Public Health Foundation of India

Disrespect and abuse (D&A) in obstetric care are recognised as a widespread and systemic problem. Quantitative, qualitative and intervention research aimed at understanding and addressing it better has pointed to the root causes of D&A within socio-economic inequality or within power hierarchies in health care provision. But there has been relatively little attempt to identify and document the actual mechanisms through which power relations translate into health care practices or behaviours. Such an effort is essential if one is to appreciate why D&A in maternal care are so widespread, and how the problem might be addressed effectively.

The centre has conducted both qualitative and quantitative research in southern India to better understand the phenomena of disrespectful and abusive in obstetric care and family planning services.

• Maternal Clinical Assessment Tool (M-CAT): This was a proof-of-concept study, leveraging digital technology to improve the quality of antepartum and postpartum clinical assessments.
• A cross-sectional community survey was designed to meet two objectives:
  • To understand rural women’s perceptions and experience of institutional obstetric care, including the strategies used to negotiate better care, and
  • To measure and explain differences in perceptions of institutional obstetric care by social location of the woman, type of institution, and stage of the village’s transition to institutional birth.
• Qualitative research with healthcare providers: The focus of our qualitative research was to explore the causes of obstetric care-linked D&A in healthcare institutions, especially the role of professional training and work cultures. Our questions were: (1) To what extent does routine obstetric practice vary from available protocols and guidelines, and why? (2) Where do these practices come from? Do they lie in insufficient training? Are these practices picked up during internships and residencies?
• A scoping review of organisational conditions and their impact on maternity providers and care in LMICs: Implications for Respectful Maternity Care

We are currently engaged in formative research on women’s health and well-being in collaboration with University of Toronto’s Centre for Global Child Health, UNFPA, Federal University of Pelotas’ International Centre for Equity in Health, and George Washington University’s Milkin School of Public Health. This cutting-edge work combines a life course approach with a gender and intersectionality lens and focuses on conceptual advancement along with metrics and dashboards to track progress on women’s health and well-being.

The Centre is conducting formative research into the growing health challenges in urban India, with a specific focus on the vulnerabilities of particular marginal groups, using an intersectional lens. The definition of the ‘urban’ is in itself complicated, particularly in the Indian context, where it could mean anything from a metro city to a district headquarters town. Each of these urban centres has a governance structure and a health system peculiar to its history and development trajectory. Also, urban poverty and marginality are multidimensional and layered, and often invisible. Despite this complexity, information around urban health is sparse. The Centre aims to bridge this gap through a focused workstream on urban health issues.

Schaaf, M., Boydell, V., Topp, S. M., Iyer, A., Sen, G., & Askew, I. (2022). A summative content analysis of how programmes to improve the right to sexual and reproductive health address power. BMJ Global Health, 7(4), e008438. https://doi.org/10.1136/bmjgh-2022-008438

Sen, G., Iyer, A., Chattopadhyay, S., & Khosla, R. (2020). When accountability meets power: Realizing sexual and reproductive health and rights. International Journal for Equity in Health, 19(1), 111.
https://doi.org/10.1186/s12939-020-01221-4

Sen, G., Kismödi, E., & Knutsson, A. (2019). Moving the ICPD agenda forward: Challenging the backlash. Sexual and Reproductive Health Matters, 27(1), 319–322.
https://doi.org/10.1080/26410397.2019.1676534

Correa, S., Germain, A., & Sen, G. (2016). Feminist mobilizing for global commitments to the sexual and reproductive health and rights of women and girls. In E. Chesler & T. McGovern (Eds.), Women and Girls Rising: Progress and Resistance Around the World (pp. 51-68). New York, USA: Taylor& Francis.
DOI: https://doi.org/10.4324/9781315708379-5

Srinidhi, V., Iyer, A., Sreevathsa, A., & Shankar, M. (2016). Translating Research into a Capacity-Building Tool to Strengthen Obstetric Competence. BMJ Global Health, 1:A26.
https://doi.org/10.1136/bmjgh-2016-EPHPabstracts.34

