‘Safe’, yet violent? Women’s experiences with obstetric violence during hospital births in rural Northeast India

Abstract

The majority of maternal health interventions in India focus on increasing institutional deliveries to reduce maternal mortality, typically by incentivising village health workers to register births and making conditional cash transfers to mothers for hospital births. Based on over 15 months of ethnographically informed fieldwork conducted between 2015 and 2017 in rural Assam, the Indian state with the highest recorded rate of maternal deaths, we find that while there has been an expansion in institutional deliveries, the experience of childbirth in government facilities is characterised by obstetric violence. Poor and indigenous women who disproportionately use state facilities report both tangible and symbolic violence including iatrogenic procedures such as episiotomies, in some instances done without anaesthesia, improper pelvic examinations, beating and verbal abuse during labour, with sometimes the shouting directed at accompanying relatives. While the expansion of institutional deliveries and access to emergency obstetric care is likely to reduce maternal mortality, in the absence of humane care during labour, institutional deliveries will continue to be characterised by the paradox of "safe" births (defined as simply reducing maternal deaths) and the deployment of violent practices during labour, underscoring the unequal and complex relationship between the bodies of the poor and reproductive governance.

The shifting axes of marginalities: the politics of identities shaping women’s experiences during childbirth in Northeast India

“…Some Bengali Muslims used the word "sub-human" to describe their experience of childbirth and accessing health care. 11 This perception is reinforced, when we examine "native Assamese" and mainstream discourses that often label Bengali Muslims as "illegal immigrants". Bengali Muslims are blamed for "large" populations, unregulated fertility, and for poor health statistics in the areas where they live, and are perceived as being cunning and more adept at accessing state entitlements than the "native" population.…”

“…Empirical work in Assam finds several instances of abuse in state facilities in rural Assam and argues that such violence is gendered " … and intersects with other axes of structural inequalities, such as caste/ethnicity, class and region in India, producing a negative and often violent experience of pregnancy and childbirth in India". 11 Using a mix of clinical observations and quantitative methods, a study based in state and private facilities in urban and rural Uttar Pradesh, North India, reveals that while all women experienced at least one type of mistreatment during childbirth across facilities, women who were either Scheduled Tribes or Scheduled Castes, as well as multiparous women, reported greater and more intense forms of mistreatment. 12 The latter include actions with significant possibilities of harm, such as extreme fundal pressure, using dirty rags to wipe the perineal area, physical abuse, and sexually humiliating comments.…”

“…Home birth is viewed as strictly Adivasi practice by these other tribal groups in that they feel that they have become "one of them" if birth happens at home. 11 Thus, Adivasis like Muslims face a dual burden of marginalisation; marginalisation by the state which denies them their rights in Assam, and by other citizens, including other tribal groups, who may be non-dominant, but are not equally marginal and are differently discriminated from them.…”

“…While many of these women actively use state facilities and private care if they can afford it, indigenous women and their families are often scolded by doctors and nurses for screaming too loudly during labour or asking too many questions about the care they receive, a common form of abuse during childbirth that is reflected in the experiences of women with low levels of education or in poverty. [11][12][13][14][15] It is possible that the discrimination that indigenous tribal women encounter, emanates more from the state, than from their fellow citizens, unlike their Adivasi or Bengali Muslim counterparts, who bear the burden of not only state-sponsored mistreatment, but also prejudices held by their fellow citizens.…”

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“…In consonance with this, studies have documented the forms of D&AC childbearing women 4 have experienced in healthcare facilities. The women in these studies reported that they were physically abused [19], psychologically abused [19], detained for non-payment of bills [20], examined without consent [21,22], discriminated against because of their social status [21,22], denied of their choice of birthing position because of facility-recommended guidelines [22][23][24], and subjected to iatrogenic procedures such as episiotomies, in some instances done without anaesthesia, and with improper pelvic examinations [25]. This D&AC, Sen, Reddy & Iyer [26] argued, is driven by socioeconomic inequalities and institutional structures and processes.…”