Complications of pregnancy and childbirth remain the leading cause of death and disability for childbearing women in many low and middle income countries. Of the estimated 529,000 maternal deaths globally each year, 99% take place in the developing world [1
]. over half in just six countries [2
]. The obvious remedy is to provide competent maternal health care during pregnancy and childbirth [3
]. Contemporary policy espoused by the World Health Organization and the United Nations Population Fund (UNFPA) promotes this medicalized approach, which subsequently has grounded the national maternal health policies of many developing countries, including Pakistan [6
However, despite significant international investment under the Safe Motherhood Initiative and strategies to achieve Millennium Development Goal No. 5, countries with the highest burden of maternal mortality are failing to reduce their mortality rates [8
]. This suggests the medicalized approach may be necessary but is insufficient to achieve the desired reductions in maternal mortality. A large, but parallel body of public health and development literature demonstrates that women’s use of reproductive health services is determined not only by the physical availability of such services, but also by gendered inequities that shape women’s access to education, ability to travel, financial and social resources, and decision-making authority in key aspects of their lives [11
]. These gendered inequities are further intersected by class and caste-based hierarchies, resulting in large differentials in access to services between rich and poor women within countries. Consequently, maternal health care is one of the most inequitably distributed health resource even within poor countries. A recent analysis of Demographic Health Survey data from 33 low and middle income countries shows that the odds of having a skilled birth attendant at delivery for women in the poorest quintile are 94% lower than for women in the highest wealth quintile [14
]. Women with primary education are five times more likely to have skilled birth attendance compared to women with no formal education [15
Generally lacking from this body of literature, however, is insight into the underlying political and social dynamics that create and reinforce these inequities in access to care. An understanding of the root causes, and the political and social dynamics that reinforce these inequities remains a critical gap in our knowledge. In particular, we know very little about the ways in which economic class and gender influence healthcare policy formation, resource allocation, the design and delivery of maternal health services, and disadvantaged women’s access to health services. Material poverty alone does not explain the large disparities in access to maternal health care between the rich and poor [18
]. Poverty is relational and embedded within power hierarchies [19
]. We therefore drew upon the concepts of social exclusion and adverse incorporation [21
] to understand how power hierarchies operating at family, community and state levels conspire to prevent women from accessing timely maternity care despite the physical accessibility of maternity services [19
]. Three frameworks grounded our inquiry: the Monopoly paradigm describes cultural distinctions such as class, political power, and economic priorities as perpetuating inequality and domination [26
]. Kabeer expands this approach to include perceptions of social identity related to caste membership [27
], and the “social relations” analytical framework addresses gender [28
The current paper presents early findings from an innovative research study in rural Punjab, Pakistan that aimed to address these issues. Pakistan’s maternal mortality rate stands at 297/100,000 live births, among the six worst rates in the world. Pakistan is also characterized by deeply entrenched gender inequities [29
] and vast inequities in access to maternal health care services, illustrated by the fact that while 77% of women in the highest wealth quintile report receiving skilled care at delivery, this figures is just 16% in the lowest wealth quintile [30
]. Two broad questions were addressed by the research 1) how are the axes of social exclusion constructed, mobilized and experienced in Pakistan, particularly in relation to class and gender divisions? 2) how do these forces affect access to maternal health services?
Through the case histories of two women who died shortly after childbirth that we present below, we can begin to see how gender and socio-economic hierarchies, underpinned by societal discourses that sytematically devalue particular sub-groups and legitimize discriminatory behaviors, and shaped by wider ideologies and economic structures, contribute to tragic outcomes in a location where maternal health services are physically available.
Here we present a brief overview of the social structure of the village for we argue that not only does it underpin chronic poverty, it also determines the nature of social relations and modulates women’s access to maternal health services. Village Gaind-Pind is a well-defined settlement that is connected by an all-weather road to the main highway of the country. Although agriculture and livestock rearing are key economic activities, the village is situated in the ‘martial belt’ of northern Punjab from which the Pakistan Army has traditionally drawn its soldiers.
Consequently, a large proportion of men work in the army, police and the government. There is a small oil and gas development company recently established in the village, but it has minimum interaction with the villagers. There are three primary schools in the village, one for boys and girls each and one co-educational. A range of maternal health care services are available in this community, including three public sector first-level care facilities that provide round the clock obstetric services, and a physician who provides basic obstetric care in a private practice. Within an hour’s drive are a popular birth attendant of uncertain training, and a large district hospital; two teaching hospitals exist about four hours’ drive away.