“Analyzing Maternal and Neonatal Healthcare in Uttarakhand, India: A Transnational Feminist Approach” by Uma Kuwar

Analyzing Maternal and Neonatal Healthcare in Uttarakhand, India: A Transnational Feminist Approach

Uma Kuwar, The College of New Jersey

ABSTRACT

Maternal and neonatal healthcare in the mountainous region of Uttarakhand, India, is significantly impacted by geographical isolation. Previous research suggests that climate and terrain are the primary factors for the increasing mortality rates of both groups. However, this framing overlooks the intersectional disparities that are foundational within healthcare. This paper utilizes a transnational feminist framework to examine the effects of geography, cultural traditions, medical practices, and women’s voices, or the absence of women’s voices, on medical access in communities across the state of Uttarakhand. This study employs a mixed-methods approach to propose culturally competent, community-driven interventions that address increasing mortality rates and bridge the gap between qualitative and quantitative data in research.

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1. INTRODUCTION  

Biomedical systems in both the East and the West have failed to meet the expectations and needs of vulnerable, marginalized populations. As a result, we see the direct consequences reflected in mortality rates. In the East, India contributes 20 percent of maternal mortality to the world’s maternal mortality rate (Sankar et al. S3). In India, each state contributes an unequal share of neonatal mortality, but Uttar Pradesh, Madhya Pradesh, Bihar, and Rajasthan account for over half of the ascribed deaths (Sankar et al. S5). Alarmingly, Uttarakhand, a separate state just recently carved out of Uttar Pradesh, has a neonatal mortality rate that is higher than other Indian states such as Kerala.  Kerala boasts approximately 6 infant deaths per 1000 live births from 2018 to 2023, which is approximately 4.3 times lower than Uttarakhand (Rakholia et al. 202). These differences reinforce that maternal and neonatal healthcare are two critically underserved fields and intrinsically form the basis of the state's standing. Not only do these rates reflect health outcomes, but they act as measures to understand the equity and quality of the healthcare system, as well as the socio-economic conditions for living in Uttarakhand. 

The focus of this paper is primarily on Uttarakhand, as my ancestors originate from the state, and I am curious to understand the root causes of high infant and maternal mortality rates. While this paper primarily focuses on cis-Indian women, trans-Indian women, queer-Indian women, and gender nonconforming individuals do exist within the country and the state. Their access to healthcare, gender-confirming care, maternal healthcare, and neonatal healthcare is also declining at an increasing rate; their marginalization needs to be taken seriously but will not be the focus of this paper.

In investigating the causes and consequences of limited healthcare, I came to a standstill: maternal and neonatal projects and research were limited or simply non-existent. What is the cause of this gap in literature and collective action? My initial guess was based on the rurality of Uttarakhand. Based on what my grandparents and parents have said, the state is not urban-based like New Delhi. This prompts differences in resources and the viability of those resources. However, as time continues, states evolve. Therefore, the rurality of the state could not be the only individual factor considered.

As a result of this gap, I employed a transnational feminist theory and emphasized cultural studies to locate interventions that could find a home in Uttarakhand. Countries with similar geography, mortality rates for women and babies, climate, and agricultural schemes were optimal for comparison and assessment. Examining practices in other countries is not to impose external frameworks of care but to see how successful practices can be adapted in Uttarakhand that center women’s autonomy. Being defined by the geography of a home should not act as the catalyst for relocation to experience safe birth experiences and practices. Likewise, these same women should not have to forgo sterile perinatal, intranatal, and postnatal experiences. These concerns inform the guiding questions of this paper: Why are women and their children in Uttarakhand, India, understudied and experiencing high death rates, and what transnational feminist interventions can be taken for both groups' betterment?

2. LITERATURE REVIEW   

Women and babies in rural Uttarakhand face a multitude of inequalities in healthcare. Previous research suggests underlying commonalities regarding the presence of inequities for women in Uttarakhand. One main agreement stems from the concept of intersectionality. Overarching arguments focus mainly on the terrain and cultural practices that give rise to high mortality rates (Jat et al. 9). While these two facets push forth overwhelming evidence, environmental issues, lack of birth attendants - doctors, nurses, midwives - at healthcare facilities, the placement of healthcare facilities, colonialism, and the caste system, amongst others, should also be factored in when looking at this multidisciplinary issue. Feminists have argued for reproductive justice, which includes reduction in maternal and child mortality as a fundamental human right. 

