Complications of pregnancy and childbirth remain the leading cause of death and disability for childbearing women in much of the developing world. Of the estimated 529,000 maternal deaths each year, 99% take place in the developing world [1
]. Just thirteen countries are estimated to account for two-thirds of all these deaths. Today, the lifetime risk of death from complications of pregnancy and childbirth is one in 89 for Pakistani women, compared to 1 in 17,400 in Sweden [2
Two decades of the Safe Motherhood initiative and inclusion of maternal mortality rate as the target for Millennium Development Goal 5 have not, to date, had a significant impact on maternal mortality rates in countries with the highest burden [3
]. The clustering of mortality around delivery suggests that all women should have access to skilled attendance at birth and immediately after, with timely referral for emergency care if necessary. A large body of literature describes various programmatic strategies that, if put in place and accompanied by sufficient political will, funding and strengthening of the health systems infrastructure, will reduce maternal mortality [6
]. The theme underlying these initiatives and in this literature to date is that “we know what works” and we now need to implement the interventions [6
Missing from the published literature, however, is a rigorous analysis of why
these simple, evidence-based, and cost-effective strategies have not been implemented. Instead, discussions rarely progress beyond acknowledging a lack of political will or the existence of inequities and systematic disparities in maternal health care services [8
]. A critical gap in our knowledge today is a detailed understanding of the root causes of these inequities and of the political and social dynamics that reinforce these inequities. In particular, we know very little about how class and gender influence the formulation of healthcare policy, the allocation of resources, the design and delivery of maternal health services and how these factors shape disadvantaged women’s access to health services. Does the fact that maternal health services are meant for women only lead to lack of political will to provide these services? Why do some women have access to state-of-the-art care that is unavailable to others?
The present study will examine these questions in the context of Pakistani society and culture. Specifically, the proposed research will investigate (1) the ways in which disparities in access to maternal health care in Pakistan are related to gender- and class-based exclusion of specific sub-groups of the population, and (2) whether and how maternal health policies and health systems may be signalling and reinforcing larger societal values and processes of marginalization that reduce the quality of care, delay timely intervention, and/or prevent access to entirely. This research is urgently needed in Pakistan, a country characterized by poor maternal health indicators and vast inequities in availability and access to maternal health care services. Underpinned by social constructionist and critical theory approaches, the research will draw upon the “social relations” [10
] analytical framework for understanding gender and class. The central focus of this framework is that social structures, processes, and relations create differences in the social positioning of women and men and that it is through these gendered relations that men are given a greater capacity to mobilize a variety of cultural roles and material resources to pursue their own interests. The “social relations lens” will also be used to understand why and how resources, material, human and social, may be unequally distributed between groups [12
]. Knowledge transfer and policy advocacy will form important components of the research.
Maternal mortality rate is one of the few health indicators that can be rapidly and consistently decreased - almost to the point of negligibility - if appropriate actions are taken. Malaysia and Sri Lanka halved their maternal mortality rates every 6–12
years during the 1950s-1990s, a phenomenon demonstrating the importance of political will in reorganizing health services even when national GDP is relatively low [13
]. But maternal health care is one of the most inequitably distributed of all health resources [14
]. Survey data from 45 low- and middle-income countries indicates that even in countries with low overall levels of health care use, inequalities in skilled attendance at birth are much larger than inequalities in other types of care [15
The present study will draw from and build upon two distinct, yet inter-related conceptual approaches to understanding the phenomenon of inequity in maternal health care services: social exclusion and health systems as social institutions.
