{"id":180,"date":"2018-07-22T10:06:27","date_gmt":"2018-07-22T10:06:27","guid":{"rendered":"http:\/\/socp10.epgpbooks.inflibnet.ac.in\/?post_type=chapter&p=180"},"modified":"2018-12-31T04:38:43","modified_gmt":"2018-12-31T04:38:43","slug":"gender-and-health","status":"publish","type":"chapter","link":"https:\/\/ebooks.inflibnet.ac.in\/socp10\/chapter\/gender-and-health\/","title":{"rendered":"Gender and Health"},"content":{"raw":"
\"epgp<\/a>\r\n<\/span><\/div>\r\n
\r\n\r\n \r\n\r\n \r\n\r\n \r\n\r\n \r\n\r\nTABLE OF CONTENTS<\/strong>\r\n\r\nIntroduction<\/strong>\r\n\r\n \r\n\r\n1.\u00a0 Causes of Poor Quality of Women\u2019s Health\r\n\r\n2.\u00a0\u00a0 Women\u2019s roles and Reproductive Health Policies\r\n\r\n3.\u00a0\u00a0 Increasing Medicalization of Reproduction\r\n\r\n4.\u00a0 Re-conceptualizing Gender and health Conclusion\r\n\r\n<\/div>\r\n
\r\n\r\n \r\n\r\nINTRODUCTION<\/strong>\r\n\r\n \r\n

Health forms an important variable in assessing the quality of a population and as such is a much discussed and debated area. Health of a population is a significant indicator of a nation\u2019s growth and development trajectory, and thus should form an important arena of intervention for state policies. In India, there is a prevalence of private healthcare industry which is relatively unregulated and inaccessible to all sections of the society. Women are noted amongst the high risk groups who cannot or do not have access to affordable health care. This can simply be gleaned from the prevalent high sex-ratio disparity that exists in the country. To add to this, women\u2019s health is not treated as independent factor, rather it is clubbed with children\u2019s health and termed as \u2018women and child health\u2019. These point towards the existing social mind-set behind the policies aimed at improving women\u2019s health, where women\u2019s health is not looked upon as a women\u2019s rights issue but rather part of the larger family health policies of the country. In recent years there have been quite a few advancements in the field of reproductive technologies like IVF, possibility of egg donations, surrogacy, etc. This has further complicated the already existing gender bias against women in the health arena. This module is divided into the following four sections, in an attempt to present a brief overview of how gender and health are related:<\/p>\r\n \r\n\r\n\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Causes of poor quality of women\u2019s health\r\n\r\n\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Women\u2019s roles and Reproductive Health policy\r\n\r\n\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Increasing Medicalization of Reproduction\r\n\r\n\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Re-conceptualizing Gender and Health\r\n\r\n \r\n\r\n1.\u00a0\u00a0\u00a0\u00a0 Causes of poor quality of women\u2019s health<\/strong>\r\n\r\n \r\n

Women in India are an \u2018at-risk\u2019 group as far as health is concerned. This is largely due to the lack of conception of \u2018women\u2019 as an independent category. The health industry and the state health policies focus on women\u2019s reproductive health. The high risk periods in their lives are early childhood and reproductive years. Inadequate and poor nutrition, non-access to primary health care, poor\u00a0reproductive health and discrimination against girls are four major causes fo r higher female mortality between ages one and five and high maternal mortality rates. Gender disparity in nutrition starts from infancy to adulthood. Girls are breastfed less in infancy. Malnutrition is an underlying cause of death among girls below age five. Nutritional deprivation amongst girls leads to improper growth and anemia. Anemia is more prevalent amongst girls, pregnant and lactating women. This not only complicate childbearing and result in maternal and infant deaths, maternal depletion and low birth weight infants, but also severely affect women\u2019s productivity and quality of life.<\/span><\/p>\r\n\r\n<\/div>\r\n

\r\n

One of the reasons for this persisting gender difference in health is the existence of male preference in the socio-cultural milieu of India. Male preference in Ind ia stem from the patriarchal social set-uo which undervalues women and the productive labor. Women are seen as temporary members of their natal families and as such are viewed as a reason of drainage of wealth. Sons on the hand are seen as productive members of the economic labor force and as permanent members of their families; they are valued as breadwinners and seen as providing support in old-age. Socially, women are seen as potentially threatening to a family\u2019s or larger community\u2019s honor and status. The division of labor within households follows stringent gender ideologies, where women are seen as relegated to the domestic arena and looked upon as care-givers and nurturers, whereas men are seen as bringing in monetary remuneration from work outside the domestic sphere. The sexual division of household labor and further the division of labor among women of the household has implications for women\u2019s health at two levels. Firstly, in terms of the actual physical burden imposed by continuous labor, with little respite during weakness or illness. Secondly- the continuous daily demands made on women\u2019s time makes it very difficult for them to take \u2018time out\u2019 to consult health specialists. The desire of women to have children, daughters to help at home when they are young and sons to bring in their wives\u2019 labor, works significantly towards achieving a reduction in their work burden (Unnithan-Kumar, 1999).<\/p>\r\n\r\n<\/div>\r\n