Germain, A., Sen, G., Garcia-Moreno, C., & Shankar, M. (2015). Advancing sexual and reproductive health and rights in low- and middle-income countries: Implications for the post-2015 global development agenda. Global Public Health, 10(2), 137–148.
https://doi.org/10.1080/17441692.2014.986177

Sen, G., & Govender, V. (2015). Sexual and reproductive health and rights in changing health systems. Global Public Health, 10(2), 228–242.
https://doi.org/10.1080/17441692.2014.986161

Sen, G., Germain, A., Garcia-Moreno, C., & Shankar, M. (Guest Eds) (2015) Sexual and Reproductive Health and Rights for the next decades: What’s been achieved? What lies ahead? Global Public Health 10(2).
https://www.tandfonline.com/toc/rgph20/10/2

Martopullo, I., Neves, P. A., Baird, S., Liang, M., Keats, E. C., Cherkas, A., … & Bhutta, Z. A. (2024). Understanding progress and challenges in women’s health and wellbeing in exemplar countries: a time-series study identifying positive outliers. The Lancet Global Health, 12(12), e2012-e2023.

Iyer, A., & Sen, G. (2020). Unjust social differences: Health inequalities in India. In A. Mehdi & I. Rajan (Eds.), Health of the nation: Perspectives for a new India (pp. 86-100). New Delhi: Oxford University Press.
https://india.oup.com/product/health-of-the-nation-9780199499830

Sen, G., & Iyer, A. (2019). Beyond economic barriers: Intersectionality and health policy in low- and middle-income countries. In O. Hankivsky & J. Jordan-Zachery (Eds.), The Palgrave Handbook of Intersectionality in Public Policy (pp. 245-261). Palgrave Macmillan.
https://www.academia.edu/81464343/The_Palgrave_Handbook_of_Intersectionality_in_Public_Policy?f_ri=34327

Sen, G., & Iyer, A. (2016). The Mechanisms of Intersectioning Social Inequalities in Health. BMJ Global Health, 1(Suppl 1).
https://doi.org/10.1136/bmjgh-2016-EPHPabstracts.47

Mason, E., Sen, G., & Yamin, A. E., on behalf of the United Nations Secretary-General’s Independent Accountability Panel for Every Woman, Every Child, E. A. (2020). Ensuring UHC protects the health and rights of women, children and adolescents. Accelerating Universal Health Coverage, Bulletin of the World Health Organization (Theme Issue), 98(2), 79-79A.
https://doi.org/10.2471/BLT.19.249474

Sen, G., Virani, A., Iyer, A., Reddy, B., & Selvakumar, S. (2017). Translating health research to policy: Breaking through the impermeability barrier. In J. Georgalakis, N. Jessani, R. Oronje, & B. Ramalingam (Eds.), The Social Realities of Knowledge for Development (pp. 32–51). Brighton: IDS Impact Initiative.
https://www.researchgate.net/publication/320212414_Translating_Health_Research_to_Policy_Breaking_through_the_Impermeability_Barrier

Sen, G., & Iyer, A. (2015). Health policy in India: some critical concerns. In E. Kuhlmann, R. H. Blank, & I. L. Bourgeault (Eds.), The Palgrave International Handbook of Healthcare Policy and Governance (pp. 154–170). Hampshire: Palgrave Macmillan.
https://link.springer.com/book/10.1057/9781137384935

Seshadri, S. R. (2022). The Covid-19 Pandemic and the Health Sector: What have we learned? In School of Policy and Governance in association with the Constitutional Conduct Group (Ed.), Understanding Post-Covid 19 Governance Challenges in India. Azim Premji University.
https://azimpremjiuniversity.edu.in/publications/2022/report/understanding-post-covid-19-governance-challenges-in-india

Fisseha, S., Sen, G., Ghebreyesus, T. A., Byanyima, W., Diniz, D., et al. (2021). COVID-19: The turning point for gender equality. The Lancet, 398(10299), 471–474.
https://doi.org/10.1016/S0140-6736(21)01651-2

Promising Practices in Integrating Gender into Government Health Programs’ project was a collaborative effort between PHFI’s Ramalingaswami Centre on Equity and Social Determinants of Health (RCESDH-PHFI), United Nations University International Institute for Global Health (UNU-IIGH),and the School of Public Health at the University of Western Cape in South Africa. The project aimed to bridge the critical evidence gap regarding successful integration of gender into large-scale government health programs, through a series of national case studies.

