Maternal mortality in Nepal is estimated to be around 540 deaths per 100,000 births. 1 One major factor is low use of maternal health care, despite government efforts to improve services, including an expanded network of rural clinics and the training of auxiliary nurse midwives. 2 Fewer than 40% of women receive any antenatal care from a trained provider, and fewer than 10% of births take place in a health facility. 3 In seeking to explain these low levels of health care use, most research has focused on the provision and geographic accessibility of services. However, no studies have looked at how sociocultural factors, such as inequitable gender roles and women' s position within the household, have influenced use of services.Earlier work in South Asia has suggested various ways in which gender roles and relations may operate to restrict women' s access to health care during pregnancy and at the time of delivery. These include heightened restrictions on women' s movement because the pregnant state is considered "shameful," young women' s lack of say within the family and the fact that pregnancy-related knowledge and decision-making authority are commonly vested in older women, young women' s lack of influence over material resources, and the exclusion of men, who are often the primary decision makers in the use of material resources, from the "polluting" event of childbirth. 4 In addition, a growing body of literature has explored the links between indicators of women' s household position and contraceptive use in South Asia. 5 However, little of this research has examined whether and how dimensions of women' s position are related to their use of maternal health care services.It is widely asserted that increased gender equality is a prerequisite for achieving improvements in maternal health. The Programme of Action adopted at the 1994 International Conference on Population and Development claimed that "improving the status of women also enhances their decision-making capacity at all levels in all spheres of life, especially in the area of sexuality and reproduction." 6 In Nepal, the low social status of women has been identified as a hindrance to progress toward national health and population policy targets. 7 Although it seems reasonable to assume that greater equality within the household leads to higher use of maternal health care services, this factor has not been explored for Nepal. We know little about how intrahousehold relations constrain or facilitate access to health care, or about the dimensions of women' s position that are most critical for achieving increased use.In this study, we examine the influence of four indicators of women' s household position on the receipt of skilled antenatal and delivery care: their involvement in decision making about their own health care and about large house- Women's Position Within the Household as a Determinant Of Maternal Health Care Use in NepalCONTEXT: Although gender inequality is often cited as a barrier to improving maternal health in Nepal, little a...

An integrated analysis of detailed ethnography and large-scale survey data is presented to explore the gendered influences on women's uptake of antenatal care (ANC) services in Punjab, Pakistan. Pregnancy and its associated decisions were shown to be normatively the older women's domain, with pregnant women and their husbands being distanced from the decision-making process. Women who successfully claimed ANC did so not by overtly challenging the dominant construction of young femininity, but rather by using existing gendered structures and channels of communication to influence authority figures. The quality of a woman's inter-personal ties, particularly with her mother-in-law and husband, were found to be important in accessing resources, including ANC. Gendered influences were moderated by social class. Family finances were an important determinant of ANC use, as was women's education. Wealthier, higher status women also found it easier to circumvent gendered proscriptions against their mobility while pregnant. As well as illuminating the ways in which the sociocultural construction of gender acts to constrain women's access to ANC, the empirical findings are used to highlight significant inadequacies in the 'autonomy paradigm' that has dominated much of the research into women's reproductive health in South Asia.

Recent research and policy discourse commonly views the limited 'autonomy' of women in developing countries as a key barrier to improvements in their reproductive health. Rarely, however, is the notion of women's autonomy interrogated for its conceptual adequacy or usefulness for understanding the determinants of women's reproductive health, formulation of effective policy or design of programs. Using empirical ethnographic data, this paper draws attention to the incongruities between the concept of 'women's autonomy' and the gendered social, cultural, economic and political realities of women's lives in rural Punjab, Pakistan. These inadequacies include: the paradigm's undue emphasis on women's independent, autonomous action; a lack of attention to men and masculinities; a disregard of the multi-sited constitution of gender relations and gender inequality; an erroneous assumption that uptake of reproductive health services is an indicator of autonomy; and a failure to explore the interplay of other axes of disadvantage such as caste, class or socio-economic position. This paper calls for alternative, more nuanced, theoretical approaches to conceptualizing gender inequalities to enhance our understanding of women's reproductive wellbeing in Pakistan. The extent to which our arguments may be relevant to the wider South Asian context, and women's lives in other parts of the world, is also discussed.

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