In India most of the women are still not receiving health facilities. Poor condition of women can be seen in availing nutritious food, prevalence of anemia and nutritional status of women. In India, sex preference is mainly manifested in the form of excessive mortality of female child. The poor health status of female relatively to males is found to be due to the discrimination against females in the allocation of food and health care within household. It is not so much an equitable distribution of food in the household which is in question as the fact that women deny the food to themselves. This fact points to the important role of gender ideologies in the inequitable distribution of resources in the household and its implications for women and children\u2019s health.<\/span><\/p>\r\n \r\n

There is gender discrimination in childhood feeding, immunization coverage, treatment seeking and nutritional status. According to NFHS-3, women consume less nutritious food than man (Mehrotra and Chand, 2012). Anemia is a major health problem in India, especially among women and children and it can result in maternal mortality, weakness, and diminished physical and mental capacity, increased morbidity from infectious diseases, prenatal mortality, premature delivery and low birth weight. NFHS show gender differentials in anemia levels for women and men. 55.3 % of women and 24.2 % percent of men, whose hemoglobin levels were tested, were found to be anemic. Thirty-nine percent of women are mildly anemic, 16 percent are moderately anemic and 2 percent are severely anemic. The prevalence of anemia for ever-married women has increased from 52 percent in NFHS-2 to 56 percent in NFHS-3. Therefore, the anemia situation has worsened over time for both women and young children. Differences in nutritional intake have long terms consequences, especially as women enter their reproductive stages. Maternal mortality and infant mortality rates are directly related to the variable of nutritional intake. Anemic women face a major threat of death from child-birth and same goes for children born to them.<\/span><\/p>\r\n\r\n

\r\n\r\n \r\n

Various researches also point to the fact that women\u2019s economic dependency on male relatives creates an impetus to deny themselves health services in a \u2018culture of silence\u2019; because of their lower bargaining power within the household.\u00a0Combined with in-access to public health care which results in seeking private medical attention (more expensive), acts as a deterrent to seeking help in matters of health, until the condition deteriorates to the point where it cannot be ignored. Especially for households from low socio-economic strata, treatment cannot always be sustained for long periods and is discontinued the moment there are any signs of the patient getting better. Women\u2019s reproductive ailments, particularly if they are in their child bearing years, tend to receive more immediate attention than reproductive problems among adolescents or in elder women. This is because men as husbands also give greater importance and value to the reproductive capacity of women. In general, there is great reticence in talking about reproductive ailments between men and women as well as among men as it is seen as embarrassing and shameful (Unnithan-Kumar, 1999). This overarching focus on women\u2019s roles as mothers is echoed in the larger patriarchal and paternalistic state policies for health concerns, as seen in the next segment.<\/span><\/p>\r\n\r\n<\/div>\r\n

\r\n\r\n \r\n\r\n2.\u00a0\u00a0\u00a0\u00a0 Women\u2019s Roles and Reproductive Health Policies<\/strong>\r\n\r\n \r\n

Women\u2019s health in India is largely a demographic concern. The Indian state has been pre-occupied with lowering the population size since the inception of the first five year plan. The family Planning Association of India (FPAI) recognizes identifies two strands or components of their national family planning programme-planning of the family, and the population control. In the view of Jyotsna Agnihotri Gupta (2000), what had started out as a family planning programme meant to met out awareness regarding fertility management, especially for women so that they could have control over their own life turned into a full-fledged population control programme which was administered not only by the Indian government but being modeled after the western population policies, also held vested interests for and was monitored and funded by various international aid agencies. Gupta maintains that far more funds were allocated towards acceptance and development of contraceptives rather than the health aspect of the programme.\u00a0Gupta (2000) notes that the Indian government has not given much importance to women\u2019s autonomy or empowerment and is rather a <\/span>results driven population control programme. It has consistently used target-oriented methods in reducing birth rates by encouraging acceptance of certain methods, in particular-sterilization. Since the early 1950s, when the Indian government initiated the Family Welfare Programme, control of a growing population has been a key policy objective. Almost from the beginning, the government sought to control population size through a complex system of targets for each contraceptive method. More importantly, the locus of official birth-control policy shifted to the woman's body and contraceptive methods developed internationally during the 1960s and the 1970s - such as the \"pill\" and the IUD which, ironically, were seen as major tools for female emancipation internationally- now became central to national population-control and reproductive-health policies. According to Jejeebhoy (1997), the fact of these policies being based on demographic targets proved them to un-balanced- focusing on immunization and the provision of iron and folic acid rather than on sustained care of women or the detection and referral of <\/span>high risk cases.<\/span><\/p>\r\n\r\n<\/div>\r\n

