Does women empowerment associate with reduced risks of intimate partner violence in India? evidence from National Family Health Survey-5.

BACKGROUND: Women empowerment is commonly believed to be an important factor affecting a woman's likelihood of facing violence from her intimate partner. Even as countries invest in policies that aim to strengthen women empowerment, studies show that increase in women empowerment does not necessarily decrease intimate partner violence (IPV) against them. Against this paradox, the present study seeks to understand the specific empowerment components that associate with IPV against women in India. It also studies the state-level distribution of the different types of IPV. METHODS: The study analyses state-level data from the National Family Health Survey, India (2019-21). A total of 72,056 women responded to the domestic violence questionnaire. The Dimension Index (DI) was used to compute composite scores for Women Empowerment and for IPV to rank states and Union Territories. The correlation between Women Empowerment and IPV scores was determined using Spearman's rank correlation coefficient. RESULTS: The state of Karnataka had the highest composite score of IPV and also showed the highest burdens of physical, sexual and emotional IPV, while Lakshadweep had the lowest burden. Physical IPV was the most common form of IPV for most states across the country. The states in the western part of India had reduced burdens for all three types of IPV. Three specific components of empowerment, viz. household decision-making and mobile phone ownership significantly associated with reduction of all three types of IPV. Hygienic menstrual practices strongly associated with reduction of sexual and emotional IPV. However, property ownership of women increased risks of all three types of IPV, while employment had no significant association with any type of IPV. CONCLUSIONS: The study found no significant reduction in overall IPV with improvement in women empowerment. However, it identifies components of empowerment that associate with IPV. Household decision-making, ownership of mobile phones, and hygienic menstrual practices associated with a lowered risk. By contrast, owning property increased the risk. The findings of this study would inform future research and intervention that aim to strengthen specific components of women empowerment in India and other low-and-middle-income countries.

Concerns and coping mechanisms of breast cancer survivor women from Asia: a scoping review.

PURPOSE: The incidence of breast cancer has increased significantly in Asia due to epidemiological transition and changes in human development indices. Advancement in medical technology has improved prognosis with a resultant increase in survivorship issues. The effects of breast cancer diagnosis and treatment are influenced by the patient's cultural beliefs and social systems. This scoping review aims to summarise concerns and coping mechanisms of women with breast cancer in Asia and understand gaps in the existing literature. METHODS: We performed a scoping review using the population-concept-context strategy. A systematic search of MEDLINE (PubMed, Web of Science), CINAHL, SCOPUS, and Embase was conducted for studies conducted in Asia on women diagnosed with breast cancer, identifying their concerns and coping mechanisms, published between January 2011 and January 2021. Data from included studies were reported using frequencies and percentages. RESULTS: We included 163 studies, of which most (81%) were conducted in hospital settings. Emotional and psychological concerns were reported in 80% of studies, followed by physical appearance and body-image concerns in 46%. Social support (59%), emotion-based coping (46%), spirituality, and problem-based coping (37%) were the major coping systems documented. CONCLUSION: The mapped literature documented that anxiety, depression, and fear of cancer recurrence dominated women's emotional concerns. Women coped with the help of social support, positive reappraisal, and faith in God and religion. Sensitization of caregivers, including healthcare professionals and family members, to context-specific concerns and inquiry into the patients' available support systems is essential in strengthening breast cancer women's recovery and coping.

Geographic and socioeconomic inequities in cesarean delivery rates at the district level in Madhya Pradesh, India: A secondary analysis of the national family health survey-5.

BACKGROUND: In India, caesarean delivery (CD) accounts for 17% of the births, of which 41% occur in private facilities. However, areas to CD in rural areas are limited, particularly for the poor populations. Little information is available on state-wise district-level CD rates by geography and the population wealth quintiles, especially in Madhya Pradesh (MP), the fifth most populous and third poorest state. OBJECTIVE: Investigate geographic and socioeconomic inequities of CD across the 51 districts in MP and compare the contribution of public and private healthcare facilities to the overall state CD rate. METHODS: This cross-sectional study utilised the summary fact sheets of the National Family Health Survey (NFHS)-5 performed from January 2019 to April 2021. Women aged 15 to 49 years, with live births two years preceding the survey were included. District-level CD rates in MP were used to determine the inequalities in accessing CD in the poorer and poorest wealth quintiles. CD rates were stratified as <10%, 10-20% and >20% to measure equity of access. A linear regression model was used to examine the correlation between the fractions of the population in the two bottom wealth quintiles and CD rates. RESULTS: Eighteen districts had a CD rate below 10%, 32 districts were within the 10%-20% threshold and four had a rate of 20% or higher. Districts with a higher proportion of poorer population and were at a distance from the capital city Bhopal were associated with lower CD rates. However, this decline was steeper for private healthcare facilities (R2 = 0.382) revealing a possible dependency of the poor populations on public healthcare facilities (R2 = 0.009) for accessing CD. CONCLUSION: Although CD rates have increased across MP, inequities within districts and wealth quintiles exist, warranting closer attention to the outreach of government policies and the need to incentivise CDs where underuse is significant.

