Nara Women's University
Is Health Care a Right or an Obligation: An
Exploration of Medicalization of Childbirth in
Rural Bangladesh and in Japan
メタデータ

言語: Japanese
出版者: アジア・ジェンダー文化学研究センター
公開日: 2023-05-18
キーワード (Ja): バングラデシュ,
メディカライゼーション(医療化), 健康管理, 権利, 日本
キーワード (En): Bangladesh, Health Care, Japan,
Medicalization, Right
作成者: 松岡,悦子
メールアドレス:所属:

URL

http://hdl.handle.net/10935/5930

アジア・ジェンダー文化学研究【第 7 号】2023

Is Health Care a Right or an Obligation: An Exploration of
Medicalization of Childbirth in Rural Bangladesh and in Japan
Etsuko Matsuoka
Introduction
Two opposing situations are discussed in current maternal health care acrossthe world. One is characterized by over medicalization of childbirth, a situation known
as “too much, too soon” common in many high-income countries, and the other is“too little, too late” often found in low-income countries (Miller et al. 2016). However,in some low- and middle-income countries there are signs of over medicalization ofchildbirth, characterized by high cesarean section rates. By drawing on examples ofchildbirth in rural Bangladesh and Japan, this article analyzes the relationship between
maternal health care practiced in these countries and notions of health care defined in
the Declaration of Alma-Ata which is now known as “Health for All by the Year 2000”. 1）
The Declaration states that existing gross inequalities in the health status of people indeveloped and developing countries, as well as within countries, is politically, sociallyand economically unacceptable and urges governments across the world to provide
adequate primary health care to attain a level of health that will permit people to leada socially and economically productive life. Since this Declaration was made, healthcare provision has emerged as an important political issue for governments acrossthe world. Similarly, during the period of the MDGs (Millennium Development Goals),maternal health came forward, as Goal 5 focused on the reduction of the maternalmortality ratio. In 2015 the UN estimated annual maternal deaths worldwide to be
303,000 out of which 99% took place in low- and middle-income countries. Bangladesh
was one of these low-income countries with a high maternal mortality. It implemented
various measures to improve maternal mortality into rural areas, which resulted inchanging the way births were conducted as well as women’s experiences of birth inthese areas.
In this article, I will first talk about the notion of health and health care
described in the Declaration of Alma-Ata. I will then draw on maternal health careprovided in Bangladesh and in Japan. In the discussion, I will compare maternal healthcare provided in the two countries according to the notion of health care as definedin the Declaration of Alma-Ata. In so doing, I will propose a better way of providing
health care in which women’s rights and birth experiences are more respected byreconsidering the medicalization of childbirth from different perspectives.

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アジア・ジェンダー文化学研究【第 7 号】2023“Health for All by the Year 2000”
The Declaration of Alma-Ata with the famous goal of “Health for All by theYear 2000” was announced in September 1978 in Alma-Ata, then the capital of theSoviet Republic of Kazakhstan. The WHO set a landmark in this slogan and establisheditself as the leader in the area among the international community. The Declaration
described health as a fundamental human right and stated that governments havea responsibility for the health of their people, that the key to attaining health is theprovision of primary health care that is accessible to individuals through their fullparticipation and at an affordable cost to the community. These new ideas of healthcare drew upon the ideas and experiences of NGOs and developmental workers
practicing in Asia, Africa and Latin America at the grass roots level, rather than uponbiomedical measures which had so far been taken by developed countries (Cueto
2004, Brown and Fee 2006). Furthermore, the Declaration framed health within atriangle of economics, politics and human rights (Kickbusch 2000). The economic
framework related health with the development of countries by linking it to sociallyand economically productive lives in given populations. The political framework was
illustrated by the statement that governments have a responsibility for the health oftheir people, and that all governments should formulate national policies to launchand sustain primary health care. These statements put health on the political agenda.
Health was also associated with human rights, as the Declaration stated that health wasa fundamental human right that should be made universally accessible to individuals.
In this way this new framework of health and health care was a radical transformation
for WHO, as it contextualized health in broad sociocultural settings and in doing so
avoided narrowing it down to biomedicine.
Reading this Declaration in English, one realizes that the words health andhealth care are used consistently without employing the word medicine or medical care.
There is only one place where the word biomedical is used; (primary health care) isbased on the application of the relevant results of social, biomedical and health services
research and public health experience. There is no other place in the Declaration
where the word medicine appears. However, when this Declaration is translated into
Japanese, the word “ 医 療 ” (read as iryo ; medicine) appears many times; for example,“ 医療 ” appears three times and 保健医療 (hoken-iryo , translation of health care) appears
eleven times. Equally, the translation of referral system became “ 医療機関 ” (iryo-kikan ;medical institution) in Japanese. 2）It is worth considering why health and health care areconsistently translated as “ 医療 medicine” in Japanese, while the Alma-Ata Declaration
carefully avoided using the term ‘medicine’ and continued to use health and health care.
One reason behind this may be derived from the WHO’s efforts to see health and health26