\r\n\r\n \r\n

The highest targets were set for sterilizations, since this permanently sealed women's capacity to bear children. In reality the system worked like a top -down chain: the central government allocated separate yearly targets for the desired numbers of sterilizations, IUDs, condoms, oral pills, etc, to each state. States, in turn, allocated these targets to districts, sub-districts and primary health centers. In order to meet the mandates of these stipulated targets, the system ended up producing highly-pressured government officials, anxious to fill targets, and a system that slowly degenerated into abuse of people's rights (Datta and Misra, 2000). This has been particularly detrimental for women from lower economic strata who are forced to use government clinics as they cannot afford others and therefore are almost pushed into accepting birth control methods advocated by the family planning programme. This state controlled mechanism of population control has direct implications for women and their power over their own bodies and their autonomy on fertility management.<\/p>\r\n \r\n

Since the mid-1960s the government has attempted in succession to integrate family planning with <\/span>other programme such as Maternal and Child Health (MCH), and Child Survival and Safe Motherhood (CSSM). This was also an attempt by the government to leave behind the target based approach and focus on the health aspect. Thus by <\/span>1990\u2019s, the family planning initiative became the Reproductive and Child Health policy. This <\/span>jo int health policy for women and children is questionable from many perspectives. Chatterjee (1996) puts forth that the family welfare\u2019s concern with meeting targets had resulted in a delivery system that views women\u2019s roles primarily as <\/span>reproducers<\/em> rather than as <\/span>producers<\/em> in the economy. This construction of women has had two implications for women: (a) the health delivery system tended to ignore the provision of general health care for women, and (b) the system tended to overlook women who did not fall into the reproductive age category, for instance, adolescent girls, <\/span>un-married women, <\/span>post menopausal and infertile women.<\/span><\/p>\r\n \r\n

Reproductive Health Policies in general and by virtue of being imbibed within this, women\u2019s health has been focused on from the focal point of looking at women as mothers. Motherhood is seen as an extension of womanhood, thereby making the \u2018woman-child\u2019 dyad the central concern of health policies. The idea behind such policies is to provide women with healthcare to the extent that their children are born and raised healthy. Kumar (2002), notes that women then, are not treated as a category for development in themselves but rather health policies directed towards maternal and childcare took an instrumentalist approach towards women; signifying that policy-makers saw women as significant only in their social roles as mothers. This construction of women within the parameters of motherhood tends to exclude rather than include women from a wider range. Extrapolating from <\/span>objectives of the Reproductive and Child Health Policy initiative, Kumar (2002) concludes that women are also constructed as instrumental to the nation\u2019s larger socio-economic perspectives. Better maternal healthcare is seen as imperative in not only reducing maternal and child mortality rates but also <\/span>as way to reduce the financial burden of an ailing population on the nation-state.<\/span><\/p>\r\n \r\n

Jejebhoy (1999), in her analysis of the data gathered by the National Family Health Surveys (NHFS), notes that women\u2019s ability to exercise their reproductive choice is one of the major areas where there is data lag. The NHFS has been instrumental in gathering estimates pertaining to fertility, infant and child mortality, maternal and child <\/span>healthcare, and utilization of services provided for the same. To elucidate, the NHFS provides detailed insights into contraceptive behavior in India- the trend largely being that most couples are protected by female sterilization or by a female method of contraception. This is consistent with the priorities of the <\/span>target oriented family planning initiatives of the government. The emphasis on terminal contraception methods has led to young women being unprotected from unwanted and closely spaced pregnancies. Jejeebhoy (1999) states <\/span>that, lack of awareness regarding non-terminal contraceptive methods leads to women making uninformed choices regarding their reproductive health. The NFHS is unable to ascertain the extent to which women can make informed choices, without any coercion and the constraints they might face in accessing follow-up health care. Another example of a major gap that is not addressed by the NHFS is the lack of awareness regarding the legality of abortions and lack of information regarding infertility. According to Jejeebhoy (1999), the NFHS refers only to married women and hence does not take into account the sexual behavior of adolescent girls and the risks associated with lack of awareness regarding safe sex practices. Such lags in data point to the prevalence of traditional views regarding the role of women in the family, sexual and contraceptive behavior only within the institution of marriage, and lack of understanding of reproductive health as a women\u2019s right concern.<\/span><\/p>\r\n\r\n<\/div>\r\n

