofcarearenotseparated,itwouldbedifficultto

filteroutthemidwiferyrelatedchallengesfromnursingwhenunderstandingandworking

towardsrespectfulmaternitycare.

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8.8 Conclusion

Obstetricviolenceduringchildbirthisdrivenbyfactorsrelatedtothecareprovider,birthing

environmentandpolicyenvironmentandthewomanasacarereceiver.Itisevidentfromthis

studythatthenursesandmidwiveshavein-depthunderstandingofwhatconsistsofrespect

duringchildbirthandwhatleadstodisrespectandabuseofwomen.Theyfaceseveralchallenges

thatmakeitdifficulttosustainchanges.Implementingmidwiferypracticeandempoweringthe

existingnurse-midwivesinthecurrentworkforce,fromthestudentstotheleadersservinginthe

highestpositionsinthestateandcentre,iskeytoensuregoodqualityandrespectfulcarefor

womeninIndia.

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Chapter9 Expectedrespectabilityfromanintersectional

lens:discussionandconclusion

IaimtolearnwhatmakeswomenmorevulnerabletoobstetricviolenceinBihar,India.Todothis,

Iexploredthenatureofobstetricviolenceandfactorsthatdriveobstetricviolence.Iwantedto

understandthisfromtheexperiencesandperceptionsofwomenwhoshouldbethekey

stakeholderincareseekingandaspeoplewhoownthisknowledge;andfromtheexperiences

andperceptionsofleaderswhoaremidwives,nurse-midwivesandnurses,asprimary

stakeholdersinmaternalandreproductivehealthcareprovision,whoowntheknowledgefrom

thecareprovider’sposition.Thesetwostandpointsareessentialtoensurerespectfulmaternity

careforwomen.Iusedfeministmethodstohighlightwomen’svoicesandtheirexperiences,

supplementedbyvoicesandnarrativesoftheirnurse-midwives.

Iconcludemythesisbyansweringthequestionof‘what’and‘why’aboutobstetricviolence

throughtwoconstructs:1)expectedrespectability-thatexplainswhysomeoneisconsidered

respectableaccordingtowomen’sexpectationsofbeingrespected,disrespectedandabused

basedonthecomplexnatureoftheirexperiencesduringchildbirth;and2)intersectionality-that

explainswhywomenexperienceobstetricviolence.Parallelscanbedrawnbetweenboththese

constructs,toalsounderstandmidwivesornurse-midwives’experiencesofrespectabilityand

whatdrivestheviolenceanddisrespectagainstthem,throughintersectionality.Forwomenand

midwives(predominantlywomenintheIndiancontext),thesediscoursesinthebirth

environmentareanextensionoftheirlivesintheirsocialenvironment.

9.1 Expectedrespectability

Childbirth,asanarrative,isbeingpassedonthroughgenerationsasanexperiencethatshouldbe

endured.Women’sbirthingexperiencesbringclarityaboutwhyithasbeenanexperiencethat

Indianwomenendure,anditcanbeunderstoodasacontinuum,whichhasaspectsof

respectfulnessandobstetricviolencewhichtogetherdecidewhetherwomen’sbirthing

experiencewillbepositiveortraumatic.Ihaveattemptedtosummariseandshowthisuniquemix

ofrespectful,disrespectfulandabusiveinstancesinwomen’sexperiencesthroughtheContinuum

ofRespectfulExperiences(CORE)Model.IpresentanevolvingprototypedevelopedfromPairo’s

narrative,byplottingherexperiencesontheCOREmodelretrospectivelytoshowaspectsof

respect,disrespectandabuseinherbirthingexperience(Figure9.1).TheCOREmodelenables

visualisationofthecomplex,multi-layerednatureofbirthingexperiences,whicharenot

unidirectionalandarelonglasting.Someoftheseactionsappearonce,othersappearmultiple

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timesandmanyare‘ongoingbehaviour’(shownvertically)thatwomenexperiencethroughout

thedurationoftheirstayinthehospital.TheconfigurationsofPairo’sidentitiesandbackground

helptounderstandherintersections.Thismodelcanbeusedasatoolforfutureresearch,to

continuemakingprogressandmeasurechangingpatternsofrespectfulnessincareprovision.It

canbeoperationalisedforcareproviderstodevelopcompetenciesandwaystoaddressspecific

formsofobstetricviolence;informedbyparticipant’sexperiencesandperceptionsofrespectful

care,enablingperson-centereddecision-makinginformedbythedifferentneedsofpeople

representingdifferentidentities.Thegoalistomakethecontinuumgreenalltheway,toensurea

humanisingbirthingexperience.

Figure9.1 ContinuumofRespectfulExperiences(CORE)model(Author’sown)

Thefindingsfromchapter5demonstratedevidencethateverywomanexperiencedatleasttwo

tothreeformsofabuseduringchildbirthrangingtoamaximumof17formsofabusesmakingit

anextremelytraumaticchildbirthexperiencefortheparticipant(AppendixA).Nowoman

reportedexperiencingsexualviolenceandbeingrestrainedduringchildbirth,andreportsof

physical(2%)andverbalabuse(5%)areataminimum.Thisisinlinewithseveralstudiesthat

explainreasonsbehindunderreportingofexperiencesofobstetricviolenceinresource

constrainedsettings.Thepaperondeterminantsofobstetricviolenceduringchildbirthidentified

bythequantitativeanalysis,doesnotexplainthenumberofaccountsofviolenceundereachof

theseforms,howmanypeoplethesewomenwereabusedbyandthenatureoftheobstetric

violencewithitsdiversityinthecontextandtheimpactonwomen.I,therefore,godeeperinto

women’sembodiedexperiencesinthefollowingchaptersthroughparticipatoryarts-based

feministmethodsthatputwomen’snarrativesatthecentre,whilecuttingthroughthebarriersof

language,stigmaandpower.

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Acommonthreadinallthefindingschapters(chapter5,6,7and8),fromthestandpointof

womenandtheirnurse-midwives,isthatgrievancereportingisunusual.Women’sreportingof

violenceisinfluencedbytheirexperienceofreportingviolenceintheirroutinelives,drivenbythe

contextwithinitsdomainsofsensitivityandstigma,thatguideswhetherandwhattotalkabout

birthingexperienceswithinthediscoursesaroundsexual,reproductiveandmaternalhealthand

wellbeing.