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（特殊）Is Health Care a Right or an Obligation: An Exploration of Medicalization of Childbirth in Rural Bangladesh and in Japan

care in a wider social, political and economic perspective and by doing so avoiding
setting it in a narrow western medical context. Another example is illustrated in thestatement which went that (primary health care) relies on health workers, including
physicians, nurses, midwives, auxiliaries and community workers as applicable, as wellas traditional practitioners as needed. 3) This inclusion of traditional practitioners among
health workers takes into consideration the fact that many first level contacts of primary
health care in developing countries are not full-fledged clinicians. A comparison of the
English and Japanese version of the Alma-Ata Declaration shows that the former takes
a wider perspective in the understanding of health and health care, whereas the latter
repeatedly translates them into the narrower medicine and medical care. One reason
may be attributed to lack of appropriate Japanese word for health care apart from 保健
医療 (hoken-iryo ). However, reducing the word health care with its wider implication tohoken iryo whose focus is predominantly on medical care and medicine not only erodes
but also manipulates the original meaning and intentions of health and health care in
the Alma-Ata Declaration. The boundaries of health care and medical care are not
the same. It is possible to assume that adopting the words health and health care may
be the result of a struggle to overcome a biomedically dominated perspective even in
English speaking countries. Especially in an organization like the WHO, where nations
with different histories and background gather, a political platform, where tensions
between developed and developing countries as well as conflicts of interests, manifests
in many different forms. Perhaps in the 1970’s, in an effort to take a leadership position
in global health, the WHO adopted a wider framework of health which encompassed
the perspectives of developing countries by noting existing disparity between themand developed countries. Therefore, the Declaration of Alma-Ata was the outcome ofwider perspectives taken by the WHO to encompass both economically developing anddeveloped nations. It recommended the use of culturally appropriate technology andthe use of different types of health workers in providing primary health care, strategies
based on very extensive and comprehensive viewpoints. Overall, it is no surprisethat the Declaration was criticized for being too broad and idealistic and having an
unrealistic timetable as shown in the phrase ‘by the year 2000’（Cueto 2004）.
Furthermore, the definition of health as a fundamental human right and ofhealth care as governments’ responsibility, together with the idea that the promotionof health of the people is essential to economic and social development was achallenging task to most developing countries, because many of them had just achieved
independence from colonial powers. They had inadequate infrastructures and werepolitically unstable or ruled by corrupt governments and consequently unable toimplement sound and democratic health policies（Kickbusch 2000）. Therefore, insteadof establishing robust primary health care policies domestically, they relied on donor

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アジア・ジェンダー文化学研究【第 7 号】2023

agencies and international NGOs to implement health projects to yield outcomes within
limited time periods. The preference of donor agencies also contributed to the way
these projects were conducted; donors themselves preferred short-term medical andtechnical measures because results could be demonstrated in much shorter periods.
A sociocultural approach, on the other hand, took longer to demonstrate any results
because they aimed at improving sanitation, hygiene, education and other broader
aspects. Furthermore, governments in developing nations could not finance adequate
public health care to meet the demands of their people. Thus, they invited andformed partnerships with private health sectors to fill their inadequacies. However, theconstruction of private hospitals, most of which were profit driven, began to change
the way health care was delivered. The concept of primary health care defined in the
Declaration of Alma-Ata began to take a different shape in the 90’s in developing
countries (Koivusalo and Ollila 1997). I will illustrate such an example by drawing onchanges to childbirth in Bangladesh in the next section.

