Center for Women (ARROW), based in Malaysia took initiatives in organising a multi- country research project to develop and refine gender-sensitive advocacy ...
Gender Sensitivity in Birthing Care: A Case Study from Rural Bangladesh July 2001 Research and Evaluation Division, BRAC Kaosar Afsana1 and Sabina Faiz Rashid2 BRAC, a non-governmental organization in Bangladesh has responded to the agenda of the Beijing Platform for Action on women’s access to gender sensitive health care. This paper presents how the gender sensitivity of a maternity care was assessed at the BRAC Health Center (BHC), what lessons were learned from the study and what suggestions were made. Even with the high maternal mortality and morbidity in Bangladesh, use of hospital facilities is very low, particularly in rural areas. A qualitative approach was used to assess rural women’s low utilization of the BHC maternity care. Women’s understandings of childbirth, the quality of care and power relations within home and at the BHC were addressed to comprehend the issues of gender sensitivity in maternity care. The rural women experiencing BHC and home birthing, traditional birth attendants (TBAs) and health providers of the BHCs were interviewed and observed. The rural women understood childbirth as natural and normal event, and preferred TBAs, but they sought care from the BHC when faced complications. The concept of gender sensitivity became more concrete following the study. The TBAs seemed marginalized, even though the community preferred them. The strength of the research lies in the use of qualitative approach to assess the issues of gender sensitivity in maternity care. The following issues need to be addressed to make the BHC gender sensitive: use of comprehensive obstetric care; skills of the health providers; use of aseptic procedures; access to information; issues of privacy, dignity, caring attitudes and emotional supports; preference for women health providers; use of indigenous birthing positions; decision making power of women; costs; and transports. Substantial efforts need to be made to enhance rural women’s use of BHC maternity care, which will subsequently contribute to reductions of maternal deaths.
The International Women’s Movements, particularly, Cairo and Beijing conferences, have drawn attention to women’s health across the world. Like many developing countries, maternal health is still neglected in Bangladesh. The maternal mortality ratio, one of the highest in the world, is estimated to be 470-770 per 100,000 live births with as many as 100 morbidities occurring for every maternal death (1, 2, 3). Despite the 1 2
Senior Medical Officer, Research and Evaluation Division, BRAC, Bangladesh Research Anthropologist, Research and Evaluation Division, BRAC, Bangladesh
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evidence that use of maternity care reduces maternal deaths, in life threatening situations, its use is very low (4, 5). The Beijing platform for action has specifically underscored the issues of gender sensitivity in health care in order to increase its access to women, which eventually leads to improved health status (6). The Asian Pacific Resource and Research Center for Women (ARROW), based in Malaysia took initiatives in organising a multicountry research project to develop and refine gender-sensitive advocacy tools at local, national, regional and international levels (7). As part of the ARROW initiative, BRAC, a local non-governmental organization (NGO) in Bangladesh, planned to incorporate implications of gender sensitivity in its own health program. This paper presents how the gender sensitivity of a maternity care was assessed at the BRAC Health Center (BHC), what lessons were learned from the study and what still needs to be done at organizational, national, regional and international levels to improve maternal health. As the concerns for improving maternal health is increasing across the world, the government and the NGOs also put much emphasis on essential obstetric care (8, 9). BRAC, thus, has initiated providing maternity care through the static facilities known as BHC, and concurrently continues the community-based maternity program (10). Despite BRAC’s efforts, 92% of the births took place at home, 7% at government health facilities and 1% at BHCs (11). Various studies at national levels found that the barriers to use hospital care are not only socio-economic, cultural and access related, but the service quality available at health facilities is also a factor (12, 13, 14, 15, 16). Very few studies have addressed the quality of maternity service, which essentially has been found to be inadequate and unaffordable, with shortage of staff (12 13, 14, 17). The limited use of biomedical-trained professionals during childbirth is due to a failure to recognise women’s perspectives of childbirth (18). Due to the dismal quality of health services at the hospitals in Bangladesh, most people hesitate to seek their birthing care unless an obstetric emergency occurs (19). The BHC is also plagued by low utilisation for child deliveries. Poor communications, economic constraints, and the lack of comprehensive obstetric services discourage families from accessing BHC services (20, 21). However, the information is not in-depth and comprehensive, and no research as yet has documented women’s perspectives regarding maternity care provided at the BHC. Considering this, the research aimed to understand the reasons for low utilisation of the BHC maternity care by exploring rural women’s needs and expectations regarding childbirth events.