Inthequantitativestudy(chapter5),nowomanreportedbeingrestrained.Although,being

restrainedisoneofthemosttraumaticanecdotesinmostwomen’sbirthingstoriesinthe

qualitativestudy(chapter6),becauseofitsconnectednesstounconsentedvaginalexaminations,

toepisiotomy,tounanesthetisedepisiotomyrepairs,uterineexplorationsandfundalpressure.

Womenconsideredmanyoftheseinterventionstobeapartofqualityhealthcareprovision,

whichissupposedtobeendured.Sexualviolence,asanAsianfeministtheoristexplains,is

consideredafateworsethandeath,andhasnegativerepercussionstowardsthewomen,instead

oftheperpetrator,asthecurrentdiscourseinmostpartsofIndiagoes.Womenstandthechance

ofbeingdisbelieved,asisseenintheglobaldiscourseandinIndia,concerningtheincredulity

surroundingdomesticviolence,intimatepartnerviolenceandnowobstetricviolence.Itis

thereforenotsurprisingthatnowomanreportedsexualviolenceinthequantitativestudy,

althoughthatchangedinthebirthmappingexercisewhichcapturedwomen’sexperiencesfrom

theiruniquewaysofverbalandnon-verbalexpressions,suchasRia’sreferencetosexualviolence

as‘colourfulthings’.

Itisobviousfromwomen’snarrativesthattheattempttodisciplinewomenbodiesbyhealthcare

providers,asisinthenatureofobstetricsystems,iswellunderstoodandobeyedbywomenand

acceptedasacultureleadingtoself-disciplineinadisplayofobstetrichardiness,inlinewiththe

genderedexpectationsfromwomeningeneral,moresofromwomenrepresentingparticular

backgroundcharacteristicssuchasbeingmultiparous.Ialsopresentreportsfromwomen’sand

nurse-midwives’narrativesabouthowthisguideswomen’sexpectationofbeingrespected,

disrespectedandabusedduringchildbirth,whichIrefertoas‘expectedrespectability’.Itexplains

whetherandhowwomenexpecttobetreatedbycareproviderstreatthembasedonthesocietal

andculturalnorms,andwomen’spositioning,definingtheirrespectabilityfromanoutsider’s

perspectiveandinthiscase,careprovider’sperspective.Iexplainthisfromanintersectionallens

inthefollowingsection.

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9.2 Applyinganintersectionallens

Intersectionalitycanhelptounderstandwhywomenexperienceobstetricviolenceandwhysome

careprovidersengageininflictingobstetricviolenceduringchildbirth.Women’snarratives

indicatehowtheyaretreatedinthebirthingenvironment,obstetricandnon-obstetric,andhow

theyexpecttobetreatedduringchildbirth.Womenaretreatedinacertainmannerbecauseof

theirpositioningattheintersectionsofgender,parity,abilities/disabilities,maritalstatus,caste,

financialstatus,physicalappearance,language,religion,nationality,statehood,age,education

andhealthstatus.Ihaveattemptedtopresentthisthroughtheintersectionalitywheel,adapted

forobstetricviolence(Figure9.2).Theseintersectionsaredynamic,basedonpeople’scontext

andbackgroundcharacteristics.Theyareflexibleandcanbefluid,becausetheintersectionsare

constantlyshiftinginrelationtothechangesinwomen’sbackgroundcharacteristicsandcontext,

asisexplainedbythetheoryandconceptofconfigurations.

Inthequantitativeanalysispresentedinchapter5,Ifoundthatage,parityandeducationwere

significantindeterminingwomen’svulnerabilitytoobstetricviolence.This,alongwithother

determinants,weresharedbywomenthroughtheirbirthmaps,althoughIdidnotdirectly

exploretheunderlyingfactorsdrivingobstetricviolenceinthequalitativestudy,butwomen

completedtheirnarrativessharingthereasonsbehindbeingtreatedrespectfully,ingeneraland

inthebirthingenvironment.ThisismorepronouncedinAmrita’scommentthatalthoughsheis

darkskinnedbutshepreferscleanliness,drawingtheconnectiononhowwomen’streatmentin

thesocietyandbirthingenvironmentisdependentonthecolouroftheirskin,whilealso

indicatingtowardsthediscriminationswomenface,basedontheirskincolourandphysical

appearance.Isawapatterninwomen’snarratives,onhowthesedeterminantsinteractand

influenceeachunderthefourkeydomainsofgender,power,cultureandstructurewhile

increasingwomen’svulnerabilitytoobstetricviolenceinpaper3.Someofthesedeterminants

weremissingfromwomen’snarrativebutcouldbelearntfromnurse-midwives’perspectivesin

paper4.OneoftheseaboutvulnerabilityofwomenparticularlyfromBiharcouldbenoticedina

nurse-midwives’judgementriddencommentthatBihariwomendisplaypoorerpersonalhygiene.

Thisreflectedthestereotypesrelatedtowomen’sgeographicalpositioninginastateorcountry

couldalsoleadtoobstetricviolence.

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Figure9.2 Intersectionalitywheelofobstetricviolence(AdaptedfromSimpson,2009,p.3)

Theclarityonthiscomesfromthenurse-midwives’standpoint,whoreflectonthedeterminants

ofobstetricviolence,asprimarycareprovidersandasapartofthehealthsystem.Theyhave

experiencedthechallengesofworkinginthemedicalmodelofcare.Itisoftenmale-ledandhas

remnantsofpatriarchyembeddedinapostcolonialcontext.Apatterncanbenoticedinthe

importantfactorsthatnurse-midwifeleadersmentioned,andcouldbedividedintofactorsthat

arerelatedtothemandtowomen,inincreasingboundariesofself,immediatesurroundingsand

largerenvironment,thatinteractwitheachotherwhiledeterminingwomen’svulnerabilityto

obstetricviolence.Manyofthesefactorsarecross-cutting,betweenwomenandnurse-midwives,

suchasgender,whichconnectedthemintheirsharedvulnerabilitiesanddrewparallelsonhow

similartheirstoriesare,forwomenbeingatthebottomofthesocialhierarchyandnurse-

midwives’positionedatthebottomofthemedicalhierarchy.Thispositioning,influencedthe

otherfactorswhileconstantlyshiftingthecontextofhowwomen,nurse-midwivesandother

stakeholdersincareprovisionandcareseekinginteractwitheachotherrespectfully,

disrespectfullyandinanabusivemannerwhileconstantlycreatingnewdiscoursesowingtotheir

diversities.

