Gender and Power: Autonomous Choice in Peruvian Health Delivery
Health disparities disproportionally affect poor women in the highlands of northern Peru. This is not due to a higher susceptibility to illness and disease; rather, social dynamics between males and females, and how resources are provided to each gender, heavily affect how women receive health care and make choices about their health. Before examining this situation in the context of my experience in the Peruvian consult room, I think it's important to provide brief background information on a major health concern in Peru, maternal mortality, which will inform the social analysis that will follow.
The Social Determinant of Maternal Mortality
Globally, reducing maternal mortality rates in developing countries is a top priority for leading global health organizations, as it appears fifth on the list of Millennium Development Goals (MDGs) to be reached by 2015. Although Peru is considered a middle-income nation as a result of the economic growth that took place in the 1990s, the rate of maternal mortality has historically been unusually high, only in the past two years decreasing to a "passable" figure (67 deaths/100,000 live births) that is close to the MDG standard of 65 deaths/100,000 live births. Scholars of global health and professionals in international development contemplated why the rate was so difficult to lower, despite the rapid modernization of the country's infrastructure after the civil war. A theory of gender stratification explained that maternal mortality is correlated to women's social status and autonomy, and thus will be higher in societies where women are valued less. Suggested solutions include increasing access to health services and education of how to reduce reproductive risk factors. However, the simplification of such a significant problem, as the suggested answers imply, ignores intangible factors like gender relations. Female autonomy cannot be quantified, and as such the best way to improving it is not obvious.
Autonomy in Context
Female autonomy is defined as the ability to make choices and decisions within the household relative to their husbands (Anderson and Eswaran 2009: 179). Academic literature on the topic of female autonomy has identified major determinants of female autonomy and the direction in which they should be changed to improve women's social status. From a universalist perspective, traditional cultures from disparate geographic locales adhere to a social structure headed by males and regenerated by females. However, females carry additional roles of maintaining the home and contributing to family income, even among the poorest of families. Interestingly, it is not the type of employment that necessarily determines autonomy, but rather the location of her work--namely, whether or not it is outside of her husband's home (if she is married). Numerous case studies suggest that obtaining work outside of the home increases a woman's decision-making power and control over her resources (Anderson and Eswaran 2009: 179). This type of learned behavior is disseminated not only for socioeconomic household resources, but it can also be transferred to health decisions.
I observed a few interactions between patients and their superiors that indicated a lack of autonomous choice on the part of the female patient. Among both the old and the young, male relatives who accompanied the female patients on their doctor visit spoke for her when the doctor directed a question to the female patient. I watched entire consults where there may have been only one direct verbal communication between the female patient and her doctor, in the form of a "sí o no" question, only after the male relative had failed to answer the question himself. In some cases, women who were not accompanied by their husband or male relative still deferred to him in her answer when asked questions regarding health choices relating only to the woman herself. Such widespread behavior among this particular demographic of poor women exemplifies the power imbalance between genders. It seemed so ingrained, so accepted in the thought process of these women, from family planning to pregnancy and childbirth.
The Social Determinant of Maternal Mortality
Globally, reducing maternal mortality rates in developing countries is a top priority for leading global health organizations, as it appears fifth on the list of Millennium Development Goals (MDGs) to be reached by 2015. Although Peru is considered a middle-income nation as a result of the economic growth that took place in the 1990s, the rate of maternal mortality has historically been unusually high, only in the past two years decreasing to a "passable" figure (67 deaths/100,000 live births) that is close to the MDG standard of 65 deaths/100,000 live births. Scholars of global health and professionals in international development contemplated why the rate was so difficult to lower, despite the rapid modernization of the country's infrastructure after the civil war. A theory of gender stratification explained that maternal mortality is correlated to women's social status and autonomy, and thus will be higher in societies where women are valued less. Suggested solutions include increasing access to health services and education of how to reduce reproductive risk factors. However, the simplification of such a significant problem, as the suggested answers imply, ignores intangible factors like gender relations. Female autonomy cannot be quantified, and as such the best way to improving it is not obvious.
