Gender and reproductive health in Pakistan: a need for reconceptualisation

Abstract

This thesis is a conceptual and empirical exploration of the links between women's gendered position and their reproductive health in Pakistan. A growing body of literature seeks to identify the relationship between gender inequality and women's reproductive health, most commonly their contraceptive use and fertility. However, to-date findings have been mixed and we lack a coherent picture of how these two aspects of women's well-being are related. This thesis illustrates that the focus on female autonomy, which is central to much of the discourse concerning gender and reproductive health in South Asia, is inappropriate to this cultural setting. An alternative framework for conceptualizing and measuring women's gendered position is presented in an attempt to further our understanding of the determinants of reproductive health. The study uses an integrated analysis of quantitative and qualitative data. The Pakistan Fertility and Family Planning Survey (1996-97) data show important socio-demographic and contextual differentials in women's mobility, decision-making, control over financial resources, communication with husband, exposure to information and health knowledge. Relationships between different measures of women's gendered position and reproductive health outcomes are shown to be varied, with only joint decision-making, communication with husband, and health knowledge having positive associations with both contraceptive and antenatal care use. A detailed ethnographic study of a Punjabi village reveals kinship structures based on an ideology of akhathe (jointness), and social networks and inter-personal relationships as the primary route to resources of all kinds. Women's interests are intricately linked with their family's well-being. They aspire to be mazboot (strongly connected) members of their families rather than autonomous individuals. The qualitative data inform the interpretation of the quantitative associations and suggest ways in which measures of women's gendered position can be refined. Both fertility control and pregnancy are shown to be highly gendered processes. However, an unexpectedly high contraceptive use rate, and the emergence of antenatal care use, are found in the absence of accompanying shifts in gender ideology. In such a context, the 'centrality' approach is suggested as a valid and sensitive way of conceptual ising women's gendered position in Pakistan. This approach incorporates the kinship and social structures and suggests women's mazbooti as a more acceptable and realisable goal for improving women's reproductive health and well being.