Documentation on gender sensitivity is scarce in health care. Even within the Beijing platform for action, the concept of gender-sensitivity is not clearly explained (6). In a Chilean study, gender sensitivity was measured in terms of improving women’s health and well being, meeting expectations, showing respect, and strengthening rights and autonomy (22). According to Jasis, gender differences are expressed in the quality of health care, which impact women's health and life (23). She also argued that women should be treated as whole human beings with moral authority given to them to express their views about health and bodies (23). A gender sensitive approach also acknowledges the need for bringing about changes in the organization and in society on the strength of needs and expectations of woman clients (24, 25). ARROW further explicated gender
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sensitivity in health care by referring it to the extent to which health services are planned and implemented in a way so that issues occurring as a result of unequal gender relations are analyzed and addressed (26). It is clearly stated that the deprivation of women from their rights to health care results from inherent unequal gender relations in society. Hence, gender sensitivity in women's health care should be considered in terms of planning and implementing issues, raised from women’s own needs and expectations. (22, 23, 24, 25, 26). In this study, gender sensitivity of the BHC maternity care has been assessed by the extent to which it meets rural women’s needs and expectations during child delivery. Women’s understandings of childbirth, the quality of care, and power dynamics during childbirth experiences were addressed. The information can be used to develop strategies and modify existing service delivery approaches to enhance women’s utilisation of maternity care during childbirth. The issues raised in the study are very much pertinent to women’s rights to birthing care. Thus, its implications cannot be limited to local context rather the particular issues are worth pursing at national, regional and international levels to enhance the significance of birthing care in women’s lives.
Methods The study adopted a qualitative approach for the assessment of gender sensitivity in a maternity care of the BHC. In-depth interviews, participant observation, focus group discussions (FGDs) and informal discussions were used for data collection. Fieldwork was carried out between November 1998 and January 1999 in a district located 300 kilometres north of the capital city of Dhaka. Out of the 21 BHCs, one located in that district town was selected. This particular BHC began in 1992 as a maternity waiting home and was turned into a full- fledged BHC in 1996. We chose this particular centre because out of all of the BHCs that suffered from a low utilization, this one had a comparatively higher utilization rate for maternity care. In addition, this was one of the older health centres with a strong relationship with the community. This would allow us to speak to a greater number of women accessing care from the centre. This centre was also in close proximity to the district hospital, where complicated pregnancy cases are referred. Due to these reasons, we felt that this centre would be the most appropriate. It is also important to point out that the main purpose of selecting a BHC was to modify existing services and build up a new model of service delivery. Women aged between 20 and 40 years who had experienced birthing were chosen as the study population. Two categories of women were selected, one group who experienced both BHC and home birthing and the second group who experienced only home birthing. Reviewing program registers with the help of staff, women who had delivered at the BHC not more than two years ago were selected. Among them, fifteen women were purposively chosen from different villages by their willingness to participate. Out of the fifteen, nine of them had delivered at the BHC and six of them were referred from the BHC to the district hospital. Five women, who had given birth only at home, were purposively selected from those villages as well, in consultation with the other respondents of the first category, and also by their willingness to participate. The women
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were primarily interviewed for information on live births. Two trained and three untrained TBAs were selected purposively for in-depth interviews with the assistance of the BRAC field professionals and women respondents. For FGD, 21 women within the reproductive age of 20 to 40 years were selected with the assistance of the community health volunteers. Four physicians and seven female paraprofessionals of the adjacent BHCs were chosen purposively and also requested to participate in the study. In-depth interview was considered as the principle method, because it elicited various perspectives of rural women about their birthing experiences and more importantly, women’s voices were heard in verbatim. On the first day of the interview, the community health volunteers introduced us to the respondents. We tried to establish rapport with them by initiating informal discussions. After explaining the study aims and taking verbal consent, the women were interviewed informally in a relaxed environment. The interviews lasted from two to three hours, depending upon how the respondents acted on, and the relationship was built on, and the extent of information collected. During the interview, one researcher asked questions and the other took notes. Guidelines for interviews were made to lead the discussion but not to create a dominating situation. The discussion was carried out in a way to allow various issues to emerge. Moreover, it was made to be participatory. TBAs were interviewed by following the same method to elicit their experiences in birthing practices. If any interview remained incomplete because the women were busy with household activities or other chores, they were interviewed on some other days. However, two women were