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Chapter10 Summary,policyrecommendationsandway

forward

Iaimedtoexplorewomenandnurse-midwives’experiencesandperceptionsaboutthenatureof

obstetricviolenceandtheunderlyingfactorsdrivingthisissueinBihar,India.Inthisfinalchapter,

Isummarisethefindingsfromchapter5,6,7and8,andconcludewiththepolicy

recommendationsandsuggestionsforfutureworkalongwithstatingthelimitationsofthethesis.

10.1 Summaryofresearch

Paper1(Chapter5)-

• Women’sexperiencesofobstetricviolencearepluralandmultilayered,whichmaygoon

fortheentiredurationoftheirstayintheobstetricsetting.Mostoftheparticipantsofthe

studyexperiencedatleast2-3formsofobstetricviolenceduringchildbirthinBihar,while

themaximumformsofabusesexperiencedbyawomanwas17.

• Bribery,extortionandunclearfeestructureisthecommonestformofabusethatevery

womanexperienced,regardlessofherbackgroundcharacteristics.

• Parity(numberofbirths),ageandeducationincreasedwomen’svulnerabilityto

experienceobstetricviolenceduringchildbirthinBihar.

• Noparticipantreportedbeingsexuallyabused.

• ThreetypesofobstetricviolenceemergefromthedatainBihar:1)coercion;2)poor

communication;3)physicalandverbalabuse.

• Thesurveydatadoesnotnecessarilyelicitfulldisclosureorabusefromwomen.Butthe

extentwasconsiderableandislikelytobemore.

Paper2(Chapter6)-

• Women’sexperienceofbirthiscomplex,multilayeredanduniquewiththeircontrapuntal

voicesrepresentingthediversityandtheupsanddowns,therespect,disrespectand

abuseintheirbirthingexperienceswhicharenotunidirectional.Theseareablendoftheir

voicesofsilence,knowing,resistance,resilience,depression,sadness,trauma,isolation,

powerlessness,determination,hopelessness,relief,satisfaction,struggle,conditioning,

denial,anger,happinessandmore.

• Obstetricviolenceisexploredinseveraldomainswhichincludes,butisnotlimitedto

communication,touch,obstetricinterventions,peoplearoundchildbirth,birthsettingand

birthingenvironmenttounderstandthenatureofobstetricviolenceinordertoensure

respectfulmaternitycareineachofthesedomains.

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• Feministmethodsareessentialwhenexploringissuesbornoutofcenturiesofwomen’s

oppression.

• Arts-basedresearchisanappropriatewayoflearningaboutsensitiveissuesaround

women’ssexual,reproductiveandmaternalhealthcareandwellness.

• Birthmappingisafeministvisualarts-basedparticipatorymethodtoenablelearningfrom

women’sembodiedbirthingexperiences.

Paper3(Chapter7)-

• Gender,power,cultureandstructurebasedbarriersdriveobstetricviolenceand

respectfulmaternitycare.Thisisanextensionofthehowthesefactorsdriveotherforms

ofviolencesuchassexualharassment,intimatepartnerviolenceanddomesticviolence,

intheotherroutinephasesofwomen’sliveswhichmayincreasetheirvulnerabilityby

normalisingviolence.Thishasbeencommonlyseeninpatriarchalculturesinpostcolonial

settings.

• Thefactorsunderthesefourdomainscanbeoverlapping,thisisinthefluidnatureof

thesecross-cuttingfactorsthatmakesthemcomplexandarethereforeessentialto

explorethroughuniqueapproachesofresearch.

Paper4(Chapter8)-

• Therearemanyfactorsrelatedtothenurse-midwivesthatfunctionattheindividual,birth

environmentandpolicyenvironmentlevels;similarly,therearefactorsrelatedtowomen

thatfunctionattheindividual,communityandsocialenvironmentlevels.Thesefactors

togetherdeterminewomenandbirthingpeople’svulnerabilitytoobstetricviolence.

Manyofthesefactors,suchasgender,arecross-cutting.

• Midwivesandwomenarebothvictimsofaviolentbirthingenvironmentandan

insensitivepolicyenvironment,asaresultofmidwives’beingatthebottomofthe

medicalhierarchyandwomenpositionedatthebottomofthesocialhierarchy,

experiencingaformofdeep-rootedandcontinuedoppression.

• Midwives’perceptionofrespect,disrespectandabuseisbasedintheircontextand

culture,andhowtheyperceiveitiscrucialtoensurerespectfulmaternitycarethrough

theirrecommendationsaroundmidwiferymodelofcare,shiftingfromthecurrent

medicalmodelofreproductiveandmaternalhealthcare.

10.2 Researchcontributions

• Betterunderstandingofsocialdeterminantsofobstetricviolencefromwomenandnurse-

midwives’experienceandperspectivestoensurerespectfulmaternitycareinIndia.

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237

• Adetailedframeworkpresentingthedriversofobstetricviolencewithrecommendations

forrespectfulcareprovisionduringchildbirth.

• WHO’sEssentialRespectfulCareCourse(ERCC)-ThefindingsofthisPhDwillguide

educationofmidwivesgloballyasprimarycareprovidersbetterunderstandingobstetric

violence,itsfactorstoproviderespectfulmaternitycareblendedwithresearchfrom

otherpartsoftheworld,withtheERCC,thatisunder-developmentatWHOAcademy,

WHO,HQ.

• Apolicyframeworkreflectingontheexperienceofmidwiferyleadersandwomento

advocateforimprovedrespectfulnessinmaternalhealthcareprovisionandtothereby

ensurequalityofcare.

• Birthmapping,avisualarts-basedresearchmethodtounderstandsensitiveissuessuchas

respect,disrespectandabuselearntfromwomen’sperspectivesandexperienceofcare

duringchildbirthtoguidecareprovisioninIndia,whichcanbeadoptedtoexplore

sensitiveissueswithsensitivityinothercontexts.

10.3 Policyrecommendations

• ThecentralandstategovernmentsofIndiashouldcollaboratewithpartnerswhoplaya

keyroleinprovidingsexual,reproductiveandmaternalhealthcareanddevelopa

roadmapforawayforwardtoensureperson-centeredcompassionatecare,guidedby

womenandmidwives’.Theyneedtomakesystemicchangesbeginningatthetoplevels

ofpolicymakingwhilestayingengagedforcontinuedlearningfromthegroundrealities

fromwomenandmidwivesasthetwokeystakeholders.