Disparities in maternal health care between countries are well documented. Recent evidence suggests there are equally large disparities within countries [9
]. For example, in Chad, rich women are 23 times more likely to have a skilled attendant present during childbirth compared to poor women; in Bangladesh the difference factor is 14 [9
A growing body of research indicates that economic poverty alone does not explain the large disparities in access to maternal health care between the rich and poor and how such inequities might best be challenged and addressed [16
]. Economic poverty is relational and embedded within power hierarchies [17
]. The concept of social exclusion may therefore be a more useful concept to draw upon to understand the disparities in access to maternal health services. Originally developed in French political discourse [19
], social exclusion is a complex concept that is variably understood to range from individual ostracism or poverty to systematic societal structures that sharply define hierarchical group boundaries that serve the interests of a privileged group [20
]. In the latter concept of exclusion, termed the Monopoly
paradigm, social institutions such as class, political power, economic structures, and other cultural distinctions perpetuate inequality and domination [24
]. In South Asia, the concept of social exclusion has been expanded by Kabeer (2006) and others to include perceptions of social identity related to caste membership [26
]. In these contexts, powerful groups construct and draw upon societal beliefs, norms and values to disparage, invisibilise and demean certain groups of people, thereby justifying the denial of full rights of participation in economic, social and political life [27
]. Notwithstanding the important debates around the term and concept of social exclusion [27
], there is an emerging consensus that it is both a process and an outcome [24
], and that the discrimination occurs in private social institutions such as households as well as public institutions such as the health, education and legal systems [29
The social exclusion perspective is a useful guiding framework for the present research because it focuses attention on social relations and integrates various forms of disadvantage within a single analytic framework. The social exclusion discourse is particularly well developed in understanding the relational aspects of deprivation, how some groups are systematically denied the material and social resources that facilitate full participation in the society and the subsequent devaluation of classes thus created. It is also a useful framework to generate a greater understanding of how women in Pakistan, as a gendered group, may be socially excluded or, as some suggest, be adversely incorporated [29
] The framework will enable us to understand, in all its complexity, how the gendered social structures, processes and relations that lead to women being systematically denied resources and full participation in society become the basis for denial of maternal health services.
Health systems as purveyors of social values
Historic experience from Europe and recent empirical evidence suggests health care systems are the key to reducing maternal mortality [8
]. More recent, cutting-edge thinking suggests that health systems are not just mechanical structures that provide health care; they “are also purveyors of a wider set of societal norms and values” (p.143) [32
]. According to Freedman, health systems should be considered “core social institutions, culturally embedded, politically contingent, and part of the very fabric of social and civic life” (pg. 22) [33
]. More importantly, they are a common interface between individuals and the power structures that shape their broader society. The structures and operations of health systems may, therefore, signal and reinforce societal values and norms [33
]. Neglect, abuse and exclusion within health care systems may thus essentially be a reflection of the experience of being poor and socially marginalized in that society [33
]. Feminist bioethics scholars have long examined the dynamics of gender and western health care [35
], often extending the analysis to matters of race [38
], socioeconomic status, and related social categories. Similar inquiries regarding gender, power dynamics and health care in developing nations are still limited [39
It is necessary, but not sufficient, for health systems to ensure that good quality maternity services are widely available; utilization of these services also involves the dynamics of users’ decision-making. A large body of literature addressing the three-delays-model [40
] of maternal health care utilization in developing countries has tended to focus on the individual characteristics of women, their families and decision-making processes. This individualistic approach fails to consider how health system characteristics per se
may shape the decision-making process, including the primary decision of whether or not to seek care at all. For example, health system characteristics such as abuse and under-the-table bribes may deter women and their families from seeking the care they need [41
], yet avoidance is often regarded as a failure of the individual woman and her family to make appropriate decisions [8
]. A better understanding of the ways in which health systems, as social institutions, may be systematically creating barriers to use thereby excluding particular sub-groups of the population, and how such exclusion can be challenged is urgently needed.
Study setting: the Pakistani context
Pakistan provides an ideal opportunity to conduct a case study of social exclusion and maternal health services because it is characterized by poor maternal health indicators and vast inequities in access to maternal health care services. With a maternal mortality rate of 297/100,000 live births, it is one of the 13 countries estimated to contribute to two-thirds of all maternal deaths worldwide [1
]. Overall, 39% of all births are supervised by skilled birth attendants. When use is broken down by wealth quintile, 77% of women in the highest wealth quintile report skilled birth attendance, compared to 16% of women in the lowest wealth quintile. Highly educated women are over three times more likely to be attended by skilled birth personnel than women with no education (86% vs. 27%) [3
Class and gender in Pakistan
The structure of Pakistani society is acknowledged to be characterized by two separate institutionalized systems of inequality: class and gender [42
]. Class in Pakistan is closely related to zaat,
a multi-dimensional identifier similar to the Hindu concept of caste [44
]. Severe inequities in the distribution of land, the primary resource, are interwoven with notions of zaat
to create a hierarchical and feudal society. Ethnographic work from Northern Punjab shows that only members of the Kammi zaat
work in low prestige occupations such as butcher, barber, tailor and carpenter. They are also considered “katia”
(low class) and “kameenee”
(low form of life) (pg.167) [44
]. Individuals born in these zaats
largely remain locked in such occupations, a division of labor that causes and reinforces differential access to and control over resources of all types, including social status [46
Gender inequality is Pakistan is particularly acute. Gender roles are clearly demarcated; men are socially constructed as providers and women as dependents [47
]. The social institution of purdah2
] further demarcates boundaries between men and women and sets standards of female morality. Consequently, large differentials exist between women and men in access to resources of all types [49
]. This of course does not suggest that gender roles and relationships are non-negotiable or that there is no variation. Pakistan is a large and heterogeneous country, and women’s gendered experiences and social relations are shaped by socioeconomic, ethnic and regional variations [45
]. Nonetheless, the coexistence of social stratification in relation to class and gender means a woman may be disadvantaged because she is a woman, but her disadvantage is compounded if she is a woman belonging to a lower status zaat
Ethnographic and survey data from Pakistan also suggest gender values and norms are tightly interwoven with maternal health-seeking behavior [44
]. Moreover, the degree of adherence to these gendered norms varies by zaat
and socio-economic class [44
]. For example, gendered notions of purdah
glorify women’s seclusion, but poor women often cannot afford to adhere to these norms when the practical needs of survival necessitate their mobility outside the home to collect water, work on the farm, or even relieve themselves in the fields. Studies show that poor women’s greater mobility outside the home renders them vulnerable to sexual exploitation by the higher status zaat
or land-owning men [44
]. Clearly, these issues have major implications for poor women’s ability to access maternal health services, many of which are located at considerable distance. There is an urgent need to better understand how class and gender interact to create barriers to women’s access to maternal health care.