dropped from the study, as they were seen reluctant to proceed. The discussion with TBAs went off well. All of the interviews were crosschecked for accuracy and consistency. If gaps remained in the interviews, it was either corrected on the next day or later on a follow-up visit. Three sets of FGDs were carried out separately with a group of 6-8 rural women. Assistance of the community health workers and BRAC paraprofessionals was sought for selecting those women. The purpose of the FGD was to examine rural women’s beliefs, understandings and practices about childbirth, and attitudes towards home and hospital birthing. The FGDs were carried out at conveniently secluded sites in the participant’s house, with one moderator and one assistant guiding the discussions. The selected women were informed earlier about the schedule of the FGD. On the scheduled day, after building up rapport, women were asked to sit in a semicircle on a mat, and subsequently, the purpose of the meeting was explained. During the session, women were found to have shown their interests in the topic. Each session was tape-recorded and lasted for 1-1½ hours. Various questions were asked by the women about different issues after the completion of the discussion. They also asked to replay the cassette player to listen to their voice. The discussions were transcribed from the tape recorder afterward. Data was once again checked for accuracy and consistency. Informal discussions with the health providers took place at the BHC, one with physicians and the other with female paramedics. Various issues such as whether the centres were able to meet rural women’s needs, whether clients were satisfied with the quality of care being provided, and the barriers to providing quality of care were discussed. Each discussion continued for about three hours. The participants were very
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much enthusiastic to share their experiences and to learn more about the issues raised by the women. They also shared their limitations to providing quality services. Observation techniques were also employed to assess client-provider interaction, staff competence, availability and affordability of services, and staff attitudes towards clients and their families. Four women who gave birth at the BHC were observed from the day of admission to the day of discharge. During our stay, all of the activities at the BHC were noted down. Initially, our presence made it difficult to get an accurate picture of the events happening at the BHC. Eventually, however, the health providers became familiar with us, and a more normal and real situation analysis was possible. We made a conscious effort to act as one of them and at the same time, tried not to interfere or intrude into their work. In addition, one of the accompanying researchers were known to the BHC staff for more than six years and this made it easier for us to be accepted. Data processing and analysis continued along with data collection. Each day after completion of fieldwork, all of the data collected were transcribed. All the transcripts were carefully checked for accuracy and consistency. The major themes were identified to address the research questions of the study. The summarized data were presented in accordance with the theme of the study. The verbatim of the informants were also used to prevent their language from being lost or misrepresented, thus ensuring their ‘voices’ are heard. To validate the data, triangulation of methods and sources of information were applied. The study faced some limitations. First of all, the findings cannot be generalized as the study was conducted in a specific place amongst a limited number of people. Issues of selection bias were likely to arise during respondent selection, as we relied on the assistance of BRAC community health workers, however, it was minimized by following particular selection criteria. Observer bias could have occurred due to the presence of the researchers during the time of child delivery, however, as explained earlier, it was decreased considerably over time. Use of multiple methods and informants reduced some limitations. Moreover, by checking the internal consistency of data, few existing biases were minimized.
Women’s Understandings of Childbirth In a society, beliefs and practices are structured around prevailing experiences and indigenous knowledge. Cultural constructions of childbirth have been central to rural Bangladeshi women's own experiences which eventually influence their health care seeking during childbirth. The concepts of ‘normal’ and ‘complicated’ childbirth are constructed in the context of culture, and social practices. For the rural women, the act of childbirth was a normal, natural phenomenon, which was understood as ‘kono oshubidha hoi nai’ – ‘having no difficulties’ and should take place at home. On the other hand, ‘bekaidai’ or ‘complicated’ childbirth was seen as ‘something serious happened’ that cannot be managed by the TBAs, and was decided to be taken to the hospital. For ‘normal’ childbirth, families usually preferred experienced TBAs - locally known as dhaitanis from within the community. When the TBAs failed to manage child delivery, 5