Does women's empowerment and their socioeconomic condition affect the uptake of breast cancer screening? Findings from NFHS-5, India.

BACKGROUND: Screening for breast cancer results in early diagnosis of the disease and improves survival. However, increasing participation of women in screening programs is challenging since it is influenced by socioeconomic and cultural factors. This study explores the relationship of socioeconomic and women empowerment factors with breast cancer screening uptakes in the states and union territories of India. METHODS: We used summary reports of secondary data from all the states and union territories based on the fifth wave of the National Family Health Survey in India. This ecological study compares the uptake of breast cancer screening across states of India. We considered socioeconomic status (SES) and women empowerment status (WES) indicators from the survey as independent variables and state-wise breast cancer screening uptake as dependent variables for studying their association. The determinants of breast cancer screening were calculated using a simple linear regression model. RESULTS: We found that socioeconomic status and women empowerment status moderately correlated with breast cancer screening uptake (correlation coefficient 0.34 and 0.38, respectively). States with higher rates of literacy among women and of women who had their own bank accounts that they decided how to use reported higher uptake of breast cancer screening (p = 0.01 and 0.03, respectively). However, the correlation was not uniform across all the states. The states of Chandigarh, Delhi, Telangana, and Karnataka showed lower participation despite a higher percentage of literate women and women with their own bank accounts. CONCLUSION: This study indicates that women's literacy and having their own bank account may moderately improve their participation in cancer screening. However, higher SES and WES did not translate into better screening in many of the states. More research is needed, especially for states which had low screening uptake despite relatively higher rates of women empowerment.

Maternal Referral Delays and a Culture of Downstream Blaming Among Healthcare Providers: Causes and Solutions.

Patient referral management is an integral part of clinical practice. However, in low-resource settings, referrals are often delayed. The World Health Organization categorizes three types of referral delays; delay in seeking care, in reaching care and in receiving care. Using two case studies of maternal referrals (from a low-resource state in India), this article shows how a culture of downstream blaming permeates referral practice in India. With no referral guidelines to follow, providers in higher-facilities evaluate the clinical decision-making of their peers in lower-facilities based on patient outcome, not on objective measures. The fear of punitive action for an unfavorable maternal outcome is a larger driving factor than patient safety. The article argues for the need to formulate an ecosystem where patient responsibility is shared across the health system. In conclusion, it discusses possible solutions which can bridge communication and information gap between referring facilities.

Mapping the health systems response to violence against women: key learnings from five LMIC settings (2015-2020).

BACKGROUND: Violence against women (VAW) is a global challenge, and the health sector is a key entry point for survivors to receive care. The World Health Organization adopted an earlier framework for health systems response to survivors. However, documentation on the programmatic rollout of health system response to violence against women is lacking in low and middle-income countries. This paper studies the programmatic roll out of the health systems response across select five low- and middle-income countries (LMIC) and identifies key learnings. METHODS: We selected five LMIC settings with recent or active programming on national-level health system response to VAW from 2015 to 2020. We synthesized publicly available data and program reports according to the components of the WHO Health Systems Framework. The countries selected are Bangladesh, Brazil, Nepal, Rwanda, and Sri Lanka. RESULTS: One-stop centers were found to be the dominant model of care located in hospitals in four countries. Each setting has implemented in-service training as key to addressing provider knowledge, attitudes and practice; however, significant gaps remain in addressing frequent staff turnover, provision of training at scale, and documentation of the impact of training. The health system protocols for VAW address sexual violence but do not uniformly include clinical and health policy responses for emotional or economic violence. Providing privacy to survivors within health facilities was a universal challenge. CONCLUSION: Significant efforts have been made to address provider attitudes towards provision of care and to protocolize delivery of care to survivors, primarily through one-stop centers. Further improvements can be made in data collection on training impact on provider attitudes and practices, in provider identification of VAW survivors, and in prioritization of VAW within health system budgeting, staffing, and political priorities. Primary health facilities need to provide first-line support for survivors to avoid delays in response to all forms of VAW as well as for secondary prevention.

