Fertility, Health and Reproductive Politics

Re-imagining Rights in India

Maya Unnithan

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429878763
• Edition: 1
• Topic: Social Sciences
• Subtopic: Regional Studies
• Index: Social Sciences

Set in the context of the processes and practices of human reproduction and reproductive health in Northern India, this book examines the institutional exercise of power by the state, caste and kin groups.

Drawing on ethnographic research over the past eighteen years among poor Hindu and Muslim communities in Rajasthan and among development and health actors in the state, this book contributes to developing analytic perspectives on reproductive practice, agency and the body-self as particular and novel sites of a vital power and politic. Rajasthan has been among the poorest states in the country with high levels of maternal and infant mortality and morbidity. The author closely examines how social and economic inequalities are produced and sustained in discursive and on the ground contexts of family-making, how authoritative knowledge and power in the domain of childbirth is exercised across a landscape of development institutions, how maternal health becomes a category of citizenship, how health-seeking is socially and emotionally determined and political in nature, how the health sector operates as a biopolitical system, and how diverse moral claims over the fertile, infertile and reproductive body-self are asserted, contested and often realised.

A compelling analysis, this book offers both new empirical data and new theoretical insights. It draws together the practices, experiences and discourse on fertility and reproduction (childbirth, infertility, loss) in Northern India into an overarching analytical framework on power and gender politics. It will be of interest to academics in the fields of medical anthropology, medical sociology, public health, gender studies, human rights and sociolegal studies, and South Asian studies.

1 Fertile subjects

Global reproductive politics at the intersections of caste, class and gender

It is 4 a.m. in one of the biggest kacchi basti (informal settlements) in Jaipur city and Sunila is in the last stages of labour. She is on a paper covered mat on the floor of her parent’s single room tenement. It was over an hour ago that she had been rushed in a taxi to the house of a ‘nurse’ who works in the Jain hospital 2–3 kilometres away. She was ill and so, Vimlesh, Sunila’s mother brought her back to the basti and hurried to get nurse Suman who lives down the galli (lane) from her. There is an urgency as mothers of pregnant women do not attend to any birth work themselves, as it is embarrassing and inappropriate. As Vimlesh explains, her main task as a mother is to let the nurse attending to her daughter have the things (samaan) she needs. Chhoti, a close friend from the basti, is also called to help out while Nila, Sunila’s twin sister, is sent off to another friend’s place with their younger brother Suraj, who is twelve years old. Sunila’s father, Goga, is away as he works as a nightwatchman (chowkidar), but Nila keeps him informed by mobile phone.

This is Sunila’s second child and it comes quickly, shortly after nurse Suman arrives. Vimlesh tells her daughter to himmat rakh (keep courage) and so she does not cry out (I am told no one in the basti came to know she had given birth that morning!). According to Vimlesh, the nurse takes her ‘beepee’ (blood pressure; English abbreviation used), administers a dard vali sui (injection of the labour enhancing drug, oxytocin) and massages Sunila’s abdomen with mustard oil. Shortly afterwards she ‘catches the child’, while the placenta (olnal) comes out in a further contraction (olnal dusri dard mein aa gayi). It is a girl. The nurse cuts the cord (nala) with scissors she has brought in her box. She ties the cord with a sacred red and yellow thread provided by Vimlesh, cleans the baby with mustard oil, wraps her in 2–3 cloths, and gives her to Vimlesh to hold. The floor is wiped (by now Nila is back and helps clear everything up). The placenta is thrown in the rubbish heap (kachra mein), although if it had been a boy it would have been buried at the threshold. The nurse is paid Rs2,000/- for her akeli mehnat (handling the birthwork on her own). Sunila’s husband (admi) is back in the village and is informed much later in the morning.

(Fieldnotes, Jaipur 2016)

The baby is Vimlesh’s second grandchild. Her first grandchild (Sunila’s son Ayush who is just over four years old) was born at the same private hospital where she had her son in 2003; she tells me that a number of women from the basti go there for the birth of their children. Although she adds, ‘we had only gone there for a consultation but then her daughter Sunila’s pains started and the nurse and doctor ‘told them to stay’. We ended up paying Rs4,500/- … this was four years ago (although when we had Suraj, my son, there twelve years ago we were charged 2,500/-.)’