the birthing women were sent to the BHC. The women who did not follow particular social rules and norms were blamed to have complicated birth. With education, women’s understanding of childbirth seemed to be changed from normal to complicated that contributed to their dependency on biomedical professionals. Health care seeking was very much influenced by the rural women’s understandings and experiences of childbirth. Their understandings of evil spirits and spells were believed to cause birthing problems. During pregnancy women were considered to be vulnerable and expected to follow particular norms of conduct to experience normal home birthing. If a pregnancy did not go smoothly, in most cases, the women blamed evil spirits for casting spells on them. Their beliefs on evil spells and spirits became stronger, when biomedical professionals failed to treat complicated birthing cases. Failure of medical treatment, thereby, compelled them to seek indigenous care and reinforced their beliefs in supernatural causes. The women also viewed hospital as an environment of fear. It was commonly perceived to be a place for treating a ‘pathological’ phenomenon. Thus, for those women receiving treatment from the BHC implied that 'something abnormal had happened to their body'. A common perception in rural areas was that women would be forced to undergo surgery if they gave birth in a biomedical establishment. Any deliveries requiring surgical incisions - abdominal or perineal were known as sez or caesarean in rural areas. A perineal incision in childbirth was regarded as a social stigma, and referred to as ‘angohani’ (a defective body). Some women mentioned that if the scar remained unhealed, it affected their regular household chores, sexual performance, and eventually their social status. A typical comment was, ‘ I pray to God that my baby should not be born at the BHC.’ In a rural society, women are considered to be the repository of culture and bear the burden of lajja (shame), purity and pollution. The cultural experiences of birthing are intricately linked to issues of shame and honor. Notions of shame and honor also affect women’s mobility. Many of the rural women felt embarrassed particularly before men while going out for child delivery. One woman stated, “I felt that village men were staring at me and couldn’t even express my pain while passing the village. I was praying when we wo uld leave the village boundary.” In rural society, by upholding izzat (good character) and respect of the family, a man ensures female family members follow societal norms and rules. However, attitudes are gradually changing, with more women speaking quite candidly of their feelings. Despite societal rules regarding ‘appropriate’ conduct, these notions of shame and honor became flexible, particularly when it involved life and death situations. These cultural issues should be addressed by the gradual introduction of new knowledge, but not by ignoring the local value system.
Experiences about the Quality of Care Quality of care is a relative and multifaceted concept. The users’ viewpoints put stress on the humanitarian dimensions of health care whereas providers’ perspectives on the technical skills and availability of services (27). Various aspects of the quality of care were reflected from the amalgamation of rural women’s voice, health providers’ views and observation of the BHC.
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Issues of caring, dignity, privacy and emotional support were just some out of many behavioral factors, which influenced women’s choice of delivery care. Women perceived jotno – (caring) as 'the continual checking up of their body, receiving medications, and staff regularly asking after their health'. Treating a person with dignity was conceptualized as, “Having someone sitting close by, not neglected, being attended to, not making a person sit on a ripped mat and behaving well.” A large number of the women given birth at the BHC lauded the caring attitudes of the staff and also felt respected, “BRAC apas are busy, but take care of each patient. I won't forget them.” Despite their statement, observations at the BHC revealed incidents of misconduct directed towards poor rural wome n. A female paramedic screamed at a birthing woman, “You village woman, don’t you know the rules of delivering a baby? Push down when you feel cramps in stomach.” Some of the rural women believed that the good behavior of staff depended on their own behavior. A comment made by a woman, “To gain respect, one has to behave well.” Because of the marginalized and vulnerable status in the society, poor illiterate rural women usually expect very little and feel content with whatever services receiving from elite medical professionals. The notions of privacy are very culture-specific. The participating rural women linked it to shame, which was reflected in their statement "You can't show your private part to others, but to receive proper care, one has to compromise." The woman admitted to feeling uncomfortable lying uncovered on the labour table in front of unfamiliar faces, “In the labour room, the sisters removed my petticoat from the bottom. As I was trying to cover my private part, they said that we were all women and there was nothing to feel shy here.” The health providers were reassuring and sympathetic, but women’s understanding of privacy was not understood. Majority of the women appreciated the constant reassurance of the female paraprofessionals that gave emotional support in their birthing experiences. The female family members were allowed to remain inside the labour room to enhance the mental strength of the birthing women. Despite BRAC worker’s good behavior with community members, underlying hierarchical class distinctions always remain. Some gaps were identified in service provision, however, the role of BHC staff in providing care to birthing women has been fairly adequate and reasonably sensitive. The lack of the required services came up from the women’s voice. The services at the BHC were adequate only for performing normal vaginal deliveries. Complicated cases were usually referred to the district hospital, if blood transfusion and surgical procedures were needed. Some women and their families felt betrayed and angry, when they were forced to transfer from the BHC to the district hospital. One woman remarked, "If BHC can't handle complicated cases, they should not ask pregnant women to go there." In most cases, transferring rural women to the go vernment district hospital increased the trauma of the women and their families, as they were subjected to the poor quality care. The staff strongly felt the need to improve the extent of service provisions at the BHC, and the training and retraining for developing and strengthening their capacity. Despite the paraprofessionals’ ability to manage normal delivery, they were found to have taken less aseptic measures for the mother and newly born baby in the labour room.
