RELS 131
Hinduism Module Podcast Transcript
Caste and Maternal Health

Hi everyone,

Let’s talk about caste in India. In particular I want to discuss the relationship between caste and women’s health, but first let’s review what the caste system is.

The module notes for the Hinduism unit only briefly mention the caste system, and only in its historical and textual context. The same goes for your textbook. The notes offer a brief summary of how Hinduism, through the Vedas, codified a stratified social system, whereby (male) members of Hindu society (more on women to come) were divided into four distinct social classes. The first is the Brahmin caste, the highest social group made up traditionally of Brahmin priests who could perform rituals and teach the meaning of the Vedas. The next caste is the Kshatriya, traditionally the warriors and rulers. The third caste is the Vaishyas, who make up the mercantile class, those who deal with business and trade. Finally, the Shudras, or servants, make up the final caste. The first three castes the Brahmins, Kshatriyas, and Vaisyas make up the upper classes in this system, and are sometimes to referred to as Twice-Born, because the male children in these castes take part in an initiation ritual in which they are reborn into the caste of their fathers. The Shudras are the lowest caste and do not take part in this ceremony. All of these castes are outlined through a divine creation from Purusha, a Hindu primordial cosmic man who dismembered himself to create the human race. So this caste system is divinely entrenched in three thousand year old sacred literature.

There is also fifth caste, beyond Purusha’s creation, which consists of people labelled as untouchable or Dalits. This group consists of people relegated to doing jobs that are considered polluting or impure, such as dealing with garbage, corpses, or human waste. This group of people has long faced discrimination and abuse from people of other castes. Caste was abolished by the Indian government in 1950, however the social disabilities imposed by caste onto the Dalits continues today, particularly in rural Indian communities. Dalits are often forced to live outside of established communities, are barred from being in contact with other castes, were until recently banned from Hindu temples, underwent forced segregation in schools, and have suffered violent clashes and attacks with individuals from upper castes.

Some background: in addition to religion scholarship, I am trained in midwifery practice (and care passionately about maternal health). I thought this topic was a great way to integrate both interests and consider for a moment a contemporary impact of the caste system in India. Forgive me if I get technical for a few minutes, if only to clear up some details about what is involved with measuring maternal mortality.

Pregnancy and childbirth is not a sickness or disease, however, medical intervention can help to both prevent and treat certain complications. It is a human right that that no woman should die from pregnancy-related causes. The term maternal mortality refers to the death of a woman during pregnancy (from pregnancy-related causes), birth, or in the immediate postpartum period. Another term, maternal morbidity, refers to when a woman suffers injury, infection, or disabilities as a result of pregnancy, birth, or in the postpartum. Maternal mortality is most commonly the result of hemorrhage, which is when the bleeding after the birth of a baby cannot be stopped; hypertension, where a women’s blood pressure rises so high that it can eventually shut down internal organs; and infections. All three of these conditions can be prevented or treated through simple procedures during prenatal care or care during the birth. Postpartum hemorrhage, for example, can often be prevented with a single dose of a medicines called oxytocics, through an injection in the woman’s thigh moments after the birth of the baby, or with a host of other medicines, also given in doses after the birth, that control the bleeding. The beginnings of hypertension can be discovered through regular blood pressure checks throughout pregnancy, and if necessary, can be treated with medication until the pregnancy is complete. Infection, of course, can be treated with antibiotics at various stages of pregnancy and childbirth.

I wanted to outline these complications of pregnancy to highlight how these types of medical interventions often do not require access to extensive medical services. Yet according to the World Health Organization (WHO), every day in 2017 approximately 810 women died from preventable causes related to pregnancy and childbirth. 94% of maternal deaths occur in middle and low-income countries, primarily in Africa and South Asia. To be sure, the maternal mortality rate has dropped 38% worldwide between2000-2017. And while more economically advantaged countries such as the United States have a lower maternal mortality rate comparatively, there remains serious challenges, such as the maternal mortality rate being higher for African Americans. In fact, the U.S. has the highest maternal mortality in the developed world. The problem of maternal mortality is not exclusive to a country such as India.

