How Fertility Preferences Are Killing Women In India
Pregnancy can exacerbate pre existing health conditions such as heart disease, diabetes, autoimmune conditions and cancer. But even women in vulnerable health are often pressured to conceive, especially if they have yet to deliver a son
It was a rainy afternoon when Rajamani (name changed) walked into my room in the OPD of a Vellore hospital. She had been previously admitted to our hospital with APLA (antiphospholipid antibody syndrome), a genetically transmitted, potentially fatal disease where the body produces blood clots in many organs.
In the ICU, her heart had stopped for some time due to a clot and she had several clots in other organs as well. She was discharged when she recovered after prolonged treatment and was put on multiple medications. A few weeks later she was back at the clinic.
“I need you to give me a certificate that says I can still bear a child,” she said to my horror. I warned her that having a baby right after being so sick is not advisable. “Well doctor, what else can I do? My first child is a girl and my husband is threatening to leave me if I cannot bear him a boy child,” she said.
This is a very common occurrence in India, said Sangeetha A, an anaesthesia resident in Manipal Hospital Bangalore. “I remember a woman with severe heart disease who got pregnant four times just to get a male baby. It is very high risk to do so and with each pregnancy, her life span reduces by several years. Everyone in her family, including her, knows that.”
A research paper published in the Journal of Development Economics in 2018, studied the effects of son preference on the mortality of adult women from the pooled data of the National Family Health Surveys 1, 2 and 3. The study found that women whose firstborn was a girl were likely to live for a shorter span than those who birthed a male child first. It also showed that the prevalence of anaemia was higher in women whose first born was a girl.
The study hypothesised that these health effects can be traced to poor fertility behaviours among women such as trying for a higher number of children in the hope of a son and having multiple children in a short interval of time if their first child was a daughter.
A follow-up published in 2020 in Ideas for India tried to measure whether son preference was the causative factor for lower survival rate and anaemia among women whose firstborn was a girl. This study analysed data from 74 countries with various levels of son preference and measured it against maternal health conditions. It found that son preference leading to bad fertility behaviours also leads to far-reaching consequences for women in terms of sickness and early death.
While the data talks about healthy women who are coerced into pregnancies that are bad for their health for various reasons – inadequate spacing or frequent pregnancies, for example – a closer look reveals that this behaviour also extends to women for whom childbirth can have serious consequences for their health.
Pressure From Families, Natal And Marital
It is not just in marital homes that women are pressured to make bad health choices, said a rheumatology resident from south India who did not wish to be named. “In my experience, many women who have had illnesses diagnosed before marriage have also faced such pressures from their birth family,” she said. “I have treated patients whose parents hide the fact that their child is sick to get her married off. Some of them take medications secretly, but most of them just stop coming for treatment. The woman eventually gets pregnant and the illness flares up. They seek treatment when the disease turns severe and difficult to treat.”
Sometimes the diagnosis is made after the woman has gotten married and lived in her husband’s home for a while. “During that time, especially with autoimmune conditions – which cannot be completely treated, just controlled – we try to tell the relatives to plan the pregnancy only long after the disease is controlled. Nobody takes it well. Most women end up coming back pregnant despite their disease not being under control,” the doctor added.
Subhasri Balakrishnan, a public health activist and researcher, pointed out that medical professionals treat a miscarriage or a stillbirth as a pregnancy and advise the woman to wait a year or two, regain their health, and only then try and conceive again.
“But many of these women will be pressured by their families to get pregnant as soon as possible because of the fear of being childless. Some studies have shown that the birth interval decreases significantly when the preceding birth is a stillbirth. This puts women at risk of entering into a pregnancy with sub-optimal health, a decision that could impact her health for years to come,” Subashri said.
Risking Life For Marital Security
“Most of the time, the women themselves want a child despite the threat to their lives,” said Alfia Kaki, a general medicine consultant based in Hyderabad. It is a very complicated place to be in. “I remember a patient crying to me saying, ‘If I do not have a child, I will be either abandoned by my husband or he will bring another woman into our home. I feel that trying for a baby and dying is better than either of those options’.”
There is also a widespread pervasive thought that women do not become a part of their husband’s family till they bear his child, preferably a son, said Alfia. “My patients complain to me that they do not have a say in anything that happens in their home because they are still viewed as outsiders. They believe that once they have a child, all that might change.”