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The instruments and rubber gloves used during delivery were not properly sterilized and maintained. Although health providers appeared to be aware of the need to maintain hygienic and germ- free procedures during birthing, in reality they seemed to be less concerned about maintaining such procedures. The BHC maternity facilities were under-utilized, yet, the paraprofessionals were seen to be busy at the outpatient and with administrative tasks. The female paraprofessionals’ daily schedule was fairly hectic, sometimes working longer than 12 ho urs. Even their weekends also appeared to revolve around BHC work. They always appeared to be tired and exhausted. Job workload, long working hours and excessive responsibilities affected the type of care paraprofessionals were able to provide. Access to information that pertains to body is women’s basic right. The observations revealed that the women were not clearly informed about the reasons for various examinations and medications, the progress of labour and the condition of the baby. As a result, the expecting mothers and their families were left worrying about the impending birth and the consequences of treatment. Many women feared that the birth would require surgical interventions. Besides, information on neonatal care, immunization, and safe hygienic practices were not communicated to the birthing women. In the BHC, the female paraprofessionals were more absorbed with the clinical aspects of service delivery and appeared to be less aware of the importance of providing such information. This can be partly attributed to the lack of training in behavior and communication issues. Rights to information are continually debated in medical establishment to improve the quality of care, yet in reality they seem to get less importance. The sex of a health provider is an important factor for rural women and their families in choosing a place of delivery. At the BHC, all the health providers working in maternity care were female. The women and their husbands, therefore, felt no hesitation in accessing them. In rural society, the presence of a male doctor during child delivery is regarded as sinful. A woman visiting a male doctor is also considered as a matter of shame and dishonour that brings disgrace to the family. Such understandings indeed negatively affect women’s access to medical care. However, societal rules and norms became flexible, if the woman was in a critical condition. Posture during childbirth is considerably imperative for women’s active participation in their own birthing experiences. For generations, village women have practiced the kneeling or squatting position in child delivery in contrast to lying down position practiced by bio-medical practitioners. They claimed to feel much more comfortable in indigenous birthing positions, as they could push down with greater force. A woman commented, “I am used to deliver baby at kneeling down position but was hesitant to ask BRAC apas to allow me sit because they may not like it.” Some rural women who had already experienced delivery at the BHC were uncomfortable and reluctant to use their services in future for the birthing positions adopted at the BHC. Bio- medical practitioners are more comfortable with delivering a woman in a lying down position, and thus, ignored rural women's preferred choice of birthing positions. Incorporating the
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indigenous posture of birthing at the BHC will be an important acknowledgement of rural women’s needs during childbirth. The cost of health care was a major concern for women and their families. A majority of the wome n felt that the cost of home birthing was insignificant. Paying a TBA was not mandatory, however, their services were compensated usually with food or clothes. The basic cost of childbirth at the BHC is from US$ 2.50-3.50 (Tk.175 to Tk.275) whereas the hidden costs for normal childbirth at the hospital is US$ 31.9 (Tk.1275), and the amount quadruples for caesareans (28). Most women and their families, therefore, were reluctant to spend money on something that was perceived to be a natural event. A woman commented, " I don't want to worry about going to the BHC for treating my problems. Will you pay the money if I need to go there?" The worries of a potentially complicated childbirth and the unaffordable costs of medical care all resulted in a complex and difficult dilemma for most women. In spite of economic constraints, women did not expect free services from the BHC. The staffs were also quite aware and sympathetic to the plight of such patients, and worked out an informal system to assist the poorer families. In one case, the BHC staff hired the husband as a night guard to pay off his wife’s expenses. In certain cases, service charges were also waived. Even then, poor women were not very keen to attend the BHC for normal deliveries. Life of a mother is endangered when accessing the right transport at the right time is quite impossible, and particularly when the road communication is inconvenient. The means of transportation were usually chosen depending upon the distance to the health facility, economic status, availability of vehicles, and the state of birthing women. The local automobile, tempo was usually taken by affluent clients, whereas the cycle van (three wheelers flatbed type of vehicle) or rickshaw (three wheeler upright type of vehicle) by less well-off villagers. Even though, some lived two kilometers away from the BHC, they experienced difficulties in accessing transport. Any geographical distance, regardless of its range, can be an obstacle to seeking health care during childbirth, when the means of transportation are not available.
