Jones, Eleri
(2015)
Care-seeking for birth in urban India.
PhD thesis, London School of Economics and Political Science.
Abstract
The thesis examines care-seeking for first births in low-income settlements of urban India. Care-seeking is framed as a dynamic, social process. The thesis shifts the research focus from non-use of maternity services to a more holistic notion of care-seeking strategies, and examines how they are shaped by patterned social relationships and their content.
The study combines a prospective, qualitative design with multiple household perspectives. Seventy-seven in-depth interviews were conducted in 16 households. Matched data were collected for primiparous women and other household members, and interviews were conducted prospectively during pregnancy with a follow-up after birth. The study was conducted in Indore, a large city in the central Indian state of Madhya Pradesh, where a range of maternity care providers operate in a complex urban health system.
This population could be characterised as strategic care-seekers, aware and discriminating across the range of care options available. Managing perceived risks was central to strategies, but solutions differed due to variation in perceptions of risks and their management. The notion that childbirth requires medical management was dominant. Yet, health facilities were also regarded as a potential source of risk. Strategies were plural and contingent, combining different providers across and within sectors, giving households control and flexibility in dealing with unfolding circumstances.
Local narratives apportion responsibility for care-seeking to the household in which the woman is staying for the birth. The value placed locally on household-level ‘responsibility’ contrasts with the focus on women’s autonomy in the literature on maternal health. A corollary of responsibility is blame in the event of an adverse outcome, which impels households to seek care that meets expectations among their social ties.
The thesis generates new insight on an issue that has previously been examined largely with static approaches, underpinned by individual rational actor assumptions. Findings reveal care-seeking strategies that go beyond a decision on whether or not to use a health facility. This partly derives from a complex urban health system providing choice, but it is also a response to the challenges households face in negotiating the health system
to receive care they perceive to be ‘safe.’ The findings have implications for the policy goals of increasing births with a skilled attendant and improving quality of care.
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