In areas with poor healthcare, women might opt to have more children at risk to their health because they do not know how many will survive, said Roshine Koshy, an internal medicine consultant working in Makunda Christian Hospital in Assam.
“The biggest public health lesson I learnt was when I was working in rural Jharkhand. I was chiding a woman for getting pregnant immediately after having her first child and she asked me whether I could give her a 100% guarantee that any of her children would survive to adulthood. In that case, it does not matter whether a woman has an illness that can be worsened by multiple pregnancies because she needs to maximise the odds of her children surviving by having more of them,” Roshine said.
Some patients are also unaware that existing medical conditions need more intense treatment during pregnancy. “They keep saying she was doing well with minimal medications before pregnancy,” said Alfia.
It is a known fact that pregnancy can exacerbate pre existing conditions such as heart disease, diabetes, autoimmune conditions and cancer. There are some illnesses in which getting pregnant is a death sentence and in some others, such as diabetes, even if the disease itself does not worsen, pregnancy can predispose the woman to complications such as blindness. This is due to a phenomenon called diabetic retinopathy whose ability to harm sight becomes accelerated due to pregnancy.
“Just because pregnancy is undergone by almost one half the population, people have the wrong idea that it is easy and uncomplicated. This is very far from the truth,” said Alfia.
How Much Is A Woman’s Life Worth?
How much is a woman’s life worth? To herself? To her family? And society at large? The answer varies, often at a cost to a woman’s life.
“Unfortunately, I have heard of family members in life-threatening situations asking doctors to save the child instead of the mother,” said Roshine. This is more common in rural areas where polygamy is accepted. “Family members, especially from the marital home, tell doctors to save the baby and justify it saying the man can easily get another bride.”
Medical guidelines, however, always mention that doctors must save the mother first and most doctors try their best to abide by these. “We were conducting studies to look at the causes of maternal mortality in Central India,” says Subhasri. “So as a part of that, we would go to houses where there has been a maternal death to conduct a verbal autopsy (the act of putting together the cause of death by investigating the sequence of events as recounted by people) after two or three months of the occurrence. What shocked me was that there already was a second wife in many of these houses by that time. When asked about it, people almost always justify it saying they need someone to look after the house and the small children.”
Alfia recalled the case of a mother with sickle cell anaemia (a genetic blood condition) admitted to her hospital for the last few months of her pregnancy because she kept having terrible episodes of her condition worsening – also known as a sickle cell crisis – throughout the third trimester.
“She wanted the baby, so we tried our best to support her, but we could not save her. Eventually, we found that the relatives had thrown her body into a flowing water body on the way from the hospital. They did not even take her home. It became a huge issue with the government tracing it back to our hospital and we had to call the family back. But it broke my heart to know that all they cared about was her ability to give them a child,” the doctor said.
The concept of Indian motherhood seems to be built upon the foundation of a woman sacrificing her entire personhood (and sometimes her life) for that of her child. And movies and the media also glorify this idea.
Reproductive Empowerment
“One would think that this happens only to women with no agency, but that’s not true,” says Subhasri. “What I have noticed in all these years of working on this is that women who are successful in other spheres of life, even women community leaders do not have much of a say when it comes to their own sexual and reproductive lives.”
Parents want their daughters to go out and have professional and academic achievements but also be “family-oriented”. Marital homes too want a daughter-in-law who earns and can contribute financially but never forgets her primary role as the ‘adarsh bahu (ideal daughter-n-law)’. All this denies her reproductive freedom and agency.
A study shows that only 9% of women with college degrees get to choose their life partners but this falls to 2.2% when it comes to women who are not educated. This shows how even educated women do not have much of a choice in who they procreate with, much less when and how much. The use of women’s bodies and reproductive capacity to maintain social structures such as caste, religion and societal hierarchies remain rampant.
Education and employment do not automatically award women with bodily autonomy, said Subhasri. “We need to have conversations focused on fostering women’s ownership of their bodies with not just the women but also families and communities at large. Other stakeholders in public health such as doctors, nurses, allied health services as well as policymakers too need to be involved in this conversation.”
Media campaigns must emphasise women’s worth is not tied to their ability to produce children. And marriage must shift to being a strong relationship wherein husbands and marital homes prioritise women’s welfare. Data on women’s reproductive intentions and the barriers to achieving them must also be included in policy reforms.
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