Power, Maternity and Health Care Power relations embrace different dimensions of knowledge on what is to be excluded and who is designated as qualified to know (29). Indigenous knowledge of childbirth is often devalued or ignored in favour of ‘legitimised’ western bio- medical knowledge usually practised in the health centres or hospitals. The authoritative knowledge of the biomedical world has resulted in the devaluation and dismissal of any other kinds of knowledge (30). When women are admitted into a health center or hospital, they automatically enter into a process where they are handed over to the power and knowledge of medical practitioners, and lose control over their self and become a 'patient'. The women are forced to participate in a process where their bodies are examined, weighed and operated on. Whittaker observed a similar situation in Thai clinics where patients were expected to play a passive role in the presence of health workers (31). The existing hierarchical relationship results in an unequal encounter
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between women and health providers, thereby discouraging women from accessing formal care. At home birthing, power is not hierarchical but distributed horizontally among women. Decision- making inside home is women’s domain of concern. Female family members decide together which TBA will be chosen to assist in the birthing. The skills of the TBAs in conducting normal delivery were held in high esteem. One woman articulated it as, "Kaida jane bole baccha dhore" (She attends the birth because she knows how to conduct child delivery). The TBAs’ judgment regarding the woman’s stage of labour was linked to decisions of how and where the child delivery will take place. The TBAs’ authoritative knowledge controlled women’s body during child delivery. Even with this authoritarian role of the TBAs, the role of birthing women in the birthing process was also given importance. Most rural women and the TBAs belonged to a similar socioeconomic class. Mutual respect and familiarity with one another created a good horizontal relationship among those women, which was lacking in rural women's relationship with biomedical practitioners. The influences of modernity, the increasing community campaigns about pregnancy risks and the availability of modern health care facilities are stripping off the power from the hands of the TBAs. They have been somewhat marginalized by the introduction of new knowledge. Some rural women, particularly the more affluent and educated ones, devalued TBAs due to the distrust on their indigenous knowledge and the attitudes to poor socio-economic status. There was also a growing realisation amongst the TBAs that they were becoming gradually displaced from their traditional base of authority. Some of the TBAs appeared to have lost confidence in their own skills. They pointed out their own limitations in managing pregnancy complications, and also considered the importance of having their strong referral linkages with the BHC. In addition, they conceded to carrying out a balancing act to be able to serve the community. Some of them deliberately adopted newly introduced methods for child delivery, such as use of steel blades instead of basher chachi (bamboo blades). In the field of childbirth, the increasing authority of biomedicine has usurped to some degree the authority of TBAs. However, the women who have been engaged in delivering baby for generations, their role in poor rural women’s lives cannot be overlooked. Thus, it is important to acknowledge the role of TBAs in child delivery by encouraging their positive indigenous skills. However, their unsafe practices should be thwarted by creating awareness among themselves and in the community. In rural society, men are the prime decision- makers in extra-domestic activities and women in intra-domestic. The birthing care falls within the domestic domain, thus women could voice as to which TBA will be chosen for delivering the baby. Since the cost of a TBA service is very minimal, therefore, women are perhaps given the autonomy to decide on home birthing care. However, in case of emergencies, when the birthing women should have gone to the BHC and questions of costs were raised, the process of decision- making delayed the process. Women’s rights to access maternity care tend to be a less important issue in the battle of power and decisions within a household. Social factors, such as pardah, shame and honour worked together to restrict women’s
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movement outside the family compound. Such ideologies also became more flexible in case of obstetric emergencies. Women’s education and economic status positively affect their role in the decision-making process. One woman stated, “My husband and I decided to have my childbirth at a clinic. But my in- laws were not at all happy when they heard I am going to a clinic.” Power relations changed when women were socially and economically empowered. Hierarchies of knowledge and power either at home or at the health centres, play a central role in manipulating women on where and whom they should go to for childbirth.
Lessons Learned Many constructive issues emerged from this research. Here, we will focus on the lessons pertinent to the concepts applied and knowledge produced that aid the planners and researchers to understand the implications of gender sensitivity in maternity care. The issues raised in the study will be discussed under three broad categories: concepts of gender sensitivity; marginalization of TBAs; and implications of qualitative evaluation.