The Spiral.

Episodes of domestic violence are incredibly more common than what is documented. While we have had a law against it in India since 2005, the prevalence of domestic violence is high in India at close to 30 percent (as per National Family Health Survey, 2015-16). Yet, with interventions such as Dilaasa in Maharashtra, Bhoomika in Kerala, and Sukoon in Haryana - among others - visibility has increased; and so has support seeking behaviour. The narrative here is based on my personal observation - with some extensions from my imagination built in to give a structure to the narrative - which jarred as I saw how the consequences of violence can be so debilitating, how violence begets more violence*, becomes a question of contingent power; how it flows on through the survivor, creating more survivors.

Twin public health emergencies: Covid-19 and domestic violence.

While a virus is hardly "choosy" in finding a host, the consequences of government responses to a pandemic, such as to Covid-19, have deep implications for those already-marginalised, such as women and girls. In the absence of a systematic database examining the details of the impact, this comment synthesises existing opinions, reviews and the limited available data to show how, not only the outbreak, but particularly our response to it, are increasing the incidence of domestic violence (DV) across the globe, including in India. Despite tackling a much higher Covid caseload and mortality rate than India has, countries such as France and Spain have prioritised responding to DV in their respective societies, working out contingent mitigation mechanisms. Admittedly, low resource settings (LRS) such as India, have a bevy of additional infrastructure and budgetary challenges; but would that imply we do not respond to DV? This comment argues that in reality we have two public health emergencies to confront, the Covid-19 and domestic violence. It builds on the author's observations in the course of working on DV in an LRS context in India, and concludes with a set of recommendations on better responding to DV during Covid/lockdown times. Keywords Domestic violence, gender-based violence, Covid-19, lockdown, pandemic, low resource settings.

Between participation and signature: a response to "Autonomy and risk in HPSR studies".

Health Policy and Systems Research (HPSR) is defined as the "production of new knowledge to improve how societies organise themselves to achieve health goals" (1: p 4); the focus of HPSR studies is on generating, using and disseminating research to strengthen health systems, particularly in low-and middle-income countries. There has been an increasing focus on defining HPSR clearly and on its ethical components and challenges, especially as this domain, is fundamentally different from biomedical /clinical research. One of the imperatives of HPSR is the "co-production of knowledge" (1: p 4) by the researcher, the communities involved, and healthcare providers; and this calls for shared responsibility and ownership, which is not an essential aspect of biomedical research.

Identifying disrespect and abuse in organisational culture: a study of two hospitals in Mumbai, India.

This paper draws on findings from a qualitative study of two government hospitals in Mumbai, India, which aimed to provide a better understanding of the institutional drivers of disrespect and abuse (D&A) in childbirth. The paper describes the structural context, in which government hospital providers can exercise considerable power over patients, yet may be themselves vulnerable to violence and external influence. Decisions that affect care are made by a bureaucracy, which does not perceive problems with the same intensity as providers who are directly attending to patients. Within this context, while contrasting organisational cultures had evolved at the two hospitals, both were characterised by social/professional inequality and hierarchical functioning, and marginalising women. This context generates invisible pressures on subordinate staff, and creates interpersonal conflicts and ambiguity in the division of roles and responsibilities that manifest in individual actions of D&A. Services are organised around the internal logic of the institution, rather than being centred on women. This results in conditions that violate women's privacy, and disregards their choice and consent. The structural environment of resource constraints, poor management and bureaucratic decision-making leads to precarious situations, endangering women's safety. With the institution's functioning based on hierarchies and authority, rather than adherence to universal standards or established protocols, irrational, harmful practices endorsed by senior staff are institutionalised and reproduced. A deeper focus on organisational culture, embedded in the discourse of D&A, would help to evolve effective strategies to address D&A as systemic problems.

Assisted reproductive technologies: Conundrums and challenges.

A few weeks ago, a leading multi-city IVF clinic published an advertisement in a leading news daily. The advertisement sounded ominous, "The longer you wait, the lower your chances" - it referred to one's chances of getting pregnant. The subtext was far too easy to decipher: the content was thoroughly gendered and directed solely at women, particularly at career-oriented women who delay their marriages and childbearing plans far too long, supposedly lowering their fertility in the process. It also sounded benevolent in its attempt to warn these "erring" women. It is socially accepted that women are responsible for increasing the infertility rates in the country by their "poor, untimely, and problematic prioritisation of life choices". While men produce sperm that are regenerative, a woman's reproductive potential is perpetually on a decline; born with a fixed number of egg cells, she never produces any more in her lifetime. However, male infertility is an interesting area to delve into; 40-50% of total infertility is male factor infertility (MFI) (1).