\r\n\r\n \r\n\r\n3.\u00a0\u00a0\u00a0\u00a0 Increasing Medicalization of Reproduction<\/strong>\r\n\r\n \r\n

As it can be seen from the earlier segments, women\u2019s role as reproducers has garnered a lot of interest rather than their general overall health. Women\u2019s reproductive abilities have always been an object of interest for the field of medicine and medicalization of reproduction is a not a new concept. Starting with the invention of the caesarean birthing techniques, to contraceptive methods like the condom and pill which help manage fertility, to technologies that help conceive like IVF, IUI. This directs to the way medicine has formed a huge stronghold in the\u00a0field of women\u2019s reproduction. In contemporary times, New Reproductive Technologies (NRT\u2019s) or Assisted Reproductive Technologies (ART\u2019s) have come to the forefront of this medical intervention in reproduction. These new technologies have brought a different array of regulatory practices for women to follow and adhere to. This increasing medicalization of women\u2019s reproductive lives is a matter of concern, especially in the context of already existing skewed policies for population control.<\/span><\/p>\r\n\r\n<\/div>\r\n

\r\n\r\n \r\n

Medicalization refers to the process of transforming a previously natural, social or behavioral entity into a medical one, thereby requiring medical attention and expertise. ART\u2019s have been on the scene since the 1970\u2019s and since the onset of assisted reproduction methods, infertility has become a rising concern. It is important to note that, infertility was not a concern for state policies or for private practitioners before the advent of ART\u2019s. On the other hand, with the emphasis on lowering population rates, infertility was not even considered as a demographic variable. Medicalization also entails social construction of what is normal and what is not and hence needs to be corrected. It involves methods of regulation and social control. According to Bell (2009), the primary forms of social control associated with medicalization of infertility is the maintenance of norms regarding family and children, i.e. who should have children and having children after marriage is \u2018normal\u2019, thereby making the category of not having children \u2018abnormal\u2019.<\/p>\r\n \r\n

The invention of artificial insemination and other associated technologies like in-vitro fertilization (IVF), donor sperms and eggs, was initially seen as a way of liberating women from the politics of reproduction within the patriarchal frame. These technologies were touted as a tool of female liberation as it would give women the right over their own reproductive abilities (Firestone, 1970). On the contrary, these new technologies work within the frame of patriarchy and are guided by the traditional notions of women\u2019s role in society- as mothers. Greil, Leitko and Porter (1998) point to the fact that the medical world tends to reinforce the social and cultural constructs of women as mothers, making infertility (like fertility) fall within the purview of women and more of their responsibility than that of men. Motherhood and medicalization together have formed a narrative which excludes women who are childless, and creates a mandate to engage with\u00a0such technology in order to become normal (Ghosh, 2017). This imperative is further compounded by inherent class distinctions in terms of who can avail or afford these technologies. With a public health set-up that is focused on lowering population and managing the quality of population growth through better maternal and child care; ART\u2019s falls in the realm of a highly expensive privatized market making it difficult to be accessed by couples\/women from lower socio -economic backgrounds. Together, these trends seem to perpetuate the idea that infertility is prevalent more amongst women from higher socio-economic classes while women from lower socio-economic strata have to manage their fertility in order to curb population growth (Bell, 2009).<\/span><\/p>\r\n \r\n

In a patriarchal society like India, medicine and technology are imparted by establishments which are governed by these pre-dominant values and construct womanhood as synonymous <\/span>to motherhood. The boom of this privatized \u2018baby-making\u2019 industry runs on the pervasiveness of this ideology, making such technologies a tool of governing women\u2019s reproductive choices by guaranteeing women the \u2018choice\u2019 of an authentic biological motherhood (Ghosh, 2017). This choice that is provided is a false one, as it is choice between compulsory motherhood or not being a mother and falling within the category of abnormal\/ dysfunctional or unhealthy, thereby requiring medical attention to correct the perceived defect. This kind of meta-narrative that works through political, religious and symbolic ideology takes away any chance of agency that women may have over their own fertility and reproductive choices.<\/span><\/p>\r\n \r\n

