Rethinking the Paternal Role in Maternal and Child Health in Bihar

20140427_123903A rather vexing observation that we made while out on field work in Saharsa(Bihar), was that fathers seem to be having a rather limited role with respect to the care of the woman during her pregnancy. My initial response to this was that of irritation, it felt like a travesty that the women go through so much pain, even risking loss of life, whereas the men are seemingly oblivious to all of this.

However, as we ended up spending more time out in the field, it became increasingly clear that a big cause for the rather hands-off attitude amongst fathers was that they occupy deeply gendered spaces within the family. These are spaces wherein the man is judged (rather weakly in some circumstances) on his ability to feed the family, whereas the woman is judged (rather harshly in most instances) on her ability to have children, and more importantly male children to carry the family name forward. During an interview with a father in Saharsa, I happened to ask him why it is predominantly the women who take the child for immunization. His reasoning was that the child cries when the injection is given, and so the woman is best equipped to handle the situation. This was an opinion that is fairly consistent with how front line workers view immunization, as being a task that is primarily the responsibility of the women of the family. At present the expectation from the father is restricted to the provision of money for the delivery, whereas critical decisions for the health of the woman (such as choosing when to leave for the facility during labour, migrating to a private facility due to medical complications) are all decisions that the women of the family are being overburdened with, all because ‘pregnancy’ as a topic is often relegated to the space of the feminine. In many instances of medical complications, when the man has to choose whether the delivery is a caesarean operation right away or whether to wait, he often has to depend upon his family members’ reading of the situation. In many instances this reading is coloured by mistrust of the intentions of the front line band in seeking to conduct a caesarean section. Interviews with both FLWs and beneficiary families brought out this point, with some families alleging that this medical recommendation (of going for a caesarean section) can often be influenced with a bribe. FLWs have in fact claimed that a delay in obtaining consent (because of families not trusting medical advice) is a critical cause of child mortality in Saharsa in Bihar. In some instances the decisions to defer the caesarean section operation is taken by the mother in law, who bases her decision on her own subjective experiences of childbirth and her reading of the condition of the woman. The man of the family is effectively air dropped into decision making at this point (since getting a caesarean operation has financial ramifications). The father’s role in this point is effectively to take sides, often not knowing whether to go against the better judgement of his mother or follow her advice (which at times is at odds with the medical advice given in the hospital). What certainly doesn’t help matters is that in most cases the father has nothing but a superficial understanding of the need for the procedure (as a result of which even financial arrangements are often not taken care of beforehand). The system needs to deliberate a little harder on its expectations from the father over the course of the thousand day window. This then needs to feed back into how systems, interactions and spaces are designed in order to better involve the father (of the unborn child) in the provision of care giving for his wife. The father, as the position of authority in the family, is someone who can be a powerful medium of change, especially if the public health system desires to shift the onus of care and well being of the mother and the child back to the family. At present however, this is sadly not the case. The existing system is designed basing itself on the presumption that the father doesn’t care, and ends up functioning on the assumption that it is not his responsibility anyways. One step towards doing this is to enable our spaces of care to graduate towards becoming gender neutral. It might be a far stretch to expect that from labour rooms in rural India (although it is now happening in many urban hospitals around the world), but whether our routine immunization sites can be redesigned in a manner that encourages men to be more involved during the 1000 day window (if not for the sake of the woman, but at the very least for the sake of the child) is a proposition worth considering. It is important to encourage the father to be involved in critical decision making, at more critical points of the 1000 day window, partly because his social standing within the community (as the head of the family) empowers him to pre-empt as well as negate some of the ill-advised decisions that are often made for the mother in the interests of the family. The public health system, while succeeding in ensuring behaviour change in some aspects (such as institutional delivery), is struggling to initiate behaviour change in other aspects of the 1000 day window (for example, leaving the house for the facility at the earliest possible time during labor), because the man is deemed as not having enough awareness or knowledge about pregnancy and the needs of the woman during delivery. At present the men only take control of the care of the woman over the 1000 day window when they experience the death of the child (either due to the absence of idealized care during the pregnancy, or due to the negligence of the front line workers). Do we really need to wait for the death of a child or the mother to act as the trigger for paternal involvement? Can this predicament not be avoided by ensuring greater engagement with the father in the provision of care for the woman?

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