Medicalization of childbirth in Bangladesh: effects of MDGs
The United Nations Millennium Summit was held in 2000 with 189 countries
participating and eight goals to be achieved by the year 2015 being established. Goal
5 of the MDGs aimed to reduce the maternal mortality ratio by 75% of the 1990 figureby 2015. 4）Maternal mortality ratios across the world clearly demonstrated a disparity
between high-income and low-income countries. The maternal mortality ratio was 23
and 12 out of 100,000 births in 1990 and 2015, respectively, in high income countries,
while they were 430 and 239 in the same years in low-income countries, 20-fold higher
in the latter (Graham et al. 2016: 9). It was understood that maternal mortality wasclosely associated with multiple factors such as gender inequality, lack of educationand of access to health care, poverty, and so forth. The WHO and other internationalorganizations published trends in estimates of maternal mortality ratios by country,
between 1990-2015 and classified each nation’s progress towards MDG5 in four
categories: no progress, insufficient progress, making progress, and achieved. Although
Bangladesh did not meet the target figure of 143 per 100,000 births in 2015, its efforts
were categorized as “making progress” as it achieved a 69.1% reduction to 176 per
100,000 births (WHO 2015) (Fig. 1). Progress towards MDG5 was measured throughtwo indicators, reduction of maternal mortality ratio and births attended by a skilledattendance (SBA: Skilled Birth Attendant). 5) The government of Bangladesh’s strategies
to reduce maternal mortality were as follows: introduce EmOC (emergency obstetriccare, from 1994) at the facility level; provide safe delivery at home by SBA (training
started from 2001) and achieve a lower birth rate itself by the use of family planning

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（特殊）Is Health Care a Right or an Obligation: An Exploration of Medicalization of Childbirth in Rural Bangladesh and in Japan143

Fig.1 Trends of maternal mortality ratio with an estimated figure for 2022 and the target figure for 2030, Bangladesh(including menstrual regulation)（Koblinsky et al. 2008）. Moreover, a more drastic
strategy called demand side financing was employed in some districts. In this project,vouchers were delivered to economically disadvantaged women to encourage themto access medical care from the antenatal to the postnatal period, covering the cost ofantenatal care, facility birth or home birth by SBA, postnatal care and transportation
costs. 6）These measures clearly illustrate the assumption that high maternal mortality
could be attributed to a lack of medical care and by moving births from homes to a
medical facility and replacing TBA（Traditional Birth Attendant）with SBA, mortality
ratio could be improved. The MDGs ceased to exist after 2015 and were replaced with
SDGs where maternal mortality was defined in Goal 3. In the latter, the goal is to have amaternal mortality ration of less than 70 per 100,000 women globally by the year 2030.
Consequently, as shown in Fig. 2, the nationwide figures of facility birth andattendance by SBA both increased robustly; from 9% (1999) to 49% (2017 ～ 2018) for
facility births and 21% (1999) to 53% (2017 ～ 2018) for SBA attendance. However, theproportion of cesarean section followed suit, rising from 3% in 1999 to 33% in 2017 ～ 2018
(BDHS). Rising rates of facility birth and SBA attendance were desired outcomes of the
MDGs campaign but increased cesarean rates was an unfortunate unforeseen outcome.
％
％
％
％
％
％
％

Fig.2 Trends of SBA attencance, facility birth and cesarean section rate, Bangladesh
Source :BDHS (Bangladesh Demographic and Health Survey)

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アジア・ジェンダー文化学研究【第 7 号】2023

In the next section I want to look more closer at how childbirth has changed in
one district of Bangladesh, with a focus on women’s birth experiences. At first glance,a chart like Fig. 2 may give the impression that Bangladesh is smoothly on its way tomodernized reproduction, but if we shed light on women’s birth experiences, a very
different picture arises.

