Access to maternal healthcare services eludes poor Gujarat women of all caste groups

By Rajiv Shah 
A Swedish International Development Cooperation Agency (SIDA)-sponsored study has found strong discrimination against poorer sections of women -- irrespective of whether they belong to scheduled caste (SC), scheduled tribe (T) or general category -- in the delivery of maternal health care services in Gujarat.
Titled "Inequity in maternal health care service utilization in Gujarat: analyses of district-level health survey data", and authored by scholars Deepak Saxena,Ruchi Vangani, Dileep V. Mavalankar and Sarah Thomsen, the study says, "Women who were poor among the ‘other’ caste category were 5.65 times less likely to use antenatal care (ANC) services than the non-poor in the same caste category. Poor women belonging to an ST were 5.32 times less likely to use ANC services than the non-poor advantaged groups. Similarly, women in the poor SC category were 5.1 times less likely to utilize ANC services than the non-poor ‘others’."
The scholars say, "There were no differences between the poor in the different caste groups. However, there was evidence of effects on ANC use due to caste status among the non-poor. Women belonging to an ST, but not poor, were 2.37 times less likely to use ANC services than the non-poor advantaged groups (‘other caste’)." Nor did they find any rural-urban divide in the non-delivery of health services to the poor mothers. They underline, "Being poor was also associated with less utilization of ANC services irrespective of the place of residence. Rural poor and urban poor were 5.22 and 5.19 times less likely to utilize the ANC services respectively in comparison to the urban non-poor."
The study comments, "Two decades after the launch of the Safe Motherhood campaign, India still accounts for at least a quarter of maternal death globally. Gujarat is one of the most economically developed states of India, but progress in the social sector has not been commensurate with economic growth." It adds, "Inequities in maternal health care utilization persist in Gujarat. Structural determinants like caste group, wealth, and education were all significantly associated with access to the minimum three antenatal care visits, institutional deliveries, and use of any modern method of contraceptive. There is a significant relationship between being poor and access to less utilization of ANC services independent of caste category or residence."
The study further says, "Poverty is the most important determinant of non-use of maternal health services in Gujarat. In addition, social position (i.e. caste) has a strong independent effect on maternal health service use. More focused and targeted efforts towards these disadvantaged groups needs to be taken at policy level in order to achieve targets and goals laid out as per the MDGs. In particular, the Government of Gujarat should invest more in basic education and infrastructural development to begin to remove the structural causes of non-use of maternal health services."
In fact, the scholars say that a major reason for Gujarat's economic development is its geographical advantage. "Strategically located on the West Coast of India, Gujarat is also a gateway to the rich land-locked northern and central parts of the country. Because of its location on the coast, Gujarat also has access to all major port-based countries, including the United Kingdom, Australia, China, Japan, Korea, and the Gulf countries", they insist.
Coming to the maternal mortality rate (MMR), the study says, "The MMR in Gujarat is estimated to be 148 per 100,000 live births. This is favorable in relation to the India-wide rate of 200. Though Gujarat is an industrially developed state, the MMR of Gujarat is relatively high compared to the states of Tamil Nadu (97/100,000) and Kerala (MMR 8/100,000), whose per capita income is less than Gujarat."
It adds, "In addition, given the disparities in socio-economic measures within the state, and the above-stated importance of these variables in determining maternal health, it is likely that there are significant differences in maternal health outcomes between different population groups within the state. Furthermore, the interaction between structural determinants such as education, caste and income make it difficult for policymakers to identify where the greatest gaps remain in achieving MDG 5, and reducing health inequities, in Gujarat."
The scholars' findings suggest that "women who are urban, literate, wealthier, younger, ever-married at 18 or above use services more than their rural, illiterate, older, and ever-married younger counterparts. Over 80% of urban women are delivering in institutions. Similarly, over 80% of the non-poor attended at least three ANC visits (the recommended minimum in India) during their last pregnancy. Educational levels also show an apparent ‘dose-response’ relationship with use of all maternal health services studied here. That is, the more education one has, the more likely one is to use ANC, institutional delivery, and modern methods of contraception."
They add, "What is significant for policymakers to note here is that the high levels of use among the wealthy, urban, and educated women indicate what is possible to achieve in Gujarat. Furthermore, our study results show that there are fewer disparities in access to family planning services amongst the disadvantaged populations. This also begs the question ‘what are the family planning programs doing right that other maternal health programs are not?’ It also indicates that it should be possible to reach the poor and disadvantaged classes with other maternal health services."