Maternal health policies and services
An evolving global maternal/reproductive health discourse has resulted in formulation of three maternal health/reproductive health policies in Pakistan between 1990 and 2001 [54
]. The first two policies were silent on gender and class in reproductive health services [55
]. The 2001 policy does identify gender equity as one objective without expanding what this will entail. The latest National Maternal and Neonatal Strategic Framework, 2005–2015 has, however, pledged to “ensure availability of high quality maternal and neonatal health services to all, especially the poor and the disadvantaged” [56
Despite this apparent political commitment, available evidence suggests that delivery of maternal health services in Pakistan is patchy and fragmented, of poor quality, and inequitably distributed and utilized [55
]. Notwithstanding a wide network of facilities, a survey of public sector health facilities in Punjab showed that only 13% of facilities designed to provide basic emergency obstetric services were actually doing so [59
]. The corresponding rate in North West Frontier Province (NWFP) is 10% [60
]. The paucity of services is reflected in the very low C-section rates: 0.4% in Punjab and 0.89% in NWFP, when rates of between 5 -15% are generally deemed essential for safe childbirth [60
In seeking to understand the persistently inadequate maternal health care services, research has largely focused on parameters of service delivery [58
]. A few studies focus on poor governance [60
]. More critical analyses argue that although the most recent health policy in Pakistan focuses on women’s health, it fails to recognize and address the key
gendered obstacles to uptake of maternal health care services [61
]. These include a paucity of female health care providers, resulting in part from gender hostility in employment settings [62
] as well as limited education opportunities for females. Clearly, a robust discourse around class, gender and exclusion in the use of maternal health services has yet to start in Pakistan.
Research questions and objectives
Reconceptualising health systems as social institutions that mirror the inequalities of wider systems of social exclusion is a promising avenue to enhance our understanding of failing maternal health strategies and to identify more effective approaches. To date, however, very little research has attempted to systematically describe exactly how the exclusionary processes function in relation to maternal health services. An emerging, but still slim body of literature has largely focused on documenting disparities in access to maternal health care using secondary survey data [9
]. Still lacking are in-depth studies to determine who and what are responsible for these inequities. An understanding of these factors will provide policy-makers with much needed insight into addressing what can appear to be insurmountable, deep-seated inequalities reinforced by multiple hierarchies.
Drawing on the work by Freedman et al. [31
] the proposed research will address these issues through two key questions. First, how are the axes of social exclusion constructed, mobilized and experienced in Pakistan, particularly in relation to class and gender divisions? Second, to what extent do these dimensions of social exclusion affect the ways in which maternal health care services are conceived, designed and delivered? How do these influence poor women’s access to, and experiences of, health services?
1. Conceptual objective: The fundamental theoretical objective of the research is to develop a locally-informed, contextually-relevant conceptual framework to understand the construction and experience of key axes of exclusion relating to gender, class, and zaat in Punjab, Pakistan.
2. Empirical objectives: There are two empirical objectives:
2.1. To map women’s experiences of maternal health care use, and specifically skilled attendance at birth and emergency obstetric care, as it is related to class, zaat, and related distinctions.
2.2. To enhance empirical understanding of the ways in which class, zaat, gender and related social distinctions are reflected in maternal health policy documents and in the design and delivery of maternal health care services.
3. Knowledge transfer objective: Is to facilitate uptake of research findings to inform positive developments in maternal health policy, service design and care delivery.