That said, there are serious problems in India when it comes to equitable access to maternal healthcare. Approximately 177,000 maternal deaths occur in India each year, representing almost one quarter of maternal deaths worldwide (which is roughly one maternal death every five minutes). In India there are sharp regional and socioeconomic divides in health outcomes, with lower castes and less developed states bearing the brunt of mortality. Women born in lower castes are especially likely to lack access to quality healthcare, especially in Northern, central, and eastern parts of the country. While there are government programs aimed at providing care to individuals regardless of caste, only the richest of these lower castes benefit. Dalits especially, for reasons we will get into, are missing out on necessary healthcare when it comes to pregnancy and childbirth. They face discrimination on the account of the believed pollution that occurs when upper-caste healthcare providers face in the intimate care of pregnant bodies and in lack of education. Dalit women who live in rural parts of the country do not access the necessary and often preventative medicine they require.

India is both economically strong and technically advanced, however it is plagued with inequality and poverty. Even given the drop in the maternal mortality rate since 2000, estimates of progress cannot mask the fact that poor and caste-marginalized women are suffering maternal mortality at rates far higher than the national average. In a 2008 study called Caste and Maternal Health Care Service Use Among Rural Hindu Women in Maitha, Uttar Pradesh, India, which is one of the poorest states in India, the authors identified that fewer lower-caste women receive maternal healthcare services compared to upper-caste women in the same community. This study is particularly telling when it comes to identifying the kind of preventative maternal healthcare that could prevent so many deaths. The study considers four areas of healthcare that all women ought to have access to: regular prenatal care (at least one visit per trimester), iron folate supplements (which are necessary to prevent anemia and for the developing spinal cord of the fetus), a skilled attendant to be present at birth (and in this study a skilled attendant included a nurse or doctor), and access to the tetanus vaccine. Overall, use of these healthcare services was found to be low in this community. However, when looked at through the lens of caste, the authors found that there was a significant divide between upper and lower-caste women. While 20% of upper-caste women accessed prenatal care, only 8 % of lower-caste women did; and upper-caste women were five times more likely to deliver their babies with a skilled attendant than lower-caste women! And I quote: “Even after adjusting for significant sociodemographic variables, caste was found to be a strong determinant of tetanus toxoid use and the presence of trained birth attendants, indicating that the lower-caste women were less likely to benefit from these highly subsidized maternal healthcare services compared to upper-caste women” end quote.

There are more than a few things going on here. Let’s return for a moment to the issue of caste that we began with. As the untouchables beyond the boundaries of the Vedic caste system, Dalits were prohibited from participating in India social life and were not to be touched, seen, or approached. Even as caste was officially outlawed in the country, the distinctions and discrimination continued. For example, in a study entitled Caste Matters: Perceived Discrimination Among Women in Rural India, the authors found that of the 565 villages studied, across 11 states, 33% have public health workers who refuse to enter lower caste homes, 73% do not allow lower-caste individuals to enter their homes, and 40% of lower caste children are segregated in schools. The believed pollution of the Dalits, combined with long-standing perspective that birth is also polluting (on account of the blood that is naturally a part of any birth), means that lower-caste women, Dalits in particular, suffer disproportionate levels of discrimination that leads to an increase in maternal mortality.

Because the delivery of maternal healthcare involves the socially prohibited physical contact between the two caste groups (since most nurses and doctors are from the upper-castes), upper caste healthcare providers prefer to cater to upper-caste women and lower-caste women choose to seek care from the traditional birth attendants to avoid the embarrassment of caste discrimination. An interesting example from the earlier study of Uttar Pradesh found that the only form of maternal healthcare that wasn’t divided by caste was iron folate supplementation. Why? It seems that because this supplementation is simply a pill, there was no physical contact involved.

Before I finish up, one word about the distinction between the lower-caste traditional birth attendants and the upper-caste medically trained birth attendants. Labelling the lower-caste attendants as traditional is not meant to dismiss their work. For centuries and centuries women have given birth with the help of these women and their traditions of knowledge. But what these traditional attendants do not often have is training and access to medical support, such as oxytocics or medications of hypertension. Maternal mortality can be improved with this kind of support.

Caste is clearly a barrier to maternal healthcare service use. How can we use what we’ve learned about Hinduism thus far to contextualize this issue?

Last updated: 6/3/2020 By KA

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