• Birthmapscanbeutilisedinthecurriculumformidwifery,nursingandmedicalstudents

tolearnaboutobstetricviolenceandensurerespectfulmaternitycaretowomenfrom

women’sexperiencesandperspectives.Birthmappingisauniquewaytolearnwomen’s

embodiedexperiencesandbeforestudentspracticehealthcareprovisiononpeople.

• GovernmentofIndiashouldensureimplementationofprofessionalmidwiferycadre,

independentoftheirnursingroletoensurecompassionaterespectfulmaternitycarefor

allwomenandbirthingpeople,regardlessoftheirbackground,inanequitablemanner.

• Governmentsshouldenactlawsatthecentralandstates,againstobstetricviolenceinline

withothercountriessuchasinLatinAmerica,whohavelawsinplaceagainstviolencein

obstetricsettings.

• Largescalesurveysarerequiredtogenerateevidenceforobstetricviolence.Government

canensureinclusionofquestionsexploringnatureandextentofobstetricviolencein

NationalFamilyHealthSurveysjustasitexploresquestionsonintimatepartnerviolence.

Chapter10

238

• Inclusionofnursingandmidwivesandnursingandmidwiferyleadersateverylevelof

decisionmakingandpolicymaking,startingfromthegrassrootsandprimarylevelofcare

provision.Thiswillhaveimplicationsineducationandpractice.

• Empowermenthastobeatalllevelsformidwifery,nursingandmedicinestudentsand

careprovidersandteachingprofessionalsonhowtotakeastandforwomenandpeople

whoserightsarebeingviolated,onhowtopreservetheirdignity,throughrolemodelling.

• Everytimethereisanindicatorfallingbehindinhealthcare,nursesandmidwivesareon

thefiringlineandinterventionsareparticularlydesignedjusttotrainorretrainthem.This

impliesashiftingofblameonthem,forbeingapre-dominantlywomendominated

profession.Thisisagender-basedchallengeandsystemicbiasthatneedstobeaddressed

throughteam-basedinter-professionallearningforrespectfulmaternitycare.Thisneeds

tobeinthecurriculumandeducationalstandardssothattheregulatoryandaccreditation

systemsofIndiacanincorporateit.

10.4 Limitations

• SurveydatadoesnotcaptureeverythingaboutthenatureofobstetricviolenceinBihar,

India.

• Surveysaresubjecttosamplingerrorswhichcannotbeunderestimated.

• UnderreportingcouldbeachallengeinlowresourcesettingssuchasBihar,where

women’sexpectationsofcarecouldlowwhichmayleadtoacceptanceofpoorquality

anddisrespectfulandabusivecare.

• Whilebodymappingcaptureswomen’sembodiedexperiences,culturalunderstandings

andsocialcontextcouldpotentiallyinfluencethecontentsofmappingexercise.

• Althoughmeasureswereinplacetoreduceresponsebiases,thenursingandmidwifery

leaders’interviewscouldhavebeeninfluencedbytheirrolesaskeypolicymakersand

beingapartofhealthcaresystems.

• Practicingmidwives(nurse-midwives’intheIndiancontext)werenotincludedinthe

study.

10.5 Futureresearch

• Researchaimingtocreateanatlasofbirthmapsfromcountriesandcontextsaroundthe

worldtounderstandthediversenatureofwomenandbirthingpeople’sexperiencesof

respectfulmaternitycareandobstetricviolenceduringchildbirth.

Chapter10

239

• Researchshouldexploretheextentofobstetricviolencewithindifferentformsofabuse

whichhavebeenrecognisedandtheonesthatarecontextspecificandremaintobe

identifiedindifferentstatesandinIndia.

• Researchonwomen’sexperiencesofallformsofviolencealongwithobstetricviolence

throughsensitive,feminist,embodiedparticipatorymethodstounderstandtheconstruct

ofallformsofviolenceinwomen’sliveswithoutsegregatingthedifferentformsof

violence.

• Researchandconsultationbasedonlearningsfromsystemicliteraturereviewtodevelop

plansforawayforwardtoaddressthedriveridentifiedatallthelevels,individual,

birthingenvironment,socialandpolicylevels,whichcanenablerespectfulmaternitycare

provision.

• Researchtounderstandobstetricviolenceinuniquecircumstancessuchassurrogacy,

prison,conflictandhumanitariansettings,naturalcalamitiesandpandemictoensure

respectfulcareinthesecontextsforsexual,reproductiveandmaternalhealthcare.

• Researchonoverlappingterritoriesandconstructssuchasreproductiveviolence,

reproductiveinjustice,reproductivepoliticsandgovernanceetc.howtheyoverlapwith

anddifferfromobstetricviolence,tofurtherunderstandthewholegamutofwomen’s

experiencewithinsexual,reproductiveandmaternalhealthandhealthcare.

• Researchonmidwivesandnurse-midwives’experienceofobstetricviolenceand

respectfulmaternitycarewhentheygivebirth,andhowthatinfluenceshealthcare

provision.

• Researchonteamcultureonobstetricviolenceandalsoonrespectfulmaternitycare,and

howteamscanbeaddressedtogetherininitiativestoensurecompassionatecare.

• Largescalequantitativeresearchoncareprovidersrelatedbarrierstoensurerespectful

maternitycareinIndia.

• Researchexploringpainandpleasureinwomen’ssexual,reproductiveandmaternal

healthrelatedembodimentstounderstandhowtheyinfluenceeachother,andtheir

experiencesandexpectationsfromhealthcare.

• Researchonobstetricviolenceandrespectfulmaternitycarefromtheperspectiveof

senseofsight,smell,speech,soundandtouch.

• Researchonbirthingenvironmentinfrastructureandarchitectureforlowresource,high

workloadsettings.

• Understandingthecontrapuntalvoicesquantitativelytoknowthedurationofthese

voicesrepresentingconcordanddiscordinanattempttomakeashifttowardsmore

concord,insensitiveissuesofbirthingwherewomen’smayhesitatetosharetheir

experiencesofobstetricviolence.