Uttarakhand’s geography is essential to understanding high mortality rates. The state is in the northern region of India on the southern slope of the Himalayas. Its location is one of isolation. Water scarcity, poor connectivity to and from places, as well as unmatched supply and demand, are some of the major issues that the people in Uttarakhand face (Mustafa and Shekhar 2). Distance to and from facilities increases neonatal mortality rates, excluding institutionalized deliveries (Prochaska 2434). Accessibility is a major issue for all residents of the state, but with pressing urgency for pregnant women. Although the Rural Health Statistics provided information that the state has plenty of health facilities, these facilities are underutilized (Mustafa and Shekhar 2). There is a significant difference in utilization of Maternal and Child Healthcare (MCH) services between hilly and plain regions (Mustafa and Shekhar 2). Additionally, there were differences in full immunization and vaccination against tetanus, as well as utilization of postnatal care when comparing hilly to plain areas. Children born in hilly regions like Uttarakhand are 18 percent less likely to receive full immunization than those born in plain regions (Mustafa and Shekhar 8). The local government has tried to help in the past by implementing birth attending programs. Trained female community health workers were introduced under the National Health Mission to serve as a connecting link between providers and the mothers in rural and urban areas (Devi et al. 52). However, more research needs to be conducted on whether these programs have fared well and how they have affected the mortality rates of both mothers and their neonates.

It is important to note that while generalizations can be made to the entire state of Uttarakhand regarding access to healthcare, such as environmental impacts, there are cities and towns within the state that abide by different customs and practices. An overarching reason as to why complications arise in both maternal and neonatal healthcare resides in cultural practices. Perinatal exploratory studies on tradition in Uttarakhand were conducted. Certain beliefs, like pregnant women should not eat green vegetables, yams, red onions, papayas, or mangoes during pregnancy, as it could be detrimental to the fetus, remain present. (Saxena et al. 159). Pregnant mothers are also advised not to drink too much water, as it could put pressure on the baby; wearing red is also a sign of misfortune and should be avoided at all costs (Saxena et al. 159). Another belief is that papayas should not be eaten during pregnancy, as they are used for abortion measures (Saxena et al. 159). Yet, there is no evidence that these cultural beliefs are standing the test of time or that these beliefs negatively impact birthing outcomes. Nevertheless, these beliefs may put the women who abide by them in tension with biomedical practices and their communities.

Feeding practices are also very important in the state of Uttarakhand. The National Family Health Survey revealed that there is a gradual increase in the prevalence of malnutrition throughout infancy (Rathaur et al. 46). An observational, cross-sectional study on feeding practices in Uttarakhand was conducted, with the World Health Organization classification of malnutrition at the forefront (Rathaur et al. 46). Initiation of breastfeeding within 1 hour is viewed as critical, as a study for Ghana showed that it could cut 22 percent of all neonatal mortality (Rathaur et al. 50). Having less prelacteal feeding can be associated with better health outcomes as well. However, not all women can breastfeed after giving birth. Unintended consequences can arise after giving birth that can compromise the health of the woman. Additionally, bottle feeding is easier to do, and while research does state that easier availability and long working hours for the mothers can act as obstacles for breastfeeding, acknowledging other pertinent key elements in the birthing process, like postpartum depression, aids in developing a solution (Rathaur et al. 50).

Conducting a cross-sectional, transnational study on Uttarakhand can foster critical questioning that is lacking within the field. I hope that this research will allow individuals who are not as informed or who are interested in this topic to learn more and ask follow-up questions. I aim to amplify the need to study women holistically. Mortality rates for women and their neonates are increasing in Uttarakhand, transcending issues just within healthcare: a multifaceted perspective must be taken to further understand limited research, resources, and care. On a personal level, compiling data through the feminist lens has further opened my eyes to the polarity in healthcare worldwide. By doing this, my overall goal is to safeguard the women and neonates of Uttarakhand, giving them the proper supplies and attention they deserve.