The resultant case study series consists of three stand-alone summaries with key findings spanning policy, systems, institutional, and community levels.

• https://bit.ly/case-study_maharshtra
• https://bit.ly/case-study_TamilNadu
• https://bit.ly/case-study_Nepal

Beneria, L., & Sen, G. (2021). Feminist economic challenges to development. In I. Berik & E. Kongar (Eds.), The Routledge Handbook of Feminist Economics. Taylor & Francis.
https://www.routledge.com/The-Routledge-Handbook-of-Feminist-Economics/Berik-Kongar/p/book/9780367074142

https://www.downtoearth.org.in/health/cancer-the-hidden-hazard-in-indias-construction-industry

https://www.deccanherald.com/opinion/urban-decay-and-spread-of-superbugs-3196692?utm_source=whatsapp&utm_medium=referral&utm_campaign=socialshare

Commission on Social Determinants of Health Knowledge Networks et al. (2011) Improving Equity in Health by Addressing Social Determinants, Geneva: WHO
http://apps.who.int/iris/bitstream/10665/44793/1/9789241503037_eng.pdf

Sen, Gita and Ostlin, Piroska (2011) Gender inequity in health, In Improving Equity in Health by Addressing Social Determinants Geneva, WHO, 2011
http://apps.who.int/iris/bitstream/10665/44793/1/9789241503037_eng.pdf

Sen, Gita and Ostlin, Piroska (2011) Priorities for research on equity and health: Towards an equity-focused health research agenda in PLoS Medicine, November, 8 (11): e1001115 (doi:10.1371/journal.pmed.1001115) (selected for the special WHO/PLoS collection, “World Health Report 2012: No Health Without Research”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3206017/pdf/pmed.1001115.pdf

Sen, Gita and Ostlin, Piroska (2011) Gender based inequities in global public health in Richard Parker and Marni Sommer (Eds) The Routledge International Handbook on Global Public Health, Routledge
https://www.routledge.com/Routledge-Handbook-of-Global-Public-Health/Parker-Sommer/p/book/9780415818896

Sen, Gita and Ostlin, Piroska (Eds) (2010) Gender Equity in Health: The Shifting Frontiers of Evidence and Action, New York: Routledge Studies in Health and Social Welfare
https://www.routledge.com/Gender-Equity-in-Health-The-Shifting-Frontiers-of-Evidence-and-Action/Sen-Ostlin/p/book/9780415654937

Sen, Gita and Ostlin, Piroska (2010) Gender as a Social Determinant of Health –Evidence, Policies and Innovations In Gita Sen and PiroskaOstlin (Eds) Gender Equity in Health: the Shifting Frontiers of Evidence and Action, New York, Routledge Studies in Health and Social Welfare (Abridged version published in N Visvanathan, L Duggan, N Wiegersma and L Nisonoff Eds. 2011 The Women, Gender and Development Reader, London: Zed Books, 2nd edition)
https://www.routledge.com/Gender-Equity-in-Health-The-Shifting-Frontiers-of-Evidence-and-Action/Sen-Ostlin/p/book/9780415654937

Sen, Gita (2009) Health inequalities: gendered m and conundrums. The 10th Annual Sol Levine lecture Social Science and Medicine, October, 69 (7): 1006-1009
http://dx.doi.org/10.1016/j.socscimed.2009.07.027