Chapter10

240

• ResearchandimplementationoftheContinuumofRespectfulExperiences(CORE)model.

0

241

Postscript:Thestoryofmybirth

My1stfamilypicture:Baba(curlyhair),Ma(wearingasareecutfromtheclothofthecurtain),me

(camouflagingonmymother’slap)andDidi(turtleneck)

IwasborninamilitaryhospitalinthewesternstateofRajasthaninIndia,at10amonathursday,December11th,1986.

Soonafter,mymawasshiftedtoapostnatalcareroomthatshesharedwithaRajasthaniaunty.

Let'scallherBinti.

Bintiauntygavebirthtoher4thsonandwasverysad!

MrsandMrBintialwayswantedagirlandhad4sonswhiletryingforagirl.

Mymahadadaughteralready,ourbelovedKeya.

Iamhersecondgirl,soBintiauntydrooledallovermefromthesecondshesawmeandhadabrilliantidea.

"Let'sexchangeourbabies,Kalpana"shesaidtomymother"thatwaywewillbothcompleteourdreamfamilywithperfectmale:femaleratioandthesecretwillremaininthispostnatalroom".

Let'scallhersonDhinku.

Concerned,IlookedatDhinkuandthoughtthere'snowaymymawillgivemeupforhim.

(PleaserefertomeinthepictureinExhibitA:Myfirstfamilypicture)

Importantdetail-noneofthefathershadseentheirrespectivebabiesyet.

Bintikeptpleading.

Masaidno.

Shesaidplease.

Masaidno.

0

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DhinkuandImadeeyecontactandcried,undecidedwho'sgoingtogetaBengaliupbringingandwhowillberaisedRajasthani.

Bintibrokeintotears,inconsolable.

Mr.Bintijumpedin,saidplease.

Masaidno.

Everybodystartedcrying!

TheysaidaskMr.Kalpana,he'llsurelywantDhinku(2.5kgs)inexchangeofa2nddaughter(4kgs).

Keya,mydidi,clueless,ifherparentsarebringinghomeasisterorabrother.

Mr.Kalpanaheardaboutthedealofbabyexchangeonthetable(inthecrib)andgotfurious.

Mr.Kalpanaranhishandthroughhiscurlyheadfullofhairandsaidno.

Forwhateverreason,together,MrsandMrKalpanadecidedtokeeptheirdaughter(4kgs)andtheylivedhappilyeverafter.

****************************

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AppendixA

245

AppendixA Trahi’sbirthingexperience

Trahi(pseudonym)isa21-year-oldhomemaker.Shehastwochildren,andherlastchildwasborn

18daysago.SheisaHindubyreligionandbelongstoschedulecaste.Shehasreceived4yearsof

formaleducation,belongstoahouseholdfrompoorsocio-economicbackground,whoareall

casuallabourersinothersfarms.Thehouseholddoesnothaveaccesstoelectricity.

Trahitravelledwithhermother-in-lawandarelativetothehealthcarecentre.Shemadetwo

visitsforantenatalcareatapublichealthcarefacilityduringherpregnancyandfeltthatsheis

treatedveryrespectfullyduringherante-natalvisits.Goingtothisfacilitywasherfamily

member’sdecision.Itwasthesamefacilitywhereshewentforherantenatalcareandfeltthe

providerstreattheirclientswell.Sheexpectedawellequippedfacility,cleanenvironment,good,

affordableandspecialisedservices.Whenshevisitedthehealthcarecentretogivebirththe

healthcareproviderscheckedherbloodpressure,thefetalheartrateandconductedan

ultrasonography.Herbirthwasassistedbyadoctor,nurse,mamtaandASHA.Hermother-in-law

accompaniedasherbirthcompanion.

Trahiexperiencedmanyinstancesofobstetricviolenceduringherstayatthehealthcarefacility

duringchildbirth.Sheexperiencedphysicalabuse,verbalabuse,stigma,discrimination,therewas

poorrapportwithhealthcareproviders,afailuretomeetprofessionalstandardsofcareand

healthsystemconstraints.Thehealthcareprovidersusedrudelanguagewithherandmade

judgementalandaccusatorycomments.Shewasthreatenedtobehitbecauseshewasscreaming

fromthepainfulcontractions.Theyphysicallyabusedherbypullingherbyherleg,shewasalso

slappedorhitorpinched.Therewaspoorcommunicationandshefeltlikeapassiveparticipant

becauseshewasnotinformedthefindingsofhergeneralandvaginalexaminations.Shewasnot

communicatedaboutthewardenvironmentandtheprogressinherlabour.Shefeltneglected

andabandoned.Herprivacywasnotmaintainedandconfidentialitywasbreached.Herconsent

wasnotsoughtwhenconductinginterventionsonher.

Trahi,orthebabyweredetainedatthehealthcarefacilityfortheinabilitytomakepayment.Her

familypaid500rupeesinbribeand3500rupeesformedicationatthegovernmenthealthcare

facility.ShehadnotreceivedtheJSYmoneyinthe18dayssincebirth,whichsheissupposedto

receiveimmediatelyinherbankaccount.Shefeltthatthestaffattitudetowardsherwasvery

poor.Shewasnotallowedanyfoodorfluidduringlabourandbirth,andwasnotallowedtowalk

around.Shewasnotallowedtogivebirthinapositionofherchoiceandhadtogivebirth

standing.Herbabywasputonherchestrightafterbirth.Shetooknoactionabouttheobstetric

AppendixA

246

violencesheexperienced.Shesharesthatshewillnotrecommendthishealthcarefacilityto

otherstogivebirth.Trahiratedtherespectfulnessshowntoherduringchildbirthandstayinthe

facilityaspoor.

AppendixB

247

AppendixB Bodymappingaidedin-depthinterview

guide

Background

No. Question Response

A1 Participantcode

A2 Participantchosenpseudonym

A3 Age

A4 Numberofchildren

A5 Education(no.ofyears)

A6 Occupation

Householdinformation

No. Question Response

B1 Istherewatersupplyinthehousehold?

B2 Isthereelectricityinthehousehold?

B3 Doestheparticipanthaveabankaccounttohername?