Concepts of gender sensitivity Women’s voices sharing their own experiences of the birthing care gave us indications as to how the concepts of gender sensitivity should be delineated and what should be its implications in maternity care. The rural woman’s expressed and repressed needs manifested in the study identified the barriers to access the BHC birthing care. It is obvious that women were deprived from their rights to maternity care, which eventually impedes in bringing social change. What is underscored in the framework of gender sensitivity is that, unmet needs in maternity care occur as a result of unequal gender relations in society. Issues which were raised in the study and also felt appropriate in conceptualizing gender sensitivity are as follows: Comprehensiveness of maternity services; Economic access; Access to information; Caring attitudes, dignity, privacy and emotional support; Preference for women health providers; Indigenous birthing positions; Geographic access; Cultural issues, such as fear of ho spital, instruments, having defective body and being pathological; and Women’s control over childbirth. These issues should be addressed in the BHC to improve its access to women. In order to make the BHC gender sensitive, rural women’s needs and expectations should be considered from the planning to the implementation phase of maternity care.
Marginalization of TBAs The TBAs are the first hand caregivers during delivery in rural areas. Their role is becoming marginalized, especially after the failure of TBA training programs and the introduction of emergency obstetric care. The studies in India and Bangladesh revealed that TBAs involvement in defiling jobs of childbirth affects their professional acceptance, which is contradictory to the findings of this study where TBAs were well respected in the society (32, 33, 34). There exists an overall trust and reliance on TBAs in rural areas, and thus, their role in child deliveries cannot be overlooked. It is important to acknowledge the positive practices of TBAs. Yet, the unsafe practices should be thwarted 11
not by exclusion of TBAs but by including them in the process and by continually creating awareness among them, and in the community about the danger of unsafe practices.
Use of Qualitative Approach The strength of the study lies in the use of qualitative methods for the assessment of the gender sensitivity in the BHC maternity care. The amalgamation of women’s voices, researchers’ experiences and providers’ perspectives brought into light a distinct picture of birthing care. Women’s voices would not have been possibly heard if the verbatim was not captured in in-depth interviews. On the other hand, the poor, illiterate, rural women were not aware of the technical aspects of service quality, which could ha ve been missed if it was not observed. Issues, which were not raised by the women, were brought up by the researchers’ experiences. More strength was added to research by providers’ viewpoints. In essence, the use of qualitative methods is very much appropriate to the study in order to dig out all the possible problems. Further, the use of qualitative analysis added more strength to women’s articulations of their needs and expectations.
Future Implications In order to improve women’s access to maternity care, the recommendations have been made at organizational level to enable the BHC to be gender sensitive and at national, regional and international levels to aware the world community about the issues of gender sensitivity.
Organizational level •
Upgrading of the services of the BHC: The BHC is essentially meant for providing basic obstetric care. To meet rural women’s needs, they must be upgraded with comprehensive obstetric care, particularly, provisions for surgeries, blood transfusion services and laboratory supports. For surgeries, an operation theatre should be built up by mobilizing internal and external resources. The BHC health providers should be trained in midwifery, however, to perform caesarean section, an obstetricians should be hired from outside. Blood transfusion facilities should also be availed from outside. Laboratory services need to be upgraded to facilitate surgical operations. Moreover, awareness should be created for taking aseptic measures during normal vaginal and surgical deliveries.
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Training of the health providers: The health providers should be trained to be aware of the cultural issues related to birth. There should be an incorporation of rural women’s understandings of childbirth and birthing care into health provider training programs. Issues related to women’s rights to receive quality services and to have access to information should also be included. The providers should be encouraged to share relevant information with women and their families. They
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should be given support to form an interactive problem-solving group to discuss the issues of gender sensitivity. •
Acknowledgement of indigenous positive practices: The health providers should be encouraged to introduce indigenous birthing positions during child delivery at the BHC maternity care that will set an example in medical history for recognizing people’s knowledge.
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Incentives of the health providers: The health providers of the BHC should be given incentives for their performance by rewarding them with scholarships for short and long training courses either at home or abroad.
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Creating awareness of rural women: Rural women should be made aware of the issues related to women’s rights to obstetric care and quality services, control over birthing experiences and empowerment. Moreover, they should be warned about the issues related to pregnancy complications, however, the information should be communicated to them not as a fearful process but as a life saving matter. Education messages should also include information that eliminates fears about biomedical practices of childbirth and hospital environment.
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Community awareness: Husbands and families should be given information about the importance of obstetric care, and the danger signs of pregnancy complications. They should also be informed about the appropriate place of delivery and encouraged to save money for birthing care.