Sen, Gita and Ostlin, Piroska (2008) Gender inequity in health: Why it exists and how we can change it, Global Public Health 3(2): Supplement 1, 1-12; reprinted in Richard Hofrichter and Rajiv Bhatia (Eds) 2010 Tackling Health Inequities through Public Health Practice –Theory to Action, New York: Oxford University Press, (Second Edition).
http://www.tandfonline.com/doi/full/10.1080/17441690801900795?scroll=top&needAccess=true

Sen, Gita and Ostlin, Piroska (Eds) (2008) Gender Inequity in Health: Why It Exists and How We Can Change It Special Supplement, Global Public Health 3 (2): Supplement 1
http://www.tandfonline.com/doi/full/10.1080/17441690801900795

Sen, Gita, Ostlin, Piroska and George, Asha (2007) Unequal, unfair, ineffective and inefficient: Gender inequity in health – Why it exists and how we can change it, Final report to the WHO Commission on Social Determinants of Health by the Women and Gender Equity Knowledge Network
http://www.who.int/social_determinants/resources/csdh_media/wgekn_final_report_07.pdf

Sen, Gita, Iyer, Aditi and George, Asha (2007) Systematic hierarchies and systemic failures: gender and health inequities in Koppal district Economic and Political Weekly, February 24-March 2, XLII (8): 682-690; and in  Gopal Kadekodi, Ravi Kanbur and Vijayandra Rao (Eds.) Development in Karnataka: Challenges of Governance, Equity and Empowerment, New Delhi: Academic Press, 357-382
https://www.researchgate.net/publication/262698396_Systematic_hierarchies_and_systemic_failures_Gender_and_ health_inequities_in_Koppal_District

Sen, Gita, George, Asha and Ostlin, Piroska (Eds) (2002) Engendering International Health: the Challenge of Equity, Cambridge: The MIT Press
https://mitpress.mit.edu/books/engendering-international-health

Intersecting inequalities

Iyer, Aditi, Sen, Gita and Ostlin, Piroska (2010) Inequalities and intersections in health: a review of the evidence In Gita Sen and PiroskaOstlin (Eds) Gender Equity in Health: the Shifting Frontiers of Evidence and Action New York: Routledge Studies in Health and Social Welfare.
https://www.routledge.com/Gender-Equity-in-Health-The-Shifting-Frontiers-of-Evidence-and-Action/Sen-Ostlin/p/book/9780415654937

Iyer, Aditi, Sen, Gita and Ostlin, Piroska (2008) The intersections of gender and class in health status and health care In Gita Sen and PiroskaOslin (Eds) Gender Inequity in Health: Why It Exists and How We Can Change It, Global Public Health, 3(2): Supplement 1.
http://www.tandfonline.com/doi/full/10.1080/17441690801892174

Iyer, Aditi, Sen, Gita and George, Asha (2007) The dynamics of gender and class in access to health care: evidence from rural Karnataka, India International Journal of Health Services, 37 (3): 537–554.
https://jhu.pure.elsevier.com/en/publications/the-dynamics-of-gender-and-class-in-access-to-health-care-evidenc-4

Sen, Gita and Iyer, Aditi (2016), “The mechanisms of intersecting social inequalities in health”, BMJ Global Health 2016; 1(Suppl 1): A35-A36
http://gh.bmj.com/content/1/Suppl_1/A35

Sen, Gita and Iyer, Aditi (2012) “Who gains, who loses and how: Leveraging gender and class intersections to secure health entitlements”, Social Science and Medicine 72: 1802-1811
http://www.sciencedirect.com/science/article/pii/S0277953611003236

Sen, Gita, Iyer, Aditi and Mukherjee, Chandan (2009) “A methodology to analyse the intersections of social inequalities in health”Journal of Human Development and Capabilities, 10 (3): 397–415
http://www.tandfonline.com/doi/full/10.1080/19452820903048894?scroll=top&needAccess=true

Jacob, S and Chattopadhyay, S (2019) Speaking of Abuse: The Pyramid of Reporting Domestic Violence in India. Economic and Political Weekly. 54(1): 53-63. Chattopadhyay, S. (2018). The shifting axes of marginalities: the politics of identities shaping women’s experiences during childbirth in Northeast India. Reproductive Health Matters, 1–8.
https://doi.org/10.1080/09688080.2018.1502022