B4 Distance(kms)tothenearesthealthcarefacility?(PHC/CHC/DH/Tertiaryhospital)

B5 Urban/Rural

B6 Durationofstayatcurrentaddress

Birthhistory

No. Mother’sageatbirth

Placeofbirth(Hospital,Home,CSother)

Sexofnewbornatbirth

Birthcompanion Anycomplications/comments/remarks

C1

C2

C3

C4

C5

AppendixB

248

Experience,expectationsandperceptionsaboutchildbirth

No. Questionsandprobes ReflexiveNotes

Experienceofchildbirth

D1 Howwasyourbirthexperience?Probes:Shemaytalkaboutanybirthexperienceofherchoiceandevenmentionexperiencesfromdifferentbirthsshehashad.

D2 Howwereyoureceivedatthehealthfacilitywhenyouarrivedandhowwastheexperience?Probes:Whoreceivedyou,howmanypeoplewerethere,whosaidwhat,whodidwhat,waitingtimefromarrivaltolabourroomorward

D3 Whathappenedafteradmission?Wereyoutakentothelabourroomorawardtowait?Whathappenedintheantenatalroom?Probes:Wereyouallowedtomovearound?Wassomeonewithyoufromfamily?Wasthereanythingthatyoulikedordidnotlike?Didyoufeelanythingdisrespectfulorabusive?

D4 *Howwouldyoudescribethebirthingenvironment/roomwhereyougavebirth?Probes:whatwasaroundyou?Curtains,airconditioning,otherlabourtables,cleanliness,monitor

D5 *Howwasyourprivacymaintainedduringlabourandwhilegivingbirth?Probes:Whatwerepeopledoingaroundyou?Canyoushowonthemapwherearoundyoutheywerestanding?Didyoufeelyouwereproperlycovered?Howdidyoufeelaboutit?

D6 *Whatpositiondidyougivebirthinandhowdidyoufeelaboutit?Probes:lyingdown,restraints,peopleholdingdown,howwasbirthingonalabourtable

D7 *Whatinterventionswereperformedonyouinthehospitalfromadmissiontodischarge?Howdidyoufeelaboutit?Probes:consent,information,communication

D8 Didthesamecareprovidergivecaretoyoufromantenatalperiodtochildbirth?Probes:Yes,no?why?Whatwouldyouhaveliked?Howwouldithavehelped?

D9 *Howdidtheperson/peoplefromfamilyaroundyouhelpwhileyouwereinthehealthcarefacility(orhome)andwhenyouweregivingbirth?

D10 *Howdidyoudecideaboutyourbirthcompanionandwhy?

D11 Howwasthebehaviorofthecareprovideraroundyouduringchildbirth?

D12 Whatconversationsdidyouhavewiththecareprovider?Probes:Didanyonesayanythingtoyouthatyoudidnotlike?Anythingthatyouliked?

AppendixB

249

D13 Howdidyoufeelaboutaskingquestionstothecareprovidersduringchildbirth?Probe:Couldyoutalkfreelytoyourcareprovider?

D14 *Whatkindoftouchisokayduringchildbirth?Probes:Howmanypeopletouchedyouinanyway?Careprovidersandfamily?Whotouchedyouwhereandhowmanytimes?Howdidyoufeelaboutit?

D15 *Whatcomfortedyouduringlabourpains?Who(family,careproviders)helpedyou?How?Probes:Walkaround,drinkingwater,takingsomefood,usingwashroom,backmassages;Whatwasthemostdiscomforting?

D16 *Whatarethethingsthatyoulikedduringchildbirth?Whatarethethingsthatyoudidnotlike?Probes:wasinformationaboutyousharedwithothersthatyoudidnotwant?Didyouhavetopayforanyservice?

D17 *Howdidyoudecidewheretogivebirthandwhy?Howdidyoufeelaboutthatdecision?

Hopes

E1 *Whatdidyoualreadyknowaboutgivingbirth?Whatisthelanguageyouusetotalkaboutbirth?Whodoyoutalktoaboutbirth,questions,fears,doubts?

E2 *Whatdidyouhopewouldhappenwhenyougivebirth?Probes:Listallthethingsshesaysandkeepaskingspecificquestionsbasedonherresponse,couldbeunrealistic

E3 *Whatservicesshouldbethereinthehospitalthatwillmakeyourexperienceofchildbirthsatisfactoryandrespectful?Probes:birthenvironment,privacy,cleanliness,behaviorofcareproviders,wayoftalking

E4 Multipara-whatisthedifferenceinyourexperienceofbirthingintwosettings?Goodandbad?Whichwasmorerespectful&disrespectful?Why?

F Concludingquestion-Howdoyoufeelaboutthisexercise?Isthisasatisfyingexercise?Why?Probes:likes,dislikesabouttheprocessofbodymapping

Note-*Tobeaskedforhomebirthsaswell.

AppendixB

250

BodyMapKey

RespondentID/Pseudonym-

Symbolorcolour Meaningorinterpretation

Postinterviewdebrief

Debrief

Reflexivenotes

Interviewenvironment

AppendixC

251

AppendixC Nursemidwives’perspectivesonrespect,

disrespect&abuseduringchildbirthA. Backgroundinformation(Tobefilledbyparticipantifpossible)

A1 Participantcode

A2 Age

A3 Sex

A4 Designation

A5 Organisation/department

A6 State

A7 Category(selectallthatapplies) • MOHFW• INC/SNC• Hospital• TeachingInstitution• CivilSocietyOrganization• Private• Others______________________

A8 Numberofyearsofserviceinurbanandruralarea

Urban____________Rural_____________

A9 Educationalbackground(selectallthatapplies)

• ANM• GNM• BScNursing• PBBScNursing• MScNursingin_______________• PhDin______________________• Other_______________________

A10 Allthedesignationsworkedonwithpromotions(mentionpositionandnumberofyearsworkedonthesame,Eg.StaffNurses-10years)

Designation Yearsofservice

A11 Totalyearsofexperience

A12 Haveyoueverdonemidwiferyprofessionally?

Professionally-Yes/No

A13 Ifyes,forhowmanyyearsormonths?

A14 Howmanybirthshaveyouconductedintotal?(anyinthelastoneyear?Public/Private)

B. CurrentRoleandresponsibilities

B1 Howwouldyoudescribeyournursingand/ormidwiferycareer?

B2 Whatisyourcurrentroleandresponsibilities?

AppendixC

252

B3 Whatsupervisoryroledoyoucurrentlyplay?(Probes:Visitstohospitals,teachinginstitutions,meetingswithpeopleetc.)