When fiduciary duty clashes with duty to the state.

In their case study Cash and Castro discuss a situation where a physician's duties to the laws of her land stand in conflict with her fiduciary duties to her patient. This present commentary is a response to the situation they describe, and it engages with the issue of conscientious objection in medicine, to argue that the ethical responsibility of the physician should be tilted in favour of the patient, especially when the laws of the land are regressive and harmful.

The social value of research: interrogating the paradoxes.

The relation between science and society is, simply put, very complex. In the history of global bioethics, it is the Code of Nuremberg which foregrounded the acute ways in which biomedical/scientific research could (negatively) impact society; this 1947 Code became the point of reference for subsequent research concerning humans. The Code "required that medical experiments on human beings must have the potential to yield fruitful results for the good of society". The Declaration of Helsinki (DoH), 1964 reinstated this concern by stressing that "clinical research cannot be legitimately carried out unless the risks to participants are justified by the importance of the research" - invoking the idea of the "social value" of research. However, in these initial days, "social value" of research was interpreted more in terms of the moral balance of research, a balance to ensure that the benefits of research unambiguously outweighed its risks as far as its participants were concerned.

A few shades fairer, please.

This piece critically reflects on the growing Indian desire for fairer shades of skin. While skin-whitening products vanish off store shelves, notwithstanding protests against such products, the event that generated a storm some time ago in the media was the Garbha Sanskar workshops. In these workshops, women were allegedly taught methods to purify their wombs and beget fairer (and taller) children. In this article I argue that not only is it simplistic to label this ideology regressive, but that it becomes rather difficult to criticise the sanskaris because of the "register" they employ, ie the language they use to rationalise and explain their actions. The sanskaris use the rhetoric of modern medical science to justify their methods, while the same science tells us that their logic is not scientific; consequently, we are stranded between a paradox and a dead-end. A step-wise, critical look at this discourse reveals how complex its nature is, especially its attempt to lay simultaneous claims to different (and contradictory) epistemologies. I offer no easy solution, for there is none. I map some of the complexities and contradictions of the scenario as a first step.

What ails India's two-tiered healthcare system? A philosophical enquiry.

India's two-tiered healthcare system (viz the public and private sectors) has been suffering from various ailments, and each sector has been criticised for its own set of deficiencies. Against this backdrop, this article explores whether there is any possible commonality between the two sectors, and suggests that the "common logic", or common ground, is the model of biomedical knowledge, which forms the foundation of both sectors. It is to problems inherent in the "model of biomedical knowledge" that certain gaps in each sector can be traced. It is only when we have identified the lapses at the root of the structures of each sector that we can plug the gaps in healthcare. The author suggests that it would be best to analyse the gaps through a philosophical enquiry, and to offer a probable solution, turns to the methodologies of care ethics and feminist standpoint epistemology.

The absent discourse of communication: understanding ethics of provider-patient relationship in six hospitals in urban India.

Understanding the complexities of a provider-patient relationship is considered to be of critical importance especially in medical ethics. It is important to understand this relation from the perspectives of all stakeholders. This article derives from a qualitative study conducted across six obstetric care providing institutions in the cities of Mumbai and Navi Mumbai, India, over a period of 10 months. Thirty obstetricians were interviewed in-depth to understand what they perceived as the most important aspect in developing a good provider-patient relationship. The study found that while most providers highlighted the point of communication as the most critical part of the provider-patient relationship, they admitted that they could not engage in communication with the patients for various reasons. Obstetric consultants and residents said that they were too overburdened to spend time communicating with patients; providers working in public hospitals added that the lack of education of their patients posed a hindrance in effective communication. However, providers practicing in private institutions explained that they faced a challenge in communicating with patients because their patients came from educated families who tended to trust the provider less and were generally more critical of the provider's clinical judgement. The article shows how provider-patient communication exists as an idea among medical providers but is absent in daily clinical practice. This gives rise to a discourse shaped around an absence. The authors conclude by decoding the term 'communication' - they read the word against the context of its use in the interviews, and argue that for the providers 'communication' was not intended to be a trope towards setting up a dialogue-based, egalitarian provider-patient relationship. Providers used the word in lieu of 'counselling', 'guiding', 'talking to'. It concludes that, despite the providers' insisting on the significance of communication and complaining about its absence, what they desired in reality was not the possibility of a dialogue with the patient or a chance to be able to share decision-making power with the patient, but to be able to provide better instructions and chart out what was best for them in a more detailed way.