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Sadhu R. Beyond Purdah: understanding the barriers Indian Muslim women face in accessing and utilizing maternal health services. HPHR. 2022;63. 10.54111/0001/CCC1
Several analysts have found that the utilization rates of maternal health services, such as antenatal care visits, skilled birth attendants and institutional deliveries are lower among Muslim women relative to women of other religious groups in India. Some have attributed this to the religiosity of Muslim women, among other social determinants such as income, education, class, and parity. These authors highlight that religious practices such as purdah play a significant role in shaping Muslim women’s reluctance to access maternal services. They report that Muslim women prefer not to access facilities with male providers, and that they lack decision making autonomy regarding their reproductive health. In this article, I will uncover the limitations underlying their arguments. I present an alternate argument: Muslim women’s utilization patterns of maternal health services may be better explained by systemic factors such as financial barriers, the historical mistrust of government health services, health communication disparities, and discrimination against Muslim women by healthcare professionals. This article argues for public health researchers to adopt a sociopolitical lens in explaining and contextualizing the barriers women belonging to excluded, minoritized, or marginalized caste and religious groups in India face in accessing maternal care.
Average trends from nationally representative data indicate that Muslim women in India do not utilize maternal health services such as antenatal care, skilled birth attendants during delivery, institutional deliveries, and postnatal care to the same extent as women of other religious groups such as Hindu women.1-4 For instance, an National Family Heath Survey Analysis of young married women aged 15-24 from 1992 to 2016 indicate that Muslim women were 22% less likely to utilize antenatal services, and 42% less likely to use skilled birth attendant- assisted delivery compared to their Hindu counterparts.2 Notably, many studies with smaller sample sizes from specific states or cities in India point to similar findings, irrespective of the contextual or geographic setting of the study population and time of publication.5-8 In the past two decades, the religious beliefs and practices of Muslim women have been popularly cited as plausible explanations for their preference of not utilizing maternal health services by many scholars. In this article, I provide the perspectives of researchers, and their positions on how religious and cultural beliefs of Muslim women impact their maternal health choices. I proceed to problematize these claims and present their limitations. Subsequently, I argue that Muslim women’s utilization patterns of maternal health services should rather be treated as an unmet need stemming from larger systemic issues.
To investigate the literature on religion and maternal health service utilization in India, I conducted a narrative appraisal of the literature in three databases, namely PubMed, Google Scholar, and ScienceDirect. I ran multiple non-systematic searches from September to October 2022, with no restrictions on geographic setting within India, sample size, type of article or methodological approach. I did, however, restrict the year of publication to 2000 and after to capture articles analyzing more contemporary data. These searches contained the following key terms- ‘Muslim women,’ ‘India,’ ‘maternal health,’ ‘religion,’ ‘delivery,’ ‘systemic,’ ‘quality of care,’ ‘discrimination,’ and ‘disrespect and abuse,’ I included studies if authors analyzed quantitative and/or qualitative data pertaining to maternal health utilization of Muslim women in India and presented reasons or hypotheses for why they utilize services the way they do. Reviews which analyzed research articles that satisfied the inclusion criteria were selected for review. Studies were excluded if published before 2000, were not written in the English language, were not peer-reviewed, and did not explore underlying reasons for maternal health utilization. Ultimately, 23 articles were selected for narrative review: these included 16 quantitative studies, four qualitative studies, one mixed-methods study, and two scoping reviews. Half of the quantitative studies involved secondary data analysis of National Family Health Survey or Demographic and Health Survey Data from India. The other half included primary data collection from across cities and villages in India, particularly in Maharashtra, and Uttar Pradesh.
In this section, I explain how many analysts pervasively attribute the uptake of maternal health services of Muslim women to purdah. Purdah broadly refers to the “concealment of women, and the separation of men and women’s worlds.” 9 Purdah was observed by upper class elite Muslim women during the Mughal era and was later adopted in a more mainstream fashion by Muslim women as a sign of respectability. 9 It must be noted that women of all religions observed some form of seclusion or concealment utilizing clothing in India historically that persists till the present day. 9 To explain how Muslim women’s beliefs and practices affect their low utilization in South India, Navaneetham and Dharmalingam note 5–
“In south India, purdah is overwhelmingly practiced among Muslims. Muslim women also have less freedom of movement on their own outside the household compared to their Hindu counterparts. Also, Muslim women in general have less autonomy to interact with males outside their immediate families. If a male doctor is available in a health facility, Muslim women are, generally, less likely to go for antenatal check-up and seek delivery assistance.”
It must be noted that the authors provide no historical context or empirical evidence to contextualize to what extent purdah is practiced in South India. Furthermore, they do not provide associated data or evidence that Muslim women’s reluctance to receive care from male providers is the primary reason for their low uptake of maternal health services. Surely not all maternal healthcare providers in South India in 2002 were men, and so how would this claim explain why uptake among Muslim women was universally low across South India?