B4 Howarevariousnursingandmidwiferypoliciesmade?Howarethosedecisionsmade?(Probes:regulation,deployment,transfer,etc.)

B5 Whatroledoyouplayinnursing&midwiferyworkforcegovernance?Probe:recruitment,salary,posting&transfer,continuededucation,careerprogression,promotionCollect:policydocuments,acts,etc.Whatpercentageofthemarewithnursingandmidwiferybackground?Whoarethestakeholdersinvolvedinthesedecisionmaking?

B6 Doyoufeelnurse-midwivesareplayinganequalroleatpolicymaking?Doyoufeeltheycancontributeinanyotherwayinimprovingnursing-midwiferyworkforcegovernance?

C. Perceptionofquality&respectfulnessincarearoundbirth

Information:Hereisapaintingdrawnbyamidwifebasedonherandmyexperienceofadeliverywehadobservedtogether.(Refertoimage)

C1 Whatisyourreactiontothepainting?Probe:familiarornot,realisticornot,typeoffacility,urban/rural,home,private,public

C2 Whatdoyoufeelaretheessentialcomponentsofgoodqualityofcarearoundchildbirth?

C3 Whatdoesrespectmeantoyou?

C4 Howwouldyoudefinerespectfulmaternitycare?

Information:ThereissomeevidencecomingupfromstateslikeBihar,UttarPradesh,Jharkhand,WestBengaletc.thatwomenhavebeenphysicallyabused(hit,slapped,pinched)orverballyabused(commentsonsexlife,discriminatorycommentsbasedongender,religionorsocioeconomicstatus,physicalappearance)ortherewaslackofprivacyduringchildbirth&confidentialityduringorafter.

C5 Haveyouheardofchildbearingwomenundergoingdisrespectandabuseduringchildbirth?Whatkindofdisrespectandabusedoyouthinkwomenface?Couldyousharesomeexamplesfromwhatyoumayhaveseenorheard?

C6 Whydoyouthinksomecareprovidersabusewomenduringchildbirth?Probe:workenvironment,workpressure

C7 Howdoesthisstart?Why?Probe:Whiletheyarestudents,laterinprofession

C8 Howdoyouthinkthechildbearingwoman’sbackgroundcharacteristicplaysanyroleinwhyshegetsabusedduringchildbirth,ifany?Probe:Gender,Socioeconomicstatus,educationlevel,class,caste,religion,HIVstatus,numberofchildren,age

C9 Howdoyouthinkawoman’sphysicalappearanceplaysaroleinwhysheget’sabused?Probe:Height,weight,age,colorofskin,attire/clothing,personalhygienelevel,genitals

C10 Howdoyoufeelthetransformationhappensfromastudentwhoislearningtogivecarearoundbirthtoaprofessionalsomeyearslaterwhoabuseswomenaroundchildbirth?Probe:Medicine,midwifery,otherstaff

C11 Howcanyouensurethatrespectfulmaternitycareisprovided?Probe:Disrespectandabuseduringchildbirthisviolationofhumanrights.Howcanitberegulated?Disincentive,punishment

C12 Givenyouarenursingand/ormidwiferyleader(inIndia)howdoyouthinknursingand/ormidwiferyleadershipcanhelpimproverespectfulnessofcarearoundchildbirth?

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253

C13 Howcanournursing&midwiferystudentsbeshowntoprovideRMCintheirPreserviceeducation?

C14 Canyoulistthreethings/actionsyoucantakefromyourleveltoseethatcareprovisionaroundchildbirthisrespectful?Andwhatbarriersandfacilitatorsdoyouforeseeforthesame?

C15 Doyouhaveanychildren?Wouldyoumindsharinghowyourchildbirthexperiencewas?(Probe:Respectful,disrespect&abuse,incontrol,choice,whatdidyoulikeordislike)

AppendixD

254

AppendixD Knowledgetranslation

ThisPhDenablesunderstandingofobstetricviolenceduringchildbirth.Thefindingshighlight

needforfutureresearchtopromoteandimplementrespectfulmaternitycareandfindshortterm

andlongtermsolutionstoaddressobstetricviolenceduringchildbirth.MyPhDbeganinJanuary

2018andthefollowingactivitieshelpedinknowledgetranslationofmyPhDresearchoverthelast

fouryears.

TableD:Knowledgetranslationactivities

Month,year Event Activity

2018

August-September2018

SeminaratWHOHeadQuarters,Geneva,Switzerland

RespectfulMaternityCare:Definitions,typologies,evidenceandpoliciesPresentedtohealthandpolicyexpertsatanopentoallseminarattheWHOHQ.

August-September2018

Globalguidelinesfortrainingmidwivesonrespectfulmaternitycare,WHOToolkit(upcoming)

InternedonMidwiferyLeadershipatWHOHQPreparedacrosscuttingmoduleonRMCforaglobaltoolkitonmidwiferyeducationasadeliverableoftheinternship.Thistoolkitwillbepublishedwhenothermoduleswillbeready.

December2018

PartnershipofMaternalNeonatalChildHealth,Partner’sForum,NewDelhi,India

MidwivesVoices,Women’sChoicesOrganisedasideeventtothepartners’forumthatbroughtmidwives,womenandadolescentgirlsfrom13statesinIndiawheretheysharedtheirexperiences,needsandchallenges.Theaudienceofthiseventincludedinternationaldevelopmentorganisers,policymakers,academiciansandresearchersfrommanycountries.TheNormalBirthCampaigninIndiawasalsolaunchedinthisevent.https://www.change.org/p/government-of-india-promote-normal-birth-in-india-be-a-normal-birth-ambassador

2019

March2019 DepartmentofSocialSciencesSeminar,UniversityofSouthampton,UK

Whydocareprovidersabusewomenduringchildbirth?Presentedfindingsfromthefirstanalysisbasedonmidwiferyleadersinterviews

March2019 WhatWomenWantCampaign,UK

LeadtheglobalWhatWomenWantcampaigninUKtocollectwomenandgirl’swantsforreproductiveandmaternalhealthcare.

AppendixD

255

April2019 3MinuteThesisUniversityofSouthampton

Wonthefacultylevel3MTRepresentedFacultyofSocialSciencesattheUniversitylevelcompetition.https://www.youtube.com/watch?v=LNA6cAfzDAE

May2019 AllWalesStudentNursesConference,Cardiff,Wales

Howcanstudentmidwivesensurerespectfulmaternitycare?Invitedtospeakontherolestudentmidwiveshaveinprovidingrespectfulcareandhowrespectfulcommunicationintheteachingenvironmentinfluencesthat.