3. FEMINIST THEORY STATEMENT 

Integral to understanding the lack of research surrounding maternal and neonatal healthcare is an analysis through the perspective of transnational feminism. Transnational feminist theorist Chandra Mohanty suggests that feminism without borders is, “[…] feminism without silences and exclusion in order to draw attention to the tension between the simultaneous plurality and narrowness of borders and the emancipatory potential of crossing through, with, and over these borders in our everyday lives” (Mohanty 2).

This approach emphasizes intersectionality, interdisciplinary studies, activism, justice, and collaboration. Diverse forms of agency and resistance are also central to what it means to study a topic through a transnational feminist lens. Whether a solution is proposed by a local grassroots organization, a local government, or the federal government, all are important in the contribution made to furthering a cause. With this framework, I can engage in bridging medicine, the human body, and customs in a way that centralizes marginalized groups. To accomplish this, research must be done with a mixture of quantitative and qualitative evidence. Transnational feminism provides critical approaches to analyzing and describing the data collected, and where to look for possible interventions. With this theory, I am not bound to one location. Looking to other states in India or comparing what other post-colonial countries have done emphasizes the recognition of the diversity of gender experience without border restriction (Zerbe Enns et al. 16). 

4. METHODOLOGY 

This review utilized existing quantitative and qualitative studies to identify factors that contribute to the underrepresentation of populations in Uttarakhand. Quantitative literature focused on experimental design, relying on surveys and cross-sectional analyses. Hospital and government records were considered to serve as primary Indian documentation. Qualitative literature included evidence from grassroots organizations in rural areas of India, not just in Uttarakhand. Interview-based reports by freelance journalists, albeit not many, were also examined to reveal gaps that are not based on generalizability or captured in broader studies. By integrating both data collection methodologies, this review synthesized a diverse selection of solutions such as implementing Maternal Waiting Homes and diversifying research approaches to uncover the sources of inequitable care for women and infants in Uttarakhand, India.

5. ANALYSIS

The geography of the state is mountainous, rugged, and extremely steep, and as such, it informs agriculture, which is also affected by the environment. There are three types of agroecosystems, all of which are important to the sustainability of the populations living in the state, including mountainous ranges, rainfed hilly areas, and plain/valleys (see Fig. 1; Rana and Bisht 3).

Fig. 1: The three agricultural ecosystems that the people of Uttarakhand utilize. Reproduced unchanged from Rana and Bisht, p.8816, under CC BY 4.0. 

Many women are the primary food crop producers on farms in Uttarakhand, so when the environment changes, agriculture feels its effects, as do the women (Rana and Bisht 10).  Depending on the level of education, social network, and institutional support, coping mechanisms and strategies following seasonal changes directly impact farm livelihood (Pundir et al. 13). Women of higher socioeconomic status adopted long-term strategies that relied on agricultural technological innovations and diversification, while women of lower socioeconomic status resorted to short-term mechanisms (Pundir et al. 14; Najjar et al. 9). Barriers to accessing resources ostracize a community of women relying on agricultural produce to keep their families afloat. 

During the summer, the monsoon season approaches, indicative of torrential downpours and causing landslides. After the monsoon season comes the snow, which exacerbates transportation issues in and out of the state, as roads are already extremely narrow and winding. These conditions are highly dangerous for expectant mothers to get the proper care needed, especially for high-risk pregnancies. Neonatal care is also delayed by environmental changes. So, despite the need, these conditions have made it less likely that biomedical facilities will be set up in this landscape. When the crops die, both mothers and babies do not receive proper nutrition, feeding into malnutrition as a long-term consequence. This quickly becomes a ripple effect that endangers well-being.