Research in Madaripur District, Bangladesh
The following section is based on anthropological research conductedintermittently between 2016 and 2021 in Rajoir Upazila (population 218,095), a
subdistrict of Madaripur District which is around 80km southwest of the capital city
Dhaka. 7）To reach this area it used to take 6-7 hours from Dhaka by car and ferry
before the Padma Bridge was opened in June 2022, but now the time has beenshortened to less than 2 hours. The research was conducted in two villages in Rajoir
Upazila; in 2016 questionnaire-based research was conducted with the cooperation of
514 households, and in 2017 interviews on childbirth were conducted with 42 women,
and again in 2021 questionnaire-based research was conducted in 626 women who
had given birth within 5 months of the research date.
Fig. 3 shows the birthplace of all the babies born to women respondents by
year. It tells us that before 2005 almost all births took place at home or at a parent’s
home, but after 2005 hospital and clinic births gradually increased. Fig. 4 shows birthattendants of all children born to women respondents by year. It shows that a TBA,
who is called ‘dai’ in this area, usually assisted birth, but the attendance of a SBA
gradually increased, and in 2015-2016 about half of children were delivered by doctors.
We need to note here that a SBA in Bangladesh differs from the WHO’s definition of
a SBA. The WHO defines that a SBA is an accredited health professional - such as a

Fig.3 Trens of place of birth30

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（特殊）Is Health Care a Right or an Obligation: An Exploration of Medicalization of Childbirth in Rural Bangladesh and in Japan

Fig. 4 Trends of birth attendant

midwife, doctor or nurse - who has been educated to manage normal delivery. In otherwords, a SBA according to the WHO usage is a comprehensive term to include healthprofessionals accredited in each society and a TBA is not included in it. However, in
Bangladesh, a SBA is a type of worker who received training for six months after being
recruited from female field workers or family-planning workers and is differentiatedfrom a midwife or a doctor. In some cases, a SBA is a self-proclaimed term and a TBA
may call herself a SBA after being trained for a short period of time. Therefore, a SBA
in Fig. 4 does not include doctors or midwives but those who call themselves SBA. It
shows that childbirth in this area has undergone extensive changes in terms of place
and attendant since 2005, with recent data showing doctors attending 50% of births
and cesarean section rates coming up to 27% in 2016. 7）From a public health point ofview, this is a good sign in that birth has gradually come under medical managementwith more women giving birth in a medical facility and assisted by doctors. However,
the effect this has had on women in terms of their health and their birthing experiences
needs to be investigated further, because there is already a sign of an incessant rise incesarean section rates.
Fig. 5. Illustrates the relationship between place of birth and women’s feedbackon their birth experiences. The results show that more women answered their birthexperience was good when they gave birth at home compared to in the facility, andthis difference was statistically significant.
Fig. 6 shows women’s feedback of their birth experience by person attending
the birth. If they were assisted by a TBA or SBA, they tended to give positive feedback
compared to if they were assisted by a doctor; this difference was also statisticallysignificant. Therefore, it can be interpreted from this research that women are more
happy giving birth at home assisted by TBA or SBA than giving birth in a medical
facility.

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アジア・ジェンダー文化学研究【第 7 号】2023

Fig. 5 Women's experience of birth by place of delivery

Fig. 6 Women’s experience of birth by birth attendant

From this we are then confronted with the question, why do they give birth ata medical facility, if they did not prefer to do so. To investigate this contradiction, in
the 2021 questionnaire the following two questions were added: where did a woman
intend to give birth and where did she actually give birth. Out of 626 respondents
62.9% (389 women) intended to deliver at home, but only 33% (206 women) did so
and the rest delivered in a hospital. The reason for this is because 47% of those who
intended to deliver at home were referred to a hospital for a variety of reasons such as
cervix not dilate, contractions were too weak, waters broke, worried about the baby
and so forth. It seems that TBA agreed with the opinions of woman and her family
and even proposed that they go to hospital, rather than stopping them from going tohospital. It is interesting to note that TBA can receive incentive money from private
hospitals in return for sending patients to them. 8）This appears to be an unhealthy habit
because TBA profit financially by encouraging women to go to hospital. However, it
gives a different picture when seen in the context of the government campaign where
birth in a medical facility is strongly recommended. In such a context TBA’s behavior
is not so much irresponsible, but willingness to follow the national policy which wasdisseminated from top to the grassroots level through varieties of community healthworkers and NGOs. It may be possible to say that women did not choose where32