May2019 72ndWorldHealthAssembly,Geneva,Switzerland

WASHinHCFandMidwiferyStrengtheningRepresentedICMasayoungmidwiferyleaderandinvitedtospeakattwopanelsalongsideDirectorGeneralDr.TedrosAGhebreyesus.

June2019 WhatWomenWantReport,WhiteRibbonAlliance

Gotfeaturedinthereportasoneofthe5keyinfluencersforthecampaignthatranin114countriesandfoundrespectfulmaternitycareasthe1strankingdemandfromatotal1.2millionwants.https://www.whiteribbonalliance.org/wp-content/uploads/2019/06/What-Women-Want_Global-Results.pdf

June2019 14thNormalLabourandBirthResearchConference,Lancashire,UK

EmpowermidwivesforrespectfulmaternitycarePresentedfindingsfromfirstanalysischapterondriversofdisrespectandabuseduringchildbirthfrommidwiferyleader’sperspective.

July2019 ParlayParlour;WhiteRibbonAlliance,GlastonburyFestival2019,UK

Women’sbodies,Women’srightsSpokeonapanelfocusingonchoicesinbirthandfertilityrevolvingaroundpainandpleasure;alongsideJessePhillips,MPBirminghamYardley.https://www.theguardian.com/music/2019/jun/30/glastonbury-gender-balance-performers-headline-acts-men

August2019 RespectfulMaternityandNewbornCareGuidelines,GovernmentofIndia

ReviewedandgaveinputstothenationalguidelinesonRespectfulmaternityandneonatalcarebyGovernmentofIndia.

September2019

Resolutiontorevolution:WASHinhealthcarefacilities,Livingston,Zambia

Howdoeswater,hygieneandsanitationservicesinhealthcarefacilitieseffectcareprovider’ssafety&dignity?Presentedatathree-daymeetingorganisedbyWHOHQ,UNICEFandGovernmentofZambiabasedonpersonalexperiencesandaquicksurveyofnursesandandmidwivesonsocialmediafromotherlowermiddleincomecountries.https://www.youtube.com/watch?v=Su53NTLFkdA&feature=youtu.be

September2019

14thAnnualSocietyofMidwivesIndiaConference,Raipur,India

Domidwiveshaverespectfulbirths?InvitedtospeakonapanelonRespectfulMaternityCare(RMC)inIndiaorganisedbyWhiteRibbonAllianceIndiaatthe14thSOMIconference.

AppendixD

256

September2019

InternationalConfederationofMidwives’(ICM)

Midwiferyeducator’scurriculum;andNursePractitionerinMidwiferyCurriculum;GovernmentofIndiaConsultedwithICMonafive-memberteamofmidwiferyexpertsledbyProf.LesleyPagetopreparetwocurriculumsformidwiferyeducatorsandnursepractitionersinmidwifery(NPM)inIndia.AnewcadreofmidwivesisfinallybeingtrainedinIndiatoenablemidwiferyledcarethatisgoodqualityandrespectful.

2020

February2020

Birthingoutsidethesystem:TheCanaryintheCoalmine,Routledge

WhySouthAsianwomenmakeextremebirthchoices(BookChapter)Co-writtenwithBashiKumarHazard,fromHumanRightsinChildbirthwhoiseditingthisbookwithHannahDahlenandVirginiaSchmiedfromWesternSydneyUniversity,Australia.https://www.routledge.com/Birthing-Outside-the-System-The-Canary-in-the-Coal-Mine-1st-Edition/Dahlen-Kumar-Hazard-Schmied/p/book/9781138592704

March2020 EconomicandPoliticalWeekly(EPW)

Docsplanation!It’sanopinionpiecetohighlightthedominationandinfluenceofmedicalprofessiononmidwiferyandnursinginIndia.https://www.epw.in/journal/2020/10/postscript/docsplanation.html

April2020 WashingtonUniversityofSt.Louis

Gaveaguestlecturetoundergraduatestudentson‘Birth,genderandmidwifery’

May2020 73rdWHA,Geneva

WASHfornursesandmidwives’inCOVID-19

June2020 ThePracticingMidwifeJournal

Astarchedcottonfluorescentyellowsaree,khopa,bellybuttonandsafetypins:decodingthe‘dignifiedIndiannurse-midwife’https://www.all4maternity.com/a-starched-cotton-fluorescent-yellow-saree-khopa-belly-button-and-safety-pins-decoding-the-dignified-indian-nurse-midwife/

July2020 CollegeofObstetrics,Argentina

ParteríaInterculturalGotfeaturedinaSouthAmericanmidwiferymagazinebytheCollegeofMidwives’sinArgentinaintheirglobalinterculturalmidwiferysection.

September2020

GLOWConference

Presentedapostertitledwhysomecareprovidersdisrespectandabusewomenduringchildbirth.

December2020

15thNormalLabourandBirthResearchConference

2021

AppendixD

257

February2021

UniversityofSouthampton,UK

June2021 InternationalConfederationofMidwivesCongress,Bali,Indonesia

Abstractselectedfor3MinuteThesis:1. DisrespectandabuseofwomenduringchildbirthinIndia

(3minutethesisentry)

2021-22 Publicationsunderrevieworin-print

ThefollowingpapersareplannedfromthePhD:1. MayraK.,MatthewsZ.,SandallJ.Thecaseofsurrogate

decisionmakersforwomencompetenttoconsentduringchildbirthinBihar,India.Agenda.Inprint

2. MayraK.,MatthewsZ.,SandallJ.,PadmadasSS.Women’sexperienceofrespect,disrespectandabuseinBihar,India:abodymappingaidedcriticalfeministstudy(underreviewwithBMCPregnancyandChildbirth)

3. MayraK.BodyMapping:aparticipatorymethodtounderstandwomen’sbirthingexperience(UnderreviewwithQualitativeHealthResearch)

4. VanderwaalR.,MayraK.Obstetricviolenceasgenderbasedviolence(BookChapter,Underreview)

5. VanderwaalR.,MayraK,ObstetricViolence:It’sabolition(UnderreviewwithFeministAnthropology)

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