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"Sen, Gita"
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The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress
Despite increasing evidence about the value and importance of breastfeeding, less than half of the world's infants and young children (aged 0–36 months) are breastfed as recommended. This Series paper examines the social, political, and economic reasons for this problem. First, this paper highlights the power of the commercial milk formula (CMF) industry to commodify the feeding of infants and young children; influence policy at both national and international levels in ways that grow and sustain CMF markets; and externalise the social, environmental, and economic costs of CMF. Second, this paper examines how breastfeeding is undermined by economic policies and systems that ignore the value of care work by women, including breastfeeding, and by the inadequacy of maternity rights protection across the world, especially for poorer women. Third, this paper presents three reasons why health systems often do not provide adequate breastfeeding protection, promotion, and support. These reasons are the gendered and biomedical power systems that deny women-centred and culturally appropriate care; the economic and ideological factors that accept, and even encourage, commercial influence and conflicts of interest; and the fiscal and economic policies that leave governments with insufficient funds to adequately protect, promote, and support breastfeeding. We outline six sets of wide-ranging social, political, and economic reforms required to overcome these deeply embedded commercial and structural barriers to breastfeeding.
Journal Article
When accountability meets power: realizing sexual and reproductive health and rights
This paper addresses a critical concern in realizing sexual and reproductive health and rights through policies and programs – the relationship between power and accountability. We examine accountability strategies for sexual and reproductive health and rights through the lens of power so that we might better understand and assess their actual working. Power often derives from deep structural inequalities, but also seeps into norms and beliefs, into what we ‘know’ as truth, and what we believe about the world and about ourselves within it. Power legitimizes hierarchy and authority, and manufactures consent. Its capillary action causes it to spread into every corner and social extremity, but also sets up the possibility of challenge and contestation.
Using illustrative examples, we show that in some contexts accountability strategies may confront and transform adverse power relationships. In other contexts, power relations may be more resistant to change, giving rise to contestation, accommodation, negotiation or even subversion of the goals of accountability strategies. This raises an important question about measurement. How is one to assess the achievements of accountability strategies, given the shifting sands on which they are implemented?
We argue that power-focused realist evaluations are needed that address four sets of questions about: i) the dimensions and sources of power that an accountability strategy confronts; ii) how power is built into the artefacts of the strategy – its objectives, rules, procedures, financing methods inter alia; iii) what incentives, disincentives and norms for behavior are set up by the interplay of the above; and iv) their consequences for the outcomes of the accountability strategy. We illustrate this approach through examples of performance, social and legal accountability strategies.
Journal Article
Role of practical medical training in the provision of respectful intrapartum care: insights from two large public teaching hospitals in Southern India
Background
For over a decade, the maternal health discourse has focused on a phenomenon that is alternatively termed “obstetric violence,” “disrespect and abuse” (D&A) or the “mistreatment of women” in institutional obstetric care. The search for what drives D&A includes questions around the role of medical education in shaping not just what doctors know, but how they learn to treat women as well. However, medical education as an additional pathway to D&A is under-studied. We explore how one aspect of medical education– practical medical training during internships and residencies– operate in labour rooms in public teaching hospitals.
Methodology
We conducted 37 semi-structured in-depth interviews with a cross-section of obstetric care providers representing all cadres of two large public teaching hospitals in a south Indian city. We coded the interview transcripts thematically, examined themes related to teaching and learning, and considered their implications for Respectful Maternity Care (RMC).
Results
We identified four pathways through which practical medical training had implications for RMC: (a) professional hierarchies and social hierarchies; (b) institutional and educational prioritization of clinical outcomes over respectful care; (c) limited presence and supervision by senior providers in labour rooms; and (d) teaching responsibilities primarily falling on inexperienced and overworked peers. The results suggest that ad-hoc teaching adaptations prompted students to rely on informal learning, which fostered an obstetric practice which runs counter to the principles of RMC.
Conclusion
Reforms in practical medical training, particularly with regard to intrapartum care in resource-constrained public hospital settings, can help in the realization of RMC.
Journal Article
How power and knowledge hierarchies affect communication in intrapartum care: findings from public health facilities in two southern Indian districts
Background
Effective communication is a key element of medical care; it can foster a warm interpersonal relationship, facilitate the exchange of information, and enable shared decision-making. In the context of obstetric care, it is associated with a range of positive clinical and social outcomes for mother and baby. Extant communication frameworks and respectful maternity care (RMC) guidelines emphasize the importance of effective communication during intrapartum care. Yet, studies conducted in Indian public health settings suggest that there are gaps in the implementation of RMC guidelines.
