Structural Violence, Agency and Justice: The Maternal Health Experience of Vulnerable Women in Sri Ganganagar, Rajasthan, India

Abstract

This thesis explores the maternal health experience of vulnerable women in Sri Ganganagar, Rajasthan, India. Chapter one uses a biosocial lens to describe how structural violence is embodied as elevated risk during pregnancy, and how inequality and injustice persist despite India’s economic growth and vibrant democracy. I describe how violence in India is perpetrated though bureaucratic indifference, biopower, and an inequality of articulation and attention regarding the plight of the poor. I hypothesize that these mechanisms of violence extend to health programs, including Janani Suraksha Yojana (JSY), a conditional cash transfer program, and the National Health Mission (NHM), which are meant to improve antenatal care (ANC) and facility-based delivery (FBD) coverage for the poor. Using existing health statistics I describe how a narrative of success is constructed that, while reflecting real progress, may deepen and entrench the suffering of vulnerable women, as illustrated by two case studies of women served by the Mata Jai Kaur Maternal and Child Health Centre (MJK), a local non-profit. In chapter two, I “re-socialize” the statistical narrative by linking ethnography, epidemiology, and implementation in the context of MJK’s programs. A novel application of Lot Quality Assurance Sampling (LQAS) that combines qualitative and quantitative questions and a sampling frame that targets the most vulnerable households is developed. I follow LQAS with in-depth interviews of healthcare providers and “positive outliers” (women in low coverage areas who have sought and received ANC and FBD). 313 women were surveyed in 18 communities, and nine of 27 positive outliers were interviewed in follow-up. Quantitative results confirmed improvement related to FBD coverage, which was 90.8% compared to government estimates of 84.2% in 2012. ANC coverage remained low at 13.1%. Qualitative and ethnographic data revealed three themes that provided depth to the quantitative findings: 1) Swastha (agency); 2) hidden violence; and 3) women’s worth and sex-preference. Despite the successes of NHM/JSY, ethnographic and qualitative results show how the programs are inherently regressive and serve to entrench suffering for low-income mothers. I conclude by reflecting on the efficacy of the novel methodology and study design.