According to Gupta (2000 in Ghosh, 2017), fertility (in terms of population control) and infertility are both viewed as diseases that need biomedical solutions and solutions for both of these are acted upon women\u2019s bodies, subjecting them to control from both state policies and from a private healthcare market. ART\u2019s have also brought about a change in the way <\/span>healthcare is perceived and administered. The advent of ART\u2019s has brought about the practice of self-monitoring and self-regulation. Owing to the pervasive nature of these treatments, women are required to constantly monitor their bodies, like body temperature, days and dates of menstrual cycles, dietary patterns according to nutritionists, regulating body weight, etc. All these everyday micro-practices are built into the narrative of\u00a0<\/span>medicalization and are taken over by women who opt for such treatments. And lack of success of the treatment, i.e. not conceiving a viable pregnancy, is a failure that is located within the bodies of the women. Women tend to blame themselves for the lack of success of these treatments even though these treatments have 30 -35 percent chance of being successful. Greil, Leitko and Porter (1998) note that women tend to blames themselves for this because they perceive others as blaming them. This corresponds to the physician\u2019s orientation to the treatments as well- the woman is treated as the primary patient, even when the physiological cause of infertility does not lie with her. This exacerbates the responsibility that women feel towards reproduction because the treatments too focus on \u2018treating\u2019 only women.<\/span><\/p>\r\n \r\n

The increasing medicalization of the reproductive arena has placed greater constraints on women\u2019s choice and agency vis-\u00e0-vis their reproductive life. A pronatalist culture within a patriarchal social set-up, reproductive health policies that focus on the role of women as mothers and thereby situate them as the locus of population control policies, advent of highly privatized market of reproductive technologies which sustains itself on the ideology of motherhood, ART\u2019s creating childlessness as a disease that has solutions only in the area of <\/span>bio -medicine; all together constitute the politics of reproduction where women have to negotiate the notion of informed choice and agency, which are concepts that have been overlooked by both healthcare providers- state and private.<\/span><\/p>\r\n\r\n<\/div>\r\n

\r\n\r\n \r\n\r\n4.\u00a0\u00a0\u00a0\u00a0 Re-conceptualizing Gender and Health<\/strong>\r\n\r\n \r\n

The prevalence of ART\u2019s has also led to the availability and acceptance of the practice of surrogacy. Till the recent amendment to the Draft Assisted Reproductive Technology Bill (2008), which limits altruistic surrogacy to married couples residing in India, surrogacy was a commercial practice. The entire practice of surrogacy was un-regulated and was allowed to grow into a viable business without any policy on the ethical implications of the same. The practice of surrogacy brought into question the ethical dilemma of the rights of the surrogate mother vis-\u00e0-vis rights of the commissioning parents. It also brought into question the exploitation of women from lower socio-economic strata who are\u00a0commissioned to become surrogates on the basis of their need for money. These new types of ethical complications have to be taken into consideration while formulating health policies in the country. The old rhetoric of reproductive health policies which treat women in instrumentalist fashion have to be re-conceptualized along the lines of women\u2019s rights and agency of exercising their reproductive choices.<\/span><\/p>\r\n\r\n<\/div>\r\n

\r\n

In the light of ART\u2019s, there needs to be better designed models of gathering data pertaining to infertility. Numerous small scale qualitative studies suggest that primary infertility exists only amongst 2 percent of the entire population. The majority reasons for infertility are preventive in nature like untreated STD\u2019s, reproductive tract infections, and medical interventions under unhygienic conditions, and such. Lack of awareness regarding non-terminal methods of contraception, lack of access to proper healthcare, fear of social stigma, and decisions of using intrauterine devices rather than barrier methods increase the chances of women contracting STD\u2019s which in turn may contribute to infertility. There has to be a more sensitive understanding of women\u2019s position within the household and their inability to express or articulate their concerns owing to the lagging socio-cultural infrastructure while framing healthcare policies for women.<\/p>\r\n \r\n

In India, women operate within a very constrained box in the area of sexual and reproductive health, and have an alarming lack of agency in these matters. The advent of new and rapidly developing technologies in the field of reproduction, administered by a profit oriented private health sector in the face of lack of general healthcare by public administration, convolutes and already complicated scenario of women\u2019s health. Women\u2019s health needs to focus on empowerment as process through which women are enabled to analyze their own situations, decide their priorities, and take action based on informed choices. Instead of treating women\u2019s empowerment as an instrument or means to an end, empowerment needs to be looked at more holistically from a perspective of women\u2019s rights. Datta and Misra (2000) surmise that this objective needs to be fulfilled in two ways:<\/p>\r\n\r\n<\/div>\r\n

\r\n