Markets, morals and medicalised maternity: navigating a shifting health service terrain in Bangladesh

Abstract

This thesis lies at the nexus of recent transitions towards medicalised childbirth, marketisation of maternal health services and moralities of care, examining how women, their families and health actors navigate maternal terrains in transition in Bangladesh. Until recently, women in Bangladesh were characterised by academics, policymakers and global health practitioners as reticent to uptake biomedical pregnancy and birth care. Today, the use of advanced biomedical maternal technologies, made available through minimally regulated health markets even in the most remote areas and placed within the grasp of women of all social classes, is ubiquitous. While anthropological scholarship has primarily approached health markets as an outgrowth of global neoliberal hegemony and as de facto ‘immoral’, this thesis destabilises these assumptions, attending to the situatedness of maternal health markets in Bangladesh and seeking to understand the ways that moralities of care emerge and are renegotiated on their own terms. Based on 18 months of ethnographic fieldwork within national health policymaking and programming circles in Dhaka and among health service managers, providers and women in Kushtia district, it argues that the rise of maternal health markets in Bangladesh is embedded in and reflects a distinctly Bangladeshi political, social and economic context, rather than a global homogenising agenda. It argues that maternal health markets in Kushtia have mushroomed not in response to a perceived retreat of the state but in response to a public health system perceived as fundamentally fragmented, failing to deliver ‘care’, and existing solely to respond to ‘the poor’ (gorib manush). This thesis contends that while maternal health ‘care’ in public settings often appears ‘uncaring’, this apparent ‘uncaring-ness’ is structured by government providers’ moral imperatives to provide ‘service’ (sheba), though not necessarily personalised, hands-on ‘care’ (jotno), challenging the often taken-for-granted coupling of clinical care and affective care.

While commodified services come at a cost, both financially and in terms of clinical quality, markets provide imagined spaces where women might access ‘care’ (jotno) beyond ‘service’ (sheba). In addition to opportunities for women, maternal health markets expand possibilities to pursue formal and informal livelihoods for people of all social classes. Nevertheless, while opening economic opportunities where livelihood-making is more generally precarious, this thesis argues that morality is also central to the project of health market-making in Kushtia. Both formal and informal actors navigate and negotiate this morally ambiguous space as they seek to secure livelihoods and conform to moral imperatives. This thesis traces women’s and their families’ navigation to fulfil aspirations for maternal health services in this nebulous space-in-the-making. It argues that social navigation principally demands nurturing and leveraging social connectedness to access biomedical resources, destabilising logics underpinning conceptualisations of health services either as ‘entitlements’, delivered by a state based on citizenship or as pure ‘market commodities’, delivered through a health market according to the principles of classical economics. Indeed, rather than a manifestation of hegemonic neoliberal ideologies, the maternal health terrain in Kushtia reflects the nimble and situated navigation of actors pursuing health, economic and moral ambitions, both responding to and constituting states of flux and transition long inherent to the Bangladeshi experience.