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（特殊）Is Health Care a Right or an Obligation: An Exploration of Medicalization of Childbirth in Rural Bangladesh and in Japanthey wanted to deliver but were pushed toward facility birth by the enormous powerof government strategies as well as by corporate industrial powers that had driven
private hospitals for profit. Indeed, a significant decrease in MMR is a positive aspectof the government strategies, but this could have been brought about by not only
an increase in facility birth but by other sociocultural changes in women’s living
environments. Furthermore, it is necessary to pay attention to the negative side of the
top-down government strategies which denied women a choice in their place of birthand underestimated women’s birth experiences. Also, given the research data revealingthat medical facilities in many low- and middle-income countries fail to provide skilled,
high-quality, respectful care (Campbell et al 2016: 45), it will be necessary to explore
actual birth settings of rural women in qualitative ways in order to see how much of anincrease in facility birth has resulted in reduction of maternal mortality in Bangladesh.

New private hospitals and rising cesarean section rates
Results of the 2021 questionnaire showed a cesarean section rate of 60%
out of all respondent women, but when it was restricted to those who delivered in a
medical facility, 70% of the 626 women, the rate jumped up to 90%. This extremely
high rate of cesarean section is well known to health workers and TBA in this area,
which meant that they encouraged women for a facility birth knowing that nine out of
ten women would receive cesarean section. At the same time, they justified themselves
by saying that women and their family were prepared for this outcome at the time
when they decided to move to the hospital. One of the determinants of a facility birthalmost equating to a cesarean delivery is the fact that these births take place in private
hospitals.
In the 1990’s there was only one public hospital (Upazila Health Complex) inthis area and women did not think of delivering babies in
hospital unless there was an emergency. However, since2007 new private hospitals have been built every one orTable 1 Cumulative number ofprivate hospitals by year

two years and there are a total of 10 private hospitals
in this subdistrict in 2021 (Table 1). As these private
hospitals are for-profit, they compete with each other forprospective patients. 9) One major reason why a laboring
woman goes to a private hospital is because doctors are
not present in the public hospital outside of the opening
hours which is from 8:00 to 2:00 pm; doctors either havea private practice of their own or work in private hospitals
after 2:00 pm (Chaudhury & Hammer 2003). Also, there

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may be some patients who choose to go to a private hospital
expecting to have a private room or another more comfortable

Table 2 Number of overseas
workers by the year theyleft Bangladesh

environment (Andaleeb 2000, Andaleeb et al 2007, Adams et
al 2019). It is interesting to understand why private hospitals
started practicing from 2007, as the cost of delivery is much
more expensive there than in the public hospital or birth
at home. According to the 2021 questionnaire, the average
cost of delivery at home was 2328 taka (around 3500 yen),whereas the average cost of all the respondents was 19246
taka (29000 yen). Considering the average monthly income of
all the respondents is 21144 taka (31700 yen), the change inthe delivery fees from home birth to hospital birth is enormous
which makes me think that there must be some underlying
economic changes to make this shift possible. Table 2 isthe trend of overseas workers in the area showing that the
numbers have remained in two digits with some fluctuations since 2007 to reach up to
37 in 2016. It is plausible to think that the remittance from overseas workers contributed
to raise the overall financial situations of households in this area, the effect of which
is obvious by the size and appearance of newly built houses in the area. Therefore, I
would suggest that the building of private hospitals and the increase in the number ofoverseas workers went side by side to make drastic changes in the way women gavebirth. On the other hand, the question must be asked why private hospitals contributed
to the rising number of cesarean sections. To investigate this, I must rely on qualitative
research which employs an ethnographic description of how decisions are made duringlabor and delivery both at home and at a facility.
Sometimes one reason for the rising cesarean section rate is attributed to a
woman’s choice, saying that a woman wants a cesarean section because she cannot
or does not want to endure pain. One woman doctor in a hospital in Dhaka once
said, “Women do not want to have a normal delivery. They shout and cry. becauseof this the cesarean section rate in Dhaka has reached 70-80% now” (interviewed in2006). However, interviews conducted in 2017 depicted contradictory pictures as far
as women in this area were concerned. They said that a cesarean section took much
longer to recover from, and they do not want to have it.
“Who wants a c-section? Many complications may arise after caesareandelivery. Those who had normal delivery can lift heavy things and can do all chores,
but I had to rest for 6 months.” (Lovely, 27years, 2017, 1 son)

