Gurpriya Singh looks at the issues of healthcare facilities for women and the difficulties that they face on a day-to-day basis while accessing the same
For Ramrati, a 29-year-old woman from Patna, narrating her experience of institutional delivery of her first child was quite painful. She got pregnant two months into her marriage. She took good care of herself, and took all the prenatal medications and tests on time. But Ramrati distinctly remembers the four nights she spent in the hospital. “For four days, I kept screaming in pain. The nurse would sometimes abuse or make demeaning remarks, she’d say, ‘when you were being intimate with your husband, you didn’t feel the pain, you’re coming here and shouting.’ They would sometimes go on to make caste/religion based remarks, or ask us to give money for an operation. The doctor and interns did a finger test, I would feel as if I am not there for delivery but for them to observe and learn from my body,” Ramrati explained.
A report by the YP Foundation, a youth-led and youth-run organisation based in New Delhi, notes a similar experience of a finger test that a young person experienced while conducting a mystery audit at a community health centre in Lucknow. There are multiple such instances recounted by women, where options of detecting pregnancy are not given, and practitioners without taking informed consent routinely conduct bimanual (internal) pelvic examinations to assess the womb.
Even if the act was committed in good faith — in the interest of the patient’s well-being and time at hand — the practitioner had not thought it necessary to clarify or take informed consent of the patient, whether she would be comfortable with such an invasive procedure being carried out on her body.
This is just one example of indignity that women routinely experience in the labour room. Labour room violence is not unknown — it ranges from physical and verbal abuse, neglect of quality infrastructure, lack of informed consent or choice and financial abuse.
As part of Khud Se Pooche campaign, a women-led movement in Bihar, supported by multiple organisations in Patna, including Sakhi, Bihar Youth for Child Rights, Gaurav Grameen Mahila Vikas Manch, Population Foundation of India and Centre for Social Equity and Inclusion, to build recognition about dignified healthcare in women, many women reflected on diverse experiences in healthcare.
As part of the campaign, a number of women spoke about the extreme judgement and shaming that they had to experience, when accessing a healthcare facility due to delayed/ missed/ painful period cycles. Instead of medical diagnosis and treatment, women were asked personal, out of context and uncomfortable questions such as if they had boyfriends, or if they were having intimate affairs or relationships. In an assertive manner, before being heard, some women were told that they must be pregnant. All these responses have made women feel violated. The ones who experienced pain were told to learn to be resilient or that it will get better after marriage or after the first child. Their pain was dismissed and personal comments were made. In all these experiences, there is a gaze of suspicion and shame that women felt, further traumatising and silencing women patients. The hesitation and barriers, that sometimes young, unmarried women overcome to visit health services, interrupt women’s access to services.
Because of the stigma associated with sexual health and reproductive health, from adolescence, women are unable to express or share concerns, and there is hesitation to discuss breast asymmetry, breast cancer related issues, vaginal discharge, menstrual hygiene related queries or general curiosity about body and psychological changes. Lack of proper and dignified access to sexual and reproductive health services, that are often layered with hesitation, stigma and shame impacts mental health of women.
According to the latest National Family Health Survey-5 (NFHS-5), Quality of Care is measured by whether users were told about the side effects of the current method of family planning. For instance, in Patna, only 46.4 per cent women were made aware of this, and only 18.6 per cent of women who do not access family planning services were counselled about the same. With less than half of the women who were not made aware about the side effects, even fewer were given any counselling, while myths and misconceptions around family planning remain common. With only a two per cent decrease in unmet need among women, at 15 per cent unmet need is high, where women wish to use contraceptives to postpone next birth. All three factors are linked to lack of proper counselling, that leads to discontinuation and dissatisfaction among women.
The other big aspect of indignity that women have also experienced is discrimination, differential treatment and bias in treatment due to age, caste, class, religion, abilities, sexuality, gender, employment, education, appearances and fluency in communication.
A lot of women felt violated or discomforted by the way the doctor, compounder or nurse touched them — some of them felt that they were touched inappropriately but they didn’t know who to tell or whom to report to. They all resorted to silence.
In most cases women didn’t know who to reach out to, how or whom to explain these experiences, there is always a fear of being told, at home or at a healthcare clinic, that they are seeking attention, they are overreacting, or being frivolous. In a report by CEHAT on the mistreatment of women in the labour rooms, in similar situations, doctors, nurses and hospital orderlies mentioned that it was the women who misunderstood the situation, and that there was nothing of sexual in nature involved in the doctor’s actions.
Many women didn’t think that they could share these experiences with their families, from the fear of being told to dress properly, behave in a clinic or denied to visit a clinic in the future. There is significant power in the hands of the medical fraternity, where agency, bodily autonomy and integrity is compromised for treatment and care.
Health practitioners and experts note that doctors and medical staff members are part of the same society that normalises these practices every day and simply these go on to reflect in the healthcare, due to non-training/ sensitisation of health care professionals.
During the Khud Se Pooche workshops, women suggest setting up feedback boxes, gender sensitisation and sensitivity training, ethics training, helplines, mental health counseling sessions or committees that can take note of these experiences, and help navigate the situation.
While the experiences of indignity in healthcare are universally understood, the individual’s personal circumstances impact their health and well-being. This was starkly visible in the campaign to which most of the above anecdotes are attributed, that factors such as quality of housing, family structure, violence or conflict, working conditions, education, daily lifestyle, gender or sexuality, caste, religion or class, played a huge role on how women navigated access to healthcare.
The World Health Organisation (WHO) notes that addressing social determinants of health appropriately is fundamental in improving health and well being. These include early childhood and development, education, income and employment, housing, work-life balance and conditions, violence, among others to ensure that women health-seekers are not seen as a homogenous group and root and underlying causes are considered, in the treatment process.
(The author is the campaign lead at Khud Se Pooche, a women-led movement in Bihar.)