[Taylor and Francis]. Chattopadhyay, S. (2018) The responses of health systems to marital sexual violence – a perspective from southern India. In Aggression, Maltreatment and Trauma. Doi:
https://doi.org/10.1080/10926771.2018.1494235

[Taylor and Francis] Chattopadhyay, S., Mishra, A., Jacob, S. (2017) Safe Yet Violent: Women’s Experiences with Obstetric Violence during Hospital Births in Rural Northeast India in Culture, Health and Sexuality.
https://doi.org/10.1080/13691058.2017.1384572

[Taylor and Francis] Correa S, Germain A, Sen G. (2016) Feminist mobilizing for global commitments to the sexual and reproductive health and rights of women and girls. In: Chesler E, McGovern T editors. Women and Girls Rising: Progress and Resistance Around the World, New York, USA: Routledge; 51-68
https://www.routledge.com/Women-and-Girls-Rising-Progress-and-resistance-around-the-world/Chesler-McGovern/p/book/9781138898776

George, Asha, Iyer, Aditi and Sen, Gita (2005) Maternity in crisis: Gendered health system experiences from Koppal, Karnataka IDS Sussex Working Paper No 253, Brighton, Sussex: Institute of Development Studies, September.
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.605.2179&rep=rep1&type=pdf

Iyer, Aditi, Sen, Gita and Sreevathsa, Anuradha (2013). Deciphering Rashomon: An approach to verbal autopsies of maternal death Global Public Health: An International Journal for Research, Policy and Practice,  8 (4): 389-404.
http://www.tandfonline.com/doi/abs/10.1080/17441692.2013.772219

Iyer, Aditi, Sen, Gita, Sreevathsa, Anuradha and Varadan, Vasini (2012) Verbal autopsies of maternal deaths in Koppal, Karnataka: lessons from the grave BMC Proceedings, 6 (Suppl 1):P2
http://www.biomedcentral.com/1753-6561/6/S1/P2

Reddy, Bhavya, Sen, Gita (2013) Breaking Through the Development Silos. Sexual & Reproductive Health and Rights, Millennium Development Goals and Gender Equity: Experiences from Mexico, India and Nigeria, Reproductive Health Matters, 21(42): 18-31.
http://www.rhm-elsevier.com/article/S0968-8080(13)42743-X/pdf

Sen, Gita (2014) Sexual and reproductive health and rights in the post-2015 development agenda Global Public Health, 9 (6): 599-606
http://www.tandfonline.com/doi/full/10.1080/17441692.2014.917197

Sen, Gita (2013) Gender equality in the post 2015 development agenda: Lessons from the MDGs IDS Bulletin 44 (5-6), September: 42-48
http://onlinelibrary.wiley.com/wol1/doi/10.1111/1759-5436.12055/abstract

Sen, Gita (2010) Family Planning and Sexual and Reproductive Health and Rights: The Past as Prologue? Studies in Family Planning, June, 41 (2): 143-146
http://onlinelibrary.wiley.com/doi/10.1111/j.1728-4465.2010.00237.x/abstract

Sen, Gita, Govender, Veloshnee and Cottingham, Jane (2007) Maternal and neonatal health: surviving the roller-coaster of international policy, March, Occasional Paper Series Number 5, Centre for Public Policy, Indian Institute of Management Bangalore
http://www2.ids.ac.uk/ghen/resources/papers/MaternalMortality2006.pdf

Shankar, Mridula and Reddy, Bhavya (2012) Anaemia in pregnancy still a major cause of morbidity and mortality: Insights from Koppal district, Karnataka, India Reproductive Health Matters, 20 (40): 67-68 http://www.rhm-elsevier.com/article/S0968-8080(12)40669-3/abstract

Series on Decoding Maternal Safety

Ottersen, T., Norheim, O.F. et al. (including Gita Sen) (2014) Making fair choices on the path to universal health coverage, Final report of the WHO Consultative Group on Equity and Universal Health Coverage, Geneva: WHO
http://apps.who.int/iris/bitstream/10665/112671/1/9789241507158_eng.pdf