As we talk, I am reminded of the time that has passed since I first met Vimlesh over eighteen years ago, when I had two young children myself and her twin girls, Sunila and Nila, were nine-years-old. It was a time marked by her increasingly desperate attempts to conceive again, with visits to faith healers of different kinds and private biomedical practitioners. She gave birth to her son Suraj 3 years later and we had marked the occasion with celebrations. Ten years later I had the opportunity in 2013 to witness her shift in social status from becoming a mother (jaccha) to becoming a maternal grandmother (nani).

I ask Vimlesh to help me reflect on the changes related to having babies over this time as I know her experiences embody the tremendous shifts that have taken place in the way the residents of informal settlements (a term I find preferable to ‘slum’), villagers and migrants have experienced childbearing and birth in Rajasthan between 1998 and 2013. In this book I use her reflections as a migrant labourer and kacchi basti resident along with the accounts of other longterm respondents such as Zahida, who is a Sunni Nagori woman living in the peri-urban margins of Jaipur city in Rajasthan, to discuss how poor families negotiate shifting institutional control over their fertility and reproductive bodies.

The dominant experiences of change which emerge from the reproductive narratives of long-term informants such as Vimlesh and Zahida, and their husbands Goga and Rafique, highlight new forms of community (caste, class and religious) engagement with the state, the selective but increasing use of public health institutions, the continued resort to faith healers as well as permanent forms of contraception, and the rise in prosperity among the peri-urban poor as compared to the urban poor. I examine these issues in the following chapters in terms of the views and practices of different sets of actors who also inhabit their world: state and non-state development actors, medical and legal professionals and health and rights activists. The reproductive politics which emerges through all these accounts is framed by highly pluralistic as well as increasingly rights-based and global, market-oriented contexts in which healthcare is provided and health systems planned.

The aim of this book, overall, is to demonstrate in ethnographic detail the unique theoretical lens provided by the concept of reproductive politics to look at the diffusion of global norms such as reproductive rights and justice and what these mean for the poor in northern India. It moves us beyond an understanding of state effects to examine how changes in global ideas about reproductive health have led to changes in the functioning of the Indian State and the implications these have for institutional practices and related individual experiences of birth, health and social reproduction. In this book we consider how, through the ‘fertile body’, people experience, accommodate and challenge the simultaneous controls of caste, kin and state institutions. Equally, we learn about the changing practices of these institutions and the actors themselves. In an era of unprecedented economic and communication-based globalisation and increasingly pervasive rights-based development paradigms, the politics of the fertile, reproductive body in India provides critical insight into what concepts, such as modernity, development, equality, citizenship, health rights and social justice, come to mean in practice.

A sustained and grounded analysis of the politics of procreation, which is not just about family planning and population control in understanding social change, has been lacking in India where political theory on state-power has primarily focused on the building of modern institutions and processes in terms of political office, political parties and coalitions, elections and voting, and on development actors dis-embedded from reproductive politics. While the connection between formal political actors and the institutions of caste and kinship has been the subject of academic analyses, less focus has been placed on the gendered and sexed body as a subject of sustained political inquiry. In its focus on changing living and marriage patterns, the decoupling of marriage from child-bearing and increasing acceptance of non-marital births, fertility postponement, increased voluntary childlessness and the refusal to have undesired children, the Second Demographic Transition (SDT) theory is of importance as it takes into account the shifting social, economic and technological landscape affecting fertility and family behaviour, unlike the classic demographic transition theory before it (Zaidi and Morgan, 2017).¹ This renewed demographic theorising has engendered a process of critical reflection on individual autonomy and self-actualisation as being neither gender, context (historical and social), nor power neutral concepts in the times we live in. Yet, like the previous demographic transition theory it continues to assume similar processes and patterns of change across time, places and cultures (Zaidi and Morgan, 2017, p. 484).

