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The caste system is a complex social stratification system which has been abolished, but remains deeply ingrained in India. Scheduled Caste (SC) women are one of the historically deprived groups, as reflected in poor maternal health outcomes and low utilisation of maternal healthcare services. Key government schemes introduced in 2005 mean healthcare-associated costs should now be far less of a deterrent. This paper examines the factors contributing to this low use of maternal health services by investigating the perceptions, health-seeking behaviours and access of SC women to maternal healthcare services in Bihar, India. Eighteen in-depth, semi-structured interviews were conducted with SC women in Bihar. Data were analysed using Framework Analysis and presented using the AAAQ Toolbox. Main facilitating factors included the introduction of accredited social health activists (ASHAs), free maternal health services, the Janani Shishu Suraksha Karyakram (JSSK), and changes in the cultural acceptability of institutional delivery. Main barriers included inadequate ASHA coverage, poor information access, transport costs and unauthorised charges to SC women from healthcare staff. SC women in Bihar may be inequitably served by maternal health services, and in some cases may face specific discrimination. Recommendations to improve SC service utilisation include research into the improvement of postnatal care, reducing unauthorised payments to healthcare staff and improvements to the ASHA programme. [ABSTRACT FROM AUTHOR]

The high rate of maternal mortality in India is of grave concern. Poor rural Indian women are most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the public sector combined with financial barriers to accessing private sector obstetrician services preclude this underserved population from availing lifesaving functions of comprehensive EmOC such as C-section. In order to overcome this limitation, Government of Gujarat initiated a unique public–private partnership program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY, private sector providers render obstetric care services to poor women at no cost to patients. This paper examines the CY's effectiveness in improving availability of CEmOC services between 2006 and 2012 in three districts of Gujarat, India. Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10 was used to analyze the availability of services using two-step floating catchment area (2SFCA) method. Our analysis suggests that the availability of CEmOC services within reasonable travel distance has greatly improved in all three study districts as a result of CY. We also show that the declining participation of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a comprehensive understanding of trends in the availability of EmOC services within reasonable travel distance. This paper demonstrates how GIS could be useful for evaluating programs especially those focusing on improving availability and geographic accessibility. The study also shows usefulness of GIS for programmatic planning, particularly for optimizing resource allocation. [ABSTRACT FROM AUTHOR]

The struggle for reproductive self-determination has specific significance for women and girls in India, where a maternal death occurs every five minutes. This paper analyses the role litigation played in seeking redress for violations of the reproductive rights of Shanti Devi, who died in childbirth in 2010 in Haryana state, and some of the socio-economic, cultural, political and legal factors involved. It provides a brief overview of India's national and international obligations with regard to maternal health, and through the lens of the litigation in Shanti Devi's case, it examines how the government failed to protect, respect and fulfill her right to life and health. Litigation can be used to ensure accountability in further cases by building on case law, informing communities about these decisions and their rights, and holding government accountable at local, state and central level. Litigation also has limits, most importantly due to people's lack of awareness of their rights and entitlements, the lack of government outreach programmes informing them of these, and the lack of accountability mechanisms within health programmes when they are not transparent or functioning effectively. Thus, although constitutional justice is an important tool for democratic progress and social change, social justice will only be achieved through broader social struggle. La lutte pour l'autodétermination génésique revêt une importance particulière pour les femmes et les filles en Inde, où un décès maternel se produit toutes les cinq minutes. Cet article analyse le rôle joué par le procès intenté pour demander réparation des violations des droits génésiques de Shanti Devi, morte en couches en 2010 dans l'État d'Haryana, et certains facteurs socio-économiques, culturels, politiques et juridiques en jeu. Il décrit brièvement les obligations nationales et internationales de l'Inde dans le domaine de la santé maternelle, et s'agissant de l'affaire Shanti Devi, il examine comment les autorités ont été incapables de protéger, de respecter et de réaliser le droit à la vie et à la santé de cette femme. Les poursuites peuvent permettre de garantir la responsabilisation dans de nouveaux cas en se fondant sur la jurisprudence, d'informer les communautés de ces décisions et de leurs droits, et de demander des comptes aux autorités locales, étatiques et centrales. L'action en justice a aussi ses limites, en particulier du fait de la méconnaissance de ses droits par la population, de l'absence de programmes officiels de vulgarisation qui informent la population de ces droits et du manque de mécanismes de responsabilisation dans les programmes de santé, quand ils ne sont pas transparents ou ne fonctionnent pas efficacement. Par conséquent, si la justice constitutionnelle est un outil important pour le progrès démocratique et le changement social, seule une lutte sociale élargie apportera la justice sociale. La lucha por la autodeterminación reproductiva tiene un significado específico para las mujeres y niñas en India, donde ocurre una muerte materna cada cinco minutos. En este artículo se analiza el rol que desempeñó el litigio para buscar reparo por violaciones de los derechos reproductivos de Shanti Devi, quien falleció en el parto, en el 2010, en el estado de Haryana, así como algunos de los factores socioeconómicos, culturales, políticos y jurídicos implicados. Se expone un resumen conciso de las obligaciones nacionales e internacionales de la India con respecto a la salud materna, y a través de la lente del litigio en el caso de Shanti Devi, se examina el incumplimiento del gobierno en proteger, respetar y realizar su derecho a la vida y la salud. El litigio se puede utilizar para garantizar responsabilidad en otros casos basándose en jurisprudencia, para informar a las comunidades sobre estas decisiones y sus derechos, y para hacer al gobierno responsable a nivel local, estatal y central. Pero el litigio tiene límites, principalmente debido a que las personas no son conscientes de sus derechos, a la falta de programas gubernamentales de extensión a las comunidades para informarlas de estos derechos, y a la falta de mecanismos de responsabilidad en los programas de salud, cuando no son transparentes o no funcionan eficazmente. Por lo tanto, aunque la justicia constitucional es una herramienta importante para los avances democráticos y el cambio social, la justicia social se alcanzará solo por medio de la lucha social. [ABSTRACT FROM AUTHOR]