Methods
As part of a larger study on disrespect and abuse in Indian public hospitals, we studied the nature of communication in the intrapartum context and the extent to which it is respectful. The study is based on interviews with 29 providers across different levels of public health facilities. Interviews were translated, transcribed, and thematically coded. We examined codes related to communication to understand what kinds of communication occur during intrapartum care and the role played by knowledge and power hierarchies. We then considered their implications for RMC.
Results
We identified four types of communication that occurred in the context of intrapartum care: (a) compassionate, to comfort and support the laboring woman, (b) factual, to obtain or provide information or updates, (c) prescriptive, to obtain consent and cooperation from the woman and her family members, and (d) defensive, to protect against accusations of poor care. Knowledge and power hierarchies operated differently in each type of communication, with prescriptive and defensive communication more likely to be disrespectful than others.
Conclusions
Our findings suggest that successful implementation of RMC guidelines requires greater attention to knowledge and power hierarchies, and an understanding of the ways in which they operate in a clinical setting. Integrating this understanding into guidelines, medical education, training programmes, and interventions will facilitate effective and respectful communication during maternity care.
Journal Article
Priorities for Research on Equity and Health: Towards an Equity-Focused Health Research Agenda
Summary Points * Based on extensive review of global evidence, the recommendations of the WHO Commission on Social Determinants of Health highlight the need for strengthening research on health equity with a focus on social determinants of health. * To do so requires a paradigm shift that explicitly addresses social, political, and economic processes that influence population health; this shift is under way and complements existing research in medicine, the life sciences, and public health. * Reflecting further synthesis and stakeholder consultations, an agenda for future research on health equity is outlined in four distinct yet interrelated areas: (1) global factors and processes that affect health equity; (2) structures and processes that differentially affect people's chances to be healthy within a given society; (3) health system factors that affect health equity; and (4) policies and interventions to reduce health inequity. * Influencing regional and national research priorities on equity and health and their implementation requires joint efforts towards creating a critical mass of researchers, expanding collaborations and networks, and refining norms and standards, with WHO having an important role given recent mandates. Appropriate resources will further enable intensive efforts across WHO to integrate reduction of health inequities into national and regional research agendas and enable the WHO secretariat to facilitate Member States' requests related to resolution 62.14 [1]. (d) Ensuring that norms and standards for the monitoring and assessment of health inequalities on multiple dimensions including class, gender, age, and ethnicity are updated and used in the course of data gathering, statistical analysis, and dissemination to support countries in their efforts and wider global monitoring.
Journal Article
Addressing social determinants of health inequities: what can the state and civil society do?
In this Health Policy article, we selected and reviewed evidence synthesised by nine knowledge networks established by WHO to support the Commission on the Social Determinants of Health. We have indicated the part that national governments and civil society can play in reducing health inequity. Government action can take three forms: (1) as provider or guarantor of human rights and essential services; (2) as facilitator of policy frameworks that provide the basis for equitable health improvement; and (3) as gatherer and monitor of data about their populations in ways that generate health information about mortality and morbidity and data about health equity. We use examples from the knowledge networks to illustrate some of the options governments have in fulfilling this role. Civil society takes many forms: here, we have used examples of community groups and social movements. Governments and civil society can have important positive roles in addressing health inequity if political will exists.
Journal Article
Beyond measurement: the drivers of disrespect and abuse in obstetric care
Concerns about disrespect and abuse (D&A) experienced by women during institutional birth have become critical to the discourse on maternal health. The rapid growth of the field from diverse points of origin has given rise to multiple and, at times, confusing interpretations of D&A, pointing to the need for greater clarity in the concepts themselves. Furthermore, attention to measurement of the problem has been excessive when viewed in relation to the small amount of work on critical drivers of disrespect and abuse. This paper raises some key issues of conceptualisation and measurement for the field, puts forward a working definition, and explores two critical drivers of D&A - intersecting social and economic inequality, and the institutional structures and processes that frame the practice of obstetric care. By identifying gaps and raising questions about the deeper causes of D&A, we point to potentially fruitful directions for research and action.
Journal Article