This emphasis on purdah and seclusion has had a ripple effect in public health literature, particularly as evidence to highlight the lack of autonomy Muslim women possess to make their own reproductive choices. Hamal et al. cite Naveenatham and Dharmalingam as evidence that purdah limits Indian Muslim women’s “use of maternal health service from male service providers.” 10 Hazarika claims that the purdah system within the “closed community” of Muslims may affect Muslim women’s choices of accessing a skilled birth attendant.4 Without additional context, one wonders how or why Muslim women will adhere to seclusion from healthcare personnel of the same gender. Singh and colleagues link “religious and social customs prevalent among Muslims such as ‘burkha/niqab’” with adverse health impacts on adolescent mothers.11 In a similar vein, Kachoria et al. suggest that religion plays a role in “autonomy in decision making” and “justifiability of domestic abuse,” explaining the differences in maternal health utilization patterns of Hindus with Muslims across India and South Asia.12
These claims and deliberations were posited by eight research articles.1-5, 10-12 Seven of these articles were quantitative studies, and comprised the bulk of articles that analyzed nationally representative data (seven out of nine). This is especially problematic as readers may assume that there is some universal oppressive religious factor associated with Islam in India. They may infer from this body of work that this factor of oppression unites Muslim women across regional lines, causes their forced or chosen seclusion from public spaces nationally, results in them “shying away” from utilizing maternal health services. While all these studies acknowledge that income, education, class, family preferences and decision-making autonomy also influence Muslim women’s uptake of maternal health services, they poorly explore or discuss the specific mechanisms of how these social determinants interact with religiosity to affect health utilization. Intentionally or not, these authors imply that the religiosity of Muslim women is their own barrier to utilizing maternal health services poorly.
As I see it, there are a myriad of issues why these claims by various researchers and the implied inferences they evoke are speculative, lack nuance, and are myopic. The authors do not aim to contextualize, measure, or evaluate the religiosity of Muslim women belonging to different subcommunities in India. Not only do these studies treat Indian Muslim women as a monolith, but they also do not measure or highlight the varying degrees of individual or subgroup religious beliefs, practices, attitudes, and behaviors of Muslim women.
Furthermore, the perspectives of Muslim women themselves is erased from the discussion. As I discuss earlier, these studies collectively imply that religious practices impact Muslim women’s health choices in India. Yet it is not clear who enforces these religious practices, how Muslim women perceive their own religiosity and healthcare preferences, and how the religiosity of spouses and other family members impact the choices of women. These voyeuristic limitations preclude any inferences about the intentions behind the maternal health utilization behaviors of Muslim women to be reasonably drawn.
Most egregiously, the research articles attribute the blame of poor maternal health utilization on Muslim communities themselves. Through focusing on the religiosity of Muslim women and its consequential health outcomes in a vacuum, the researchers fail to highlight the ways health systems and healthcare providers and workers in the country may be failing to provide appropriate and accessible maternal care to Muslim women at various levels. As I see it, the systemic disadvantage of Muslims in India coupled with inadequate healthcare systems can play an instrumental role in explaining Muslim women’s underutilization of maternal health services. I will discuss this in greater detail in the next section.
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.
Through this commentary, I wish to argue that Muslim women’s religious beliefs are one plausible pathway among many pathways that explain Muslim women’s utilization of maternal health services. Systemic efforts are required by various stakeholders in health systems to make initiatives under the National Health Mission better known, to improve the quality of subsidized public obstetric care, to curb the targeted disrespect and abuse of Muslim women in all healthcare settings, and to ensure providers are held accountable in countering their own religious biases. It is extremely likely that these factors will positively influence the uptake of maternal health services among all Muslim women. More responsible and evidence-based research is required to fully understand how religious beliefs of Muslim women affect their maternal health choices. However, the interpretation of these beliefs cannot occur in a vacuum. Researchers must consider how health system factors coupled with religious practices shape barriers and choices pertaining to the uptake of maternal health services and conceptualize that these are intersectional.
The author has no relevant financial disclosures or conflicts of interest.
I would like to extend my sincere thanks to Dr. Jesse Bump for his guidance and mentorship in shaping this manuscript. Many thanks to my colleagues at RCESDH whose work has enabled me to better understand person-centered maternity care in India. I am also grateful to Riya Kumar for her thoughtful edits.
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[2] Singh P, Singh KK, & Singh P. Maternal health care service utilization among young married women in India, 1992–2016: trends and determinants. BMC Pregnancy and Childbirth. 2021;21(1), 1-13. https://doi.org/10.1186/s12884-021-03607-w
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[19] Vikram K, Sharma AK, Kannan AT. Beneficiary level factors influencing Janani Suraksha Yojana utilization in urban slum population of trans-Yamuna area of Delhi. Indian Journal of Medical Research. 2013;138(3), 340-346.
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Ravi is a second-year master student in the Global Health and Population Department at the T.H. Chan School of Public Health. He hails from USA and Bangalore, India. He obtained a dual degree in Biology and Religious Studies from Claremont McKenna College in 2019. Previously, he worked as a Research Consultant at the Ramalingaswami Center for Social Determinants of Equity and Health contributing to research on the disrespect and abuse of pregnant women in South India and respectful maternity care. He has an active interest in the social determinants of health in India and beyond, namely religion.
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