Traditional practices and sterile medical practices do not fully align in Uttarakhand, India. However, preserving culture is crucial, as colonization has stripped those freedoms and rights from the Indian population. India is a country full of vibrancy and culture, with each state having its own traditions, celebrations, and belief systems. The arrival of British colonial powers, though, altered the path of growth India has undergone. The British Raj devalued Indian women’s work, including the traditional practices in the birthing process. Medical missionaries brought over Christian values that would cleanse the “savage” birth attendants, dhais, of their influence in maternal and neonatal practices (Guha 4). Inherent in this behavior is the erasure of Indian midwifery as a practice and the framing of dais as harmful to the caregiving system they directly impact. The Indian healthcare system needed to assimilate to colonial powers, not solely because Western practices were deemed safer, but to feed into labor. Imperial rule also transformed and intensified the patriarchy, such as Brahmanical rule, in modern India (Najar 668). A caste-system-led society helps inform gender inequality that posits boys above girls. Inheritance rules often favor brothers over sisters, with property law for women severely underdeveloped (Coffey et al. 1985). These values work together to promote female feticide and socially devalue Uttarakhandi women’s decision-making abilities (Patel 239). As a result, household structure can dictate maternal nutrition. Intrahousehold ranking, such as the daughter-in-law of the youngest son ranking lower than the daughter-in-law of the oldest son, in a combined household is linked to poor infant growth. Lower-ranking mothers also had statistically lower BMIs and were more likely to be underweight than higher-ranking mothers (Coffey et al. 1997). With abandoned cultural customs from pre-colonial India and the evolution of tradition in a post-colonial India, maternal and neonatal health in Uttarakhand cannot be understood solely through the lens of biomedical care. 

To further analyze the discrepancies between culture and safe medical practices, a culturally competent lens is foundational. Researchers must ask questions about whether traditions truly equate to safe medicine. In many regions of India, kajal is utilized to keep evil eye away from the baby (Saxena et al. 160). It is traditionally placed on the waterline of the eye, which can introduce infections and allow opportunistic pathogens to enter and proliferate in the neonate's body. Truly eliminating this cultural practice takes away a part of a rich history, so instead, I recommend that mothers put kajal on the baby's thigh or behind the ear, as my mother did for me as I grew up, so bacteria are not as readily introduced to the infant microbiome. 

In Almora, Uttarakhand, new mother Suman Devi was sent 1-2 kilometers away for three weeks to bathe herself as she was deemed impure (Thapa). Labeling a mother, who went through a possibly hard pregnancy and birth, as “impure” is not conducive to stable mental or physical health (Thapa). Devi and her baby being away from each other is harmful. Many studies have statistically shown the importance of breastfeeding within the first few hours of the baby's life, so this separation breaks the vertical transfer of nutrients and immunity (Devi et al. 54).

Similarly, there is a lack of obstetric emergency services and home-based practices being spread in communities. Approximately 13.66 percent of mothers did not receive advice from Accredited Social Health Activists (ASHA) on hand hygiene, eye care, colostrum feeding, exclusive breastfeeding, and diaper rash care (Devi et al. 53). This is a huge dilemma as home-based practices affect both the quality of life for the mother and the neonate. During the intranatal period, women who cannot reach hospitals or facilities often give birth in sheds. Mortality rates, consequently, become aggravated because of the absence of education programs and proper emergency services. Education of the birth attendants themselves can differ drastically, compounding the mortality rates; 87 percent of traditional birth attendants do not wash their hands after helping a mother give birth (Saxena et al. 158). Antiseptic techniques need to be practiced thoroughly, but it is nearly impossible to do so in these remote areas where clean water or soap may be unavailable. Sterile fields break throughout this whole process, marking both the mother and their infant for ill-treatment after the first patient. 