The majority of maternal health interventions in India focus on increasing institutional deliveries to reduce maternal mortality, typically by incentivising village health workers to register births and making conditional cash transfers to mothers for hospital births. Based on over 15 months of ethnographically informed fieldwork conducted between 2015 and 2017 in rural Assam, the Indian state with the highest recorded rate of maternal deaths, we find that while there has been an expansion in institutional deliveries, the experience of childbirth in government facilities is characterised by obstetric violence. Poor and indigenous women who disproportionately use state facilities report both tangible and symbolic violence including iatrogenic procedures such as episiotomies, in some instances done without anaesthesia, improper pelvic examinations, beating and verbal abuse during labour, with sometimes the shouting directed at accompanying relatives. While the expansion of institutional deliveries and access to emergency obstetric care is likely to reduce maternal mortality, in the absence of humane care during labour, institutional deliveries will continue to be characterised by the paradox of "safe" births (defined as simply reducing maternal deaths) and the deployment of violent practices during labour, underscoring the unequal and complex relationship between the bodies of the poor and reproductive governance. [ABSTRACT FROM AUTHOR]

Despite the avoidable nature of maternal mortality, unacceptably high numbers of maternal deaths occur in developing countries. Considering its preventability, maternal mortality is being increasingly recognised as a human rights issue. Integration of a human rights perspective in maternal health programmes could contribute positively in eliminating avertable maternal deaths. This study was conducted to explore socio-cultural and service delivery–related dimensions of maternal deaths in rural central India using a human rights lens. Social autopsies were conducted for 22 maternal deaths during 2011 in Khargone district in central India. The data were analysed using thematic analysis. The factors associated with maternal deaths were classified by using the 'three delays' framework and were examined by using a human rights lens. All 22 women tried to access medical assistance, but various factors delayed their access to appropriate care. The underestimation of the severity of complications by family members, gender inequity, and perceptions of low-quality delivery services delayed decisions to seek care. Transportation problems and care seeking at multiple facilities delayed reaching appropriate health facilities. Negligence by health staff and unavailability of blood and emergency obstetric care services delayed receiving adequate care after reaching a health facility. The study highlighted various socio-cultural and service delivery–related factors which are violating women's human rights and resulting in maternal deaths in rural central India. This study highlights that, despite the health system's conscious effort to improve maternal health, normative elements of a human rights approach to maternal health (i.e. availability, accessibility, acceptability, and quality of maternal health services) were not upheld. The data and analysis suggest that the deceased women and their relatives were unable to claim their entitlements and that the duty bearers were not successful in meeting their obligations. Based on the findings of our study, we conclude that to prevent maternal deaths, further concentrated efforts are required for better community education, women's empowerment, and health systems strengthening to provide appropriate and timely services, including emergency obstetric care, with good quality. [ABSTRACT FROM AUTHOR]