Ottersen, T., Norheim, O.F. et al. (including Gita Sen) (2014) Making fair choices on the path to universal health coverage, Bulletin of the World Health Organization, 92 (6), June: 389.
http://dx.doi.org/10.2471/BLT.14.139139

Reddy, K. Srinath et al (including Gita Sen) (2011) Report of the High Level Expert Group on Universal Health Coverage, Submitted to the Planning Commission of India
http://planningcommission.nic.in/reports/genrep/rep_uhc0812.pdf

Sen, Gita (2014) Health security in Ashima Goyal (Ed) The Oxford Handbook of the Indian Economy in the 21st Century, New Delhi, Oxford University Press, pp 328-51 Sen, Gita (2012) Universal health coverage in India: a long and winding road Economic and Political Weekly February 25, XLVII (8): 45-52
http://uhc-india.org/uploads/GitaSen.pdf

Fostering Knowledge-Implementation Links Project (2012) Maternal Death Reviews:Improving the quality of evidence to support health system strengthening, Policy Brief No. 1 Bangalore: Indian Institute of Management Bangalore.
http://www.phfi.org/images/pdf/Knowledge-translation_policy_brief_1.pdf

Fostering Knowledge-Implementation Links Project (2012) Identification and management of obstetric risks and emergencies: How prepared are primary level providers? Policy Brief No. 2, Bangalore: Indian Institute of Management Bangalore.
http://www.phfi.org/images/pdf/Knowledge-translation_policy_brief_2.pdf

Fostering Knowledge-Implementation Links Project (2012) Programmatic strategies for tackling maternal anaemia: Lessons from research and experience. Policy Brief No. 3, Bangalore: Indian Institute of Management Bangalore.
http://www.phfi.org/images/pdf/Knowledge-translation_policy_brief_3.pdf

Fostering Knowledge-Implementation Links Project (2012) Pregnant women with moderate to Severe anaemia: Lacunae in screening and treatment efforts. Policy Brief No. 4, Bangalore: Indian Institute of Management Bangalore.
http://www.phfi.org/images/pdf/knowledge-translation_policy_brief_4.pdf

Srinidhi V, Iyer, Aditi, Sreevathsa, Anuradha and Shankar, Mridula (2016), “Translating research into a capacity-building tool to strengthen obstetric competence”, BMJ Global Health 2016; 1(Suppl 1): A26
http://gh.bmj.com/content/bmjgh/1/Suppl_1/A26.1.full.pdf

ASHA KIRANA: A Tool for Safer Pregnancy
A Status Report
2017
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This film presents work done by the Ramalingaswami Centre on Equity and Social Determinants of Health on improving maternal health in poor rural areas. It documents the Maternal Clinical Assessment Tool (M-CAT), a project aiming to build the capacities of Accredited Social Health Activists (ASHAs) to support better clinical assessment of pregnant and postpartum women.

Set in Koppal, a district in the southern Indian state of Karnataka, the video captures what it means to be a woman in a poor rural area through the lens of the Gender and Equity (GHE) Project. In doing this, the film subtly reveals how transforming gender injustice also leads to taking a quiet stand against caste bias and other kinds of stigma. It tells an unfinished story of resilience and change.

There are so many Koppals in India. This film is dedicated to Koppal’s women wherever they may be.

The monthly Colloquium Series is part of the Centre’s larger objective of expanding opportunities to foster conversations around health inequities, particularly those relating to gender and its intersections with other sources of structural inequality. The talks cover a range of health concerns (sexual and reproductive health, nutrition, maternal and adolescent health) and multiple axes of disadvantage (gender, caste, migrant status, tribal status, disability, etc.). Invited speakers come from a mix of research, policy, advocacy, and practice backgrounds.

Recordings: https://www.youtube.com/playlist?list=PLI_PWXNhdaCiLmkbTocl55odIzajTiLEM