The core argument made through the chapters in this book is about how existing and emerging forms of regulation of the fertile and reproductive body (reproductive governance) is understood through an interpretive lens, notably through the experiences of childbearing, infertility, contraception and loss. An emic focus on the politics of fertility, conception and childbearing provides a ‘thick’ understanding of the gendered and class dimensions of power as biopower and agency (as reproductive agency). With its focus on human reproduction, the chapters in this book take us into the intimate, moral and experiential worlds where power is mediated and negotiated within and across the household, family, kin group, civil society, development planning and policy arenas, health, medical, and legal systems both within the state and transnationally. Reproductive politics, a concept I develop throughout this book, combines the gendered struggles over the body (as a physical, social and discursive entity) and wo/manhood in the interrelated worlds of families, policymakers, state bureaucrats, legal, medical and health professionals and practitioners, as well as in civil society contexts in India. I suggest that reproductive politics is understood through the ways in which it is embodied and negotiated, especially by women who find their identities deeply entangled with motherhood and, simultaneously, symbolic of family continuity and state development goals. Reproductive politics is equally about men but, in contrast, revolves around their absence in conceptions of the reproductive within familial and state policy discourse. In their mediation and ‘translation’ of health rights, development actors and health workers, whether as men or women, midwives or nurses, or as members of health-related civil society organisations are critical to the performance of reproductive politics in that they broker experiences of citizenship and of reproduction and health as interrelated domains of power.

As the ethnography of the everyday contexts of people’s sexual and reproductive lives in the book makes clear, the boundary between localised, centralised and more transnational forms of power is not clear-cut: state and non-state (kin and civil society based) institutions are experienced as simultaneously benevolent and coercive, welfare oriented and regulatory. Here, power is conceptualised not only in a negative sense, as against individual freedom, but also as positive and supportive of individual freedom.² This dual aspect of power emerges in respondent accounts in this book in both a negative (class and gender, discriminatory and exclusionary) sense but also as a positive force of change at different levels and in different times (e.g. the beneficial aspects of state health sector restructuring, the widening provision of services, the access to ‘free’ diagnostics and drugs, the economic benefits of cash incentives attached to maternal healthcare schemes, or even as the individual freedom from reproductive and household labour entailed in the transition from motherhood to grandmotherhood).

Women’s accounts of childbearing, as we learn in the following chapters, are not simply ones of birth and family planning (from the spacing of children to the termination of fertility) but, equally, those of infant loss and often about the anxieties and realities (physiological, emotional and social) of infertility. In Rajasthan, northwestern India, where the ethnography is situated, we find that the fear of infertility affects all childbearing women irrespective of the number of offspring they have born. A focus on the infertile body, in particular, makes visible a politics which remains absent in more general political theorisations on the state and political processes of citizenship, democracy and belonging in India. The absence of any official statistics on infertility reveals the unimportance of the issue in matters of health planning. Given that it is the poor who more frequently experience conditions of secondary sterility, widely prevalent in Rajasthan (aggravated by the lack of access to quality health services), suggests that health inequities are systemically embedded as well as reproduced within governance practice. Paying attention to infertility in the context of a state obsessed with fertility regulation provides critical insight into the processes of structural violence (Farmer, 1998; Das et al., 2001), whereby forms of governance come to reproduce specific forms of reproductive stratification (Browner and Sargent, 2011; Inhorn and Van Balen, 2002; Ginsburg and Rapp, 1995).

The trope of fertility-infertility also provides a distinctive lens by which to view the complex power dynamics across state and communities; wherein women experience their communities as coercive (with an attendant social pressure to bear children to propagate the kin line, especially sons) and the state as distant and uncaring, reflected in the almost non-existent provision of assisted procreative services offered in government health centres. That a large proportion of women and men resort to faith and religious healers to address child loss and infertility speaks to a subjecthood formed in the act of fulfilling community and family, rather than state, expectation of reproductive duties and obligations. It also suggests the significance of examining the self as constituted through reproductive success or failure, and what body-self connections come to mean and how they operate in practice.

Anthropological and feminist work on gender and the ‘body’ has provided a critical, intersectional understanding of reproductive politics as experiential, lived, enacted, and of the reproductive body as simultaneously subject and object, within and beyond the material body and as caught in d...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Table of Contents
• List of figures
• Preface and acknowledgements
• List of acronyms
• 1 Fertile subjects: global reproductive politics at the intersections of caste, class and gender
• 2 State empowerment and reproductive control
• 3 Infertility and other reproductive anxieties: an ontological challenge to ‘reproductive health’ and ‘rights’
• 4 Sex selective abortion and reproductive morality: technology and the discourse on rights
• 5 Maternal risk and its mediation: learning from health worker vulnerabilities
• 6 Altruism and the politics of legislating reproductive labour: why surrogacy matters
• 7 Making rights real: legal activism and social accountability
• 8 Re-imagining rights: reproductive politics and the quest for justice
• Epilogue: the politics of measurement and the meaning of evidence
• Glossary
• Index