Indian feminist papers have shattered the monolithic narrative by exploring fieldwork methodology and questioning the default of feminism in indigenous tribal practices (Mohapatra 90; Maya 2). Papers that spotlight Indian women tend to primarily focus on one state within the country. Even so, the absence of women's voices throughout this research process was astounding. Qualitative data that emphasizes the plight of Indian women is lacking, but BehanBox, an independent, women-led online organization focused on gender journalism, is proactive in analyzing data and amplifying underrepresented communities. The space that BehanBox creates must also be reflected by making women more than subjects of research. I argue that different methodologies can be employed to counter ineffective documentation that spotlights Uttarakhandi women. Longitudinal studies that follow mothers and their neonates over a period of specified time before and after intervention are underused. Long-term research not only shows the longevity of practices but also points to safer, appropriate initiatives. Additionally, Photovoice, which visually captures the topic of interest through photographs, can be applied by researchers as well (Jaksch 2). This type of methodology reaches a larger, broader, more inclusive audience to cause discourse on the topic of healthcare in Uttarakhand. Interviewing the women directly about their birthing experience would be highly beneficial in terms of qualitative science. While Social Autopsy (SA) and Verbal Autopsy (VA) were utilized in research through interviewing the closest contact to the mother, interviews with the mothers have rarely been done (Baqui et al. 707). Open-ended questions, instead of surveys, would allow women to give honest answers. If they continue to be silenced into submission by a healthcare system that is set up to fail them, maternal and neonatal health outcomes will only become worse. To truly understand the intersectionality behind healthcare in Uttarakhand, pregnant women need to be placed at the forefront.

Rather than treating Western or Global North models of maternal and neonatal healthcare as the only solution, a transnational feminist framework recognizes that feminism is “situated,” while also highlighting that interconnected issues can produce alliance-building across borders (Zerbe Enns et al. 16). By challenging the stance that global hierarchy should dictate solutions, this framework acknowledges that marginalized countries, states, and places are also producers of knowledge, instead of recipients of help from those in power. In countries with comparable challenges to the state of Uttarakhand, feminist reproductive justice advocates contributed to the development of unique interventions. The advent of Birthing Houses (BHs), also referred to as Maternal Waiting Homes (MWHs), in countries across the globe is a direct result of community-based efforts to address difficulties in safe birthing options. BHs can house and provide for women during the last weeks of their pregnancy, sometimes requiring referral from healthcare providers. In Nicaragua, Casa Materna is a dedicated MWH serving pregnant mothers located in rural areas (Casa Materna). Perinatal death rates were significantly lower in a meta-analysis study, with 1.30 percent of MWH births resulting in perinatal death compared to 10.4 percent of non-MWH births (Smith et al. 5).  Although these outcomes demonstrate the potential of BHs, their effectiveness cannot be separated from the contexts in which they operate. In rural Zambia, while MWHs have reported positive results, they also showed that women who did have access did not utilize them due to dependence on husbands for decision-making and the poor state of MWHs (Sialubanje et al. 10). Among the different countries where BHs were implemented, it is still imperative to consider whether women have the autonomy to access and benefit from them. 

Interestingly, an article was published stating that BHs were allowed by the government to be placed in Uttarakhand (The Print). However, I have found no follow-up studies to see if the facilities were placed, utilized, or effective. This gap is particularly notable, as it could be a factor contributing to maternal and neonatal mortality rates. The sustainability of the MWHs, like the studies on Nicaragua and Zambia, needs to be completed, specifically with interviews from Uttarakhandi women who were housed or have utilized the resources from this program. Ultimately, these findings have longstanding implications not only for women and children, but for communities as a whole. 

6. CONCLUSION 

In this paper, I have bridged the gap in knowledge between two essential questions:  Why are women and their children in Uttarakhand, India, decentered and experiencing high mortality rates, and what transnational feminist interventions can be taken for both groups' betterment? A transnational feminist framework has aided me in understanding the discrepancy in maternal and neonatal healthcare and in determining possible interventions to implement in Uttarakhand to reduce mortality rates. I provide plausible answers to both questions through the overarching lens of intersectionality. 

The limitations of this research include a lack of in-person interviews with Uttarakhandi women. I would love to know if these topics are being taught in schools and what gaps in knowledge could be supplemented. School is fundamental to fostering lifelong passions in children, so interventions must be put in place to introduce healthcare through an intersectional lens to all students, regardless of gender, sex, orientation, caste, or social class. Interventions can start with education and blossom to form intra-community and inter-community dynamics that are beneficial to Uttarakhand. Women act as the backbone for progression, so the high mortality rates for them and their children, in conjunction with their exclusion, should be challenged.

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