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Making costs affordable: The costs of the BHC birthing is quite pricey for poor, rural women. To make it affordable and acceptable, it has to be highly subsidized. In this regard, rural health insurance schemes may minimise or resolve problems related to huge expenditures during childbirth. On the other hand, BRAC per se should waive the costs by mobilizing resources from the budgetary allocations reserved for the poor in emergency situations.
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Organising rural ambulance services: Rural ambulances services can be arranged by using the local transports, such as local tempo and rickshaw-van. The ambulance service should be managed and supported by the community. For example, the family of a pregnant woman should be made aware of using it in case of emergencies. BRAC should also have its own means of transportation.
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Remodeling training of birth attendants: TBA training program should be remodeled by including their understandings of body, pregnancy and childbirth in training modules. Indigenous practices that are safe can be improved upon, and incorporated into the training module. Above all, supervision of the trained TBAs should be maintained to ensure effective implementation.
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Remunerating birth attendants: TBAs cannot be expected to work efficiently in rural areas if they do not get sufficient remuneration. Pooling of resources from the community in the form of rural health insurance schemes can be experimented with, from which remuneration for TBAs can be arranged.
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Use of qualitative evaluation: Future studies on childbirth practices and the relevant issues should use qualitative approach to get more insights and perspectives from different viewpoints.
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Further research: Ethnographic research should be done to explore and understand broader viewpoints as to the issues related to birthing care in rural areas and in government health sectors.
National, Regional and International Levels •
Sensitization of policy- makers and planners: The policy- makers and planners at the national, regional and international levels should be sensitized about the issues of gender sensitivity through dialogue, forums and meetings.
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Partnership with government, NGOs and women organizations: Concerted efforts of government, NGO and women organizations are necessary to bring changes in women’s lives.
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Policy statement and Implementation of gender sensitivity: Lobbying with women’s organizations to strengthen the issues of gender sensitivity in the policy statement and to implement it in order bring changes in women’s health care which subsequently lead to social change.
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Allocation of resources: Lobbying with NGOs and women organizations to increase budgetary allocations for women’s health care, sensitization of the issues of gender sensitivity and research.
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Sensitization of people: People should be made aware about the issues of gender sensitivity through radio, television, newspaper and popular theatre.
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Education and training curriculum: Issues of gender sensitivity should be specifically addressed in any curriculum from primary school to medical education.
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Inclusion of TBAs: Lobbying with women organizations to include TBAs in the mainstream health care to recognize their knowledge and role in maternity care and also to educate them under supervised culturally sensitive training programs.
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Conclusion It is a challenging task to address the issues of gender sensitivity in the BHC maternity care. Experiences of the research enhanced the need and scope for further improving the service quality of the BHC. In doing this, the concepts of gender sensitivity were more clarified, marginalization of TBAs became obvious and the use of qualitative approach felt appropriate for its assessment. More importantly, women’s voices of expressed and repressed needs as to the BHC maternity care were evidently manifested. Challenges of translating the lessons into actions still lie ahead. The paper argues that to increase women’s access to a gender sensitive maternity care requires serious and long-term commitment. To overcome one of the worst maternal health situations in the world, efforts from different perspectives need to be addressed.
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Acknowledgements We are very grateful for the support, guidance and valuable feedback we received from Rashidah Abdullah, of ARROW (Asia Pacific Research and Resource Centre for Women), Malaysia. We would also like to thank Dr. AMR Chowdhury, Director Research, BRAC for his support. Financial supports from FORD Foundation and DANIDA in accomplishing the research are also acknowledged. Finally we are indebted to all the rural women and their families, and BRAC health staff who bore our endless questions with patience and humour. Without them this paper would not have been possible.
About the Authors Kaosar Afsana obtained her MBBS degree from Dhaka Medical College and Masters in Public Health from Harvard University. She is currently undertaking her Doctoral degree in interdisciplinary studies at Edith Cowan University, Australia. She has been working at BRAC [Bangladesh Rural Advancement Committee] for the past nine years. Her research interests are reproductive health, gender and methodology. Sabina Faiz Rashid obtained a Bachelors and Masters degree in Anthropology from The Australian National University, Australia. She is currently undertaking her Doctoral degree at the National Centre for Epidemiology and Population Health, at The Australian National University. She has been working in BRAC for the past three years. Her areas of interest are reproductive health, adolescent health and development, and gender issues.
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