Autonomy in Context
Female autonomy is defined as the ability to make choices and decisions within the household relative to their husbands (Anderson and Eswaran 2009: 179). Academic literature on the topic of female autonomy has identified major determinants of female autonomy and the direction in which they should be changed to improve women's social status. From a universalist perspective, traditional cultures from disparate geographic locales adhere to a social structure headed by males and regenerated by females. However, females carry additional roles of maintaining the home and contributing to family income, even among the poorest of families. Interestingly, it is not the type of employment that necessarily determines autonomy, but rather the location of her work--namely, whether or not it is outside of her husband's home (if she is married). Numerous case studies suggest that obtaining work outside of the home increases a woman's decision-making power and control over her resources (Anderson and Eswaran 2009: 179). This type of learned behavior is disseminated not only for socioeconomic household resources, but it can also be transferred to health decisions.
I observed a few interactions between patients and their superiors that indicated a lack of autonomous choice on the part of the female patient. Among both the old and the young, male relatives who accompanied the female patients on their doctor visit spoke for her when the doctor directed a question to the female patient. I watched entire consults where there may have been only one direct verbal communication between the female patient and her doctor, in the form of a "sí o no" question, only after the male relative had failed to answer the question himself. In some cases, women who were not accompanied by their husband or male relative still deferred to him in her answer when asked questions regarding health choices relating only to the woman herself. Such widespread behavior among this particular demographic of poor women exemplifies the power imbalance between genders. It seemed so ingrained, so accepted in the thought process of these women, from family planning to pregnancy and childbirth.
Autonomy and Reproductive Risk
Pregnancy and childbirth were two maternal health stages where women were given the opportunity to make the most informed decisions relating to their own health, as well as the health of their unborn child. Depending on her socioeconomic background, however, a pregnant woman had varying levels of expressing a lack of control over her journey to giving birth. I'll present two anecdotes of childbirth from two socioeconomically distinct women to illustrate this point.
On my first day working at Puesto de Salud Ramón Castilla, I had the opportunity to be involved in a home birth in a remote hillside home outside of the city. It was an unexpected home birth, as the obstetrician I shadowed had planned to bring the pregnant woman down from the inaccessible casa to the flatter road, where she could be transported to the health post for her birth. However, because nature never follows anyone's plans precisely, the obstetrician delivered a healthy baby girl on the dirt floor of the family's home. The pregnant woman had minor complications at the end of the delivery to the extent that the Puesto de Salud staff wished to bring her back to the health post to keep watch over her condition. However, the woman refused to give her consent, and stayed in her home. Only after hesitantly exchanging a few words with her husband did she give her negative reply, and the obstetrician remarked to me that she had wanted to come but her husband dismissed the idea, because modern hospitals were believed to expose the privacy of rural women, both physically and psychologically.
A week later, I was on rotation with the obstetrician at EsSalud, who had a pregnant patient come in for a late-second-trimester checkup and ultrasound. This patient was a schoolteacher, and her husband was also employed. The doctor saw that the fetus growing too high in the womb, and if it did not lower in the coming weeks, the woman would have to undergo C-section in order to protect her health. While C-sections are common in American obstetrics, in my rural Peruvian hospital, they were viewed as the less-desirable second option for birthing. This woman supported this viewpoint with her own response: she worriedly asked if there was something she could do to help the baby move lower and explained her husband's strong opinion against C-section delivery. I was astounded to see the same behaviors expressed in slightly different ways, but nonetheless it was clear that autonomous decisions about major health events, like pregnancy and childbirth, were completely absent. Doctors (mainly females) added that these behaviors were exhibited when determining contraceptive use and birth and obstetric emergencies as well, demonstrating the scope of the devaluation of women's power and knowledge of what was best for their own health.