Beyond Purdah: Understanding the Barriers Indian Muslim Women Face in Accessing and Utilizing Maternal Health Services

Economic inequalities between various religious groups in India reveal important healthcare utilization patterns as highlighted by Das and colleagues.¹ Using the NFHS-3 (2005-06) data, the researchers highlight that 31.1% of Muslims felt maternal healthcare was too expensive, relative to 25.1% for Hindus overall. This is corroborated by national findings that 43% of Muslims live below the poverty line,¹³ and evidence from NFHS data that consistently indicate that women in poorer and the poorest wealth quintiles tend to be overrepresented by Muslim women relative to other religious groups.¹⁴ It is likely that hundreds of Muslim families face financial barriers to affording healthcare, especially to pay for hefty payments in private facilities where the quality of care is often better in urban areas, and which are perceived to be better equipped to deal with pregnancy complications.^{14, 15}

Das et al. also note that another contributing factor of underutilization is that the likelihood of husbands not allowing women to have an institutional delivery is 2.7% higher for Muslims than Hindus, but they fail to comment on another important one of their findings possibly driving this- Muslims were 1.78 times more likely to report not trusting health facilities relative to Hindus.¹ Qualitative findings, such as the three-year ethnographic study conducted by Patricia and Roger Jefferey in rural Uttar Pradesh¹⁶ reveal deep-rooted mistrust of public healthcare facilities among Muslims. They argue that Muslims have felt especially targeted by family planning programs and coercive sterilization since the Emergency in 1971, and politics, communalism, and violence play a role in shaping regional attitudes of Muslim communities to public health facilities such as family control and reproductive health, especially post the rise of Hindu nationalism in the 1990s.¹⁷ The poor uptake of the polio vaccine among Muslims in the early 2000s,¹⁸ particularly in North India, is a testament to such a trend.

This mistrust is likely perpetuated by a lack of effort to tailor health services and communication to Muslim communities and their needs. Though there is a dearth of evidence fully exploring spatial distributions of public and private delivery facilities, it is likely that rural areas dominated by Muslims face a dearth of obstetric care services. ¹³ The Indian government has made efforts to provide inclusive and accessible maternal healthcare through the National Rural Health Mission initiated in 2005 and the subsequent National Health Mission (NHM) in 2013. However, it is likely that Muslim women have not benefited from the NHM, in comparison to other religious groups; possibly due to a lack of investment to ensure adequate implementation. Studies from Delhi and Western India indicate that Hindu women were significantly more likely to know about the conditional cash transfer associated with institutional delivery under the NHM relative to non-Hindu women, indicating a health communication disparity about the availability of maternal health services that needs to be bridged by government agencies, healthcare workers, and providers.^{19, 20}

In addition to socioeconomic barriers and mistrust, religious discrimination plays a role in the underutilization of institutional deliveries and postnatal care visits by Muslim women. This is an organizational failure that stems from lack of checks on providers, high patient and workloads and a normalized environment of disrespect and abuse of pregnant women. Research articles from various parts of India indicate that Muslim women face verbal taunts, experience differential treatment, and endure abuse and neglect from doctors, nurses and hospital staff who are often non-Muslims themselves. ^21-23 This differential treatment can compromise the safety of Muslim women; in a longitudinal representative study of Uttar Pradesh, Muslim women were 1.8 times more likely to face labor room violence than Hindu women.²⁴ These harrowing incidences of disrespect and abuse are amplified for low-income Muslim women with lower levels of education. In fact, the perceived “Muslimness” in appearance or background is likely to make Muslim women subject to religious stereotyping and pejorative treatment. Through ethnographic work, Khanday addresses discomfort and mistrust doctors and nurses felt when women wearing the burqa would attend healthcare facilities for delivery in Mumbai.²¹ This resulted in verbal taunts, coercing women to remove their veil even before examination, commenting pejoratively on their parity, or even facing physical aggression. ²¹ Without considering these complex social confluences and power dynamics, and how they affect the quality of care, one may faultily attribute the reasons behind why Muslim women access services the way that they do to merely personal choice.

Furthermore, it is essential for public health literature to critically examine how bias, neglect, and discrimination percolates into primary care settings due to the religious beliefs and attitudes of health personnel themselves. Sarin and Lunsford shed light on how Hindu ASHA community health workers in districts in Haryana and Punjab would not eat food or drink water in Muslim households due to their religious beliefs. ²⁵ This likely has an impact on Muslim women’s receptiveness towards maternal health counselling and perceived benefit of government maternal care in the region. In a related manner, a study by Seth and co-authors indicates that exposure to ASHA workers in Uttar Pradesh significantly increased the likelihood of participation in at least four ANC visits among non-Muslim women, but not among Muslim women. ²⁶ This evidence points to a possible link between the religiosity of community health workers and the trends in the uptake of maternal health services among Muslim women, rather than the religiosity of Muslim women as various scholars claim.