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（特殊）Is Health Care a Right or an Obligation: An Exploration of Medicalization of Childbirth in Rural Bangladesh and in Japan“In this village everyone prefers to have a delivery at home because money
is a concern. Nobody wants to spend 15000-20000 BDT unless there is an extreme
situation.” (Nipa, 29 years, 2017, 1 son and 1 daughter)“My daughter had a cesarean delivery and I had to take care of her for a long time.
She had to remain careful and had to move slowly after cesarean delivery. She couldn’t
even cough or run. Aren’t these problems? My daughter still feels pain in the stiches.
Normal delivery is a grace of God. “ (Jesmin, 35 years, 2 daughters and 1 son)
These are only some of the narratives collected in 2017 but all the women
except for one whose son had been damaged at the time of delivery in hospital, said
they preferred normal delivery to cesarean section. Then, there comes the question why
they ended up having a cesarean delivery. One scenario is that women visit a private
hospital for ultrasound pictures to be taken and start building a close relationship witha particular female doctor whose advice they follow all through pregnancy to delivery
which often ends in cesarean section. Another scenario is that women and family
members intend to deliver at home but after some hours start feeling anxious anddecide to go to hospital. In the hospital they receive information that the baby is at risk
and they agree to go on cesarean section. And once a cesarean section is given to a
woman, she has to have repeat cesarian section for subsequent deliveries, as known by
the phrase ‘once a cesarean, always a cesarean’. In this way, single cesarean section
may lead to repeated cesarean sections for a woman even though she agrees to it just
one time.
To summarize, the Government of Bangladesh took measures to reducematernal mortality by increasing women’s access to medical care during pregnancy andbirth. Large numbers of birth took place at private hospitals because the public facility
was only open for a limited amount of time. In this context, access to medical care wasconsidered as a right for women who were mostly poor and had been denied access to
medical care until then. But as the number of hospital births increased, it has become
obvious that births in private hospitals almost always means cesarean deliveries. Thisnot only applies to Rajoir Upazila where the research was conducted, but is confirmed
in nationwide data in which private hospitals and clinics manifest a 72.8% cesarean
section rate (Health Bulletin 2019). I argue that birth in the context of medicine which
was pursued as a woman’s right in the early stage of MDGs, was transformed to
obligation in accordance with the increase of births in private hospitals. Although awoman agrees to or wishes to deliver in hospital, it does not mean she agrees to havea cesarean birth. But given the fact that 90% of births are cesarean section in private
hospitals, her chance of having one is almost certain, even without her consent. Here a

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specific type of medical care is almost compulsory, in other words, obligatory. I would
say that medical care has been transformed from right to obligation in Bangladesh.

Childbirth in Japan
Almost all childbirths take place in a medical context in Japan and medicine
is seen as an indispensable part of pregnancy, delivery and all through the postpartum
period. Medical care is provided to women more as an obligation rather than a right.
For instance, a woman with a normal pregnancy is expected to receive 14 antenatal
check-ups and if she happens to receive none, she is categorized as a high-risk casewhich invokes a sense of irresponsibility, poverty, and harm to the fetus. Furthermore,
if a woman decides to give birth outside of a medical environment, without a midwife
or a doctor but surrounded only by family members, she is most likely to be punished.
Sanctions may vary from difficulty getting the birth registration accepