Keertana Kannabiran Tella
Reproductive justice lies at the core of the right to equal access to healthcare and maintenance of personal autonomy when it comes to decisions made about one’s own body. It is important to note that this occurs within a very patriarchal space with gendered understandings of personal autonomy and reproductive rights.
The COVID-19 pandemic has brought forth times of uncertainty exposing people to significant risk. The way communities and particularly women have come to be affected by the virus has exacerbated vulnerability as degree of severity felt differs and the structures of inequality determine this disproportionality in felt experience. The focus of health systems as gauged from reports, has been on COVID-19 related care and concerns have been raised regarding non-COVID related health problems and the kind of attention its being given as institutions are being geared towards specialized care. Here, reproductive health and consequently reproductive justice and rights come to be essential in a time where crisis has created disruptions in daily life as well as in access to healthcare and medication. Experiences of the pandemic are contingent upon structures of inequality such as caste, race, gender and occupation and understandings of good health and access to services for women are linked to these identities and how they’re articulated and received in the public sphere. Globally, discourses around race and reproductive justice have focused on the need to move away from conversations about the womb and instead move towards representation in policy and decision making while making the very approach to healthcare multidisciplinary. Locally, in the context of India, women from historically disadvantaged communities face the burden of stigma and discrimination on the basis of their socio-economic identities as well as their lack of proximity to institutional care like in the case of women from the rural areas or informal labour in the cities. Most pertinent in understanding these differentials, is that reproductive justice is a combination of reproductive rights and social justice, both aspects of critical importance to the lives of people of colour, disabled individuals, transgender individuals, people from rural areas, Dalit and Adivasi individuals for whom social inequities result in restrictions on human rights in a pandemic context. These groups are also the ones who have been historically excluded from key narratives around sexual and reproductive health and who are now facing additional anxieties in the current scenario.
Reproductive justice lies at the core of the right to equal access to healthcare and maintenance of personal autonomy when it comes to decisions made about one’s own body. It is important to note that this occurs within a very patriarchal space with gendered understandings of personal autonomy and reproductive rights. In the scenario of lockdown and/or social distancing, these rights are infringed upon and violated by virtue of the nature of the enterprise and a virus affected environment where high risks of transmission lead to compromises on autonomy. This is seen in the inaccessibility of contraceptive medication as well as clinic facilities for abortions which may also lead to the practice of unsafe abortions and consequently an increase in maternal deaths.
Structural constraints are thus evident in how India’s public health system has dealt with care. Though the Indian government has acknowledged reproductive health services as essential health services, reports show that the implementation of provisions has not been very widespread, possibly due to notions of risk on the part of both patients as well as healthcare personnel. The shortage of Personal Protective Equipment (PPE), staff and beds make availability of services scarce, and on the other hand fears of contracting the virus don’t encourage visits to institutional settings. The former is also a result of disruptions in global supply chains of equipment which has affected the strength of healthcare systems all across the world. These disruptions are not limited to equipment, but include the supply of contraceptives that are mainly sourced from Asia where factories are not functioning at full capacity with export bans on active pharmaceutical ingredients (APIs). Global responses to the virus and subsequent shortages have led to local shortages which compounds inequities in the realm of sexual and reproductive health as demand for these drugs is on the rise, while supply has not caught up.
With an overloaded and under-resourced health system, instances of discrimination have been rampant. Reproductive health rights have been violated through denials of admission into hospitals, unequal access to health institutions by virtue of location and stigma that is attached to the virus, and mistreatment of patients during labour, all instances of obstetric violence. Socio-economic inequalities manifest in these barriers to access through religious discrimination in the case of Muslim women, and physical distance which within pre-existent practices of purity and pollution through caste, becomes deeply problematic as it widens and reinforces existing power structures of hierarchy. Reports of sexual harassment of women in hospitals by staff has also rendered women more vulnerable to sexual violence in institutionalized settings. Furthermore, many of the women in rural areas and those from the informal economy in urban settings do not possess the capital to avail transport services to hospitals or pay for care, which leads to an added distress amongst pregnant women. This is also made worse by the information gap on which service to avail and where to go, which leads to delay in treatment as referral mechanisms don’t operate in an efficient manner.
