Caste-based Discrimination and Maternal Health in Dalit (“Untouchable”) Communities
For many women around the world, pregnancy represents a pivotal experience. However, in developing countries such as India, where 25% of the world’s maternal deaths occur annually, the experiences of pregnancy and childbirth are sometimes transformed into experiences surrounded by tragedy and distrust in a greater system. Maternal deaths are complex, often stemming from issues that are not purely biomedical, such as gender prejudices, caste-based discrimination, and unequal access to education – all factors stemming from social marginality. By examining the ways in which caste-based discrimination influences maternal health, our understanding of the context of maternal deaths could transform the way Dalit women in rural India experience pregnancy and childbirth.
Despite policies outlawing caste-based discrimination, social inequality based on caste still runs rampant in India; low-caste women often endure a “triple burden” of discrimination due to caste, class, and gender. With an overall maternal mortality rate (MMR) of 254, India still lags behind other countries in maternal health, such as the United States (MMR 13) or Sri Lanka (MMR 39). Although low-caste groups compromise only 16% of the Indian population, they represent at least 25% of all maternal deaths and have an MMR of 560. To understand why maternal deaths continue to occur, it is paramount to utilize anthropological views of health as being shaped by social inequalities.
In India, more than 160 million individuals are considered “Untouchables” simply because of their birth into a caste system that sees them as less than human. Untouchables, also known as Dalits, endure “a lifetime of discrimination, exploitation, and violence” simply because of their caste. Because the majority of maternal deaths in India occur among Dalit women, caste is not simply a level of stratification, but a key sociocultural determinant of health.
In examining the road to maternal death, we must first examine the caste-based factors that put Dalit women at risk to begin with – even before complications begin. One initial risk factor is unwanted pregnancy due to decreased access to contraception, which may come as a result of stark differences in education or economic status. Contraception is also sometimes perceived as a decision that occurs after having a desired number of children. Physiological factors influenced by hierarchy also put Dalit women at risk for experiencing maternal health problems before complications occur. For example, women and girls experience many obstacles in obtaining proper nutrition, which could later lead to anemia.
Once pregnancy-related complications start, there are three delays that describe the barriers that could prevent a woman from obtaining care; these delays are: (1) deciding to seek care; (2) reaching a healthcare institution; and (3) receiving quality care once at a healthcare institution. The major direct causes of maternal deaths in India are hemorrhage, infections, eclampsia and obstructed labor. Because most maternal deaths are the result of multiple factors, the three delays model, when analyzed with respect to caste, reflects this convergence.
The first delay may result from poor access to quality obstetric care, lack of awareness about the importance of maternal healthcare, as well as a woman’s lack of decision-making power in her household. One of the main determinants of seeking care is how the patient perceives her obstetric condition. In a study of the rural Indian state of Orissa, 50% of maternal deaths among Dalits occurred because the women never sought formal healthcare based on the misperception that they were not sick enough or that symptoms such as excessive blood loss were considered normal after pregnancy. Generational and gender power dynamics within the family also influence healthcare-seeking behavior. In the study of Dalit women in Orissa, the women who did seek formal healthcare for their condition described long delays during decision-making because often, the woman herself did not make the decision to seek care – her husband, mother-in-law, or mother decided whether the condition warranted further help.
The second delay of the model concerns a woman’s ability to travel to the appropriate healthcare facility. This comes as a result of infrastructural deficiencies (scarcity of healthcare institutions, poor roads, or transportation difficulties). Villages that are distant from roads often have limited access to public transportation, making it difficult to travel to the nearest health facility. Since approximately two-thirds of bonded laborers identify as Dalit, if a Dalit family cannot afford transportation to a hospital, they could become further indebted after accepting a “loan” that they may not be able to repay.
The third delay can result from dismissive attitudes by clinicians, prolonged waiting times, or deficiencies in equipment, blood, or electricity. One major factor that influences the way Dalit women receive care at a healthcare institution is bias between the upper castes and lower castes. Thus, in non-emergency situations, Dalit women generally choose to seek help from a dai (a local midwife) or an untrained birth attendant. Due to the cultural importance of massage during birth, a Dalit woman in a government facility may not feel comfortable because hospital staff may try to avoid applying compressive pressure on her abdomen due to prejudice. Additionally, Dalit women have also reported the fear of being “forcibly sterilized after the delivery,” which may result from the legacy of pressure tactics utilized by the Indian government’s historical family planning program.
With 61% of maternal deaths belonging to Dalit or tribal communities, caste-based discrimination still plays an important role in creating the unfair burden of maternal deaths among Dalit communities. Caste-based factors, including lack of access to contraception, differences in education or economic status, and physiological factors all put Dalit women at risk for experiencing maternal health problems even before complications begin. In addition, the “three delays” of accessing maternal health care while in labor are exacerbated for Dalits because of stigma, corruption, and the lack of both capital and collateral. Without an anthropological understanding of how maternal health continues to be shaped by social inequalities, India’s health initiatives, although well-intentioned, will not drastically influence the life of the average Dalit woman.
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