For women with disabilities, this information gap is further worsened as it is not made accessible to them in forms that they can gauge by themselves. The shortfall of healthcare provision during the pandemic also brings about fears of whether or not the rights of women with disabilities will be prioritized during the pandemic. Discrimination as a result of the intersection of gender and disability had been present before the onset of the crisis, which only puts them at further risk and makes them more vulnerable in uncertain times. For transgender women, access to gender affirming surgeries and hormone interventions which require constant monitoring are compromised with diversion of resources to COVID-19 care. In addition, policy interventions based on a gender binary puts them at more risk in terms of security. In another vein, for sex workers and women employed in the informal sector, economic stability is quite uncertain. This is made worse with police repression for violation of social distancing norms. Health outcomes are then affected as state protection is more or less absent, making affordability of healthcare difficult as precarity of labour and economic depravity is a reality for these women. Reports of migrant women delivering their babies on highways without adequate care being provided before continuing their journeys back home, are instances of violation of maternal health rights. Limited access to sexual and reproductive health services has thus been the norm for women from marginalized communities which is also a source of added concern in an era of restrictive policies where community participation in decision and policy making is scarce.
In addition to these limitations, the diversion of resources and personnel to COVID duty, further constrains availability and timely access to reproductive health services. Legal mechanisms and judicial deliberation seem to be the recourse in order to ensure access, as is evident from Sama’s Public Interest Litigation in the Delhi High Court. The judgement stated that the right to reproductive health is a fundamental right and listed orders to ensure access to these services to mitigate these barriers. Provision of care for women in institutional settings and protecting their right to avail it is a part of their right to health which is recognized as a fundamental right under Article 21 of the constitution. This is linked to reproductive justice for women in their negotiations with the health system, the state and society, and how this is ensured and not violated regardless of circumstance and which also needs to figure in the list of priorities.
Politics then, cannot be removed from health and health itself comes to be gendered socially. As a result of this, healthcare access becomes gendered and determines which issues are prioritized and what gets medicalized. We have seen political issues make their way into conversations about reproductive justice during the pandemic in the case of a pregnant woman facing incarceration and others being subjects of verbal and physical abuse from hospital staff on the basis of their religious identity. In order to have an informed perspective of these experiences, acknowledging different oppressions in understanding how the pandemic comes to get reconfigured around existing discourses related to autonomy and rights, is important.
Reproductive justice cannot be looked at in abstraction, but rather needs to be studied as a product of intersections between reproductive rights, disability rights, socio-economic capital and religion amongst others. India has seen reports of these issues in the debates about the manner in which women have come to experience this pandemic. Ensuring reproductive justice and protecting it, is fundamental to the maintenance of dignity and personhood of these individuals as citizens. Restrictions placed on movement and interactions compromise this, while exposing the gaps that exist in the equity of provision of healthcare for women across the country. This must also be seen as resulting in the amplification of risks that the marginalized face due to bias and social circumstance. Moving towards community-centric provision of care is central to ensuring that reproductive rights remain protected, while simultaneously acknowledging that structures of power that delegitimize and disadvantage communities do exist and need to be addressed in this effort towards equitable and informed access. Mechanisms to ensure that these rights are protected are fundamental to the very endeavour of reproductive justice, which in the long run in a pandemic ridden world should be considered a given rather than be open to negotiation, with an emphasis on inclusivity.
Blog piece contributed by Keertana Kannabiran Tella, Masters in Development Studies at the Department of Liberal Arts, Indian Institute of Technology, Hyderabad as a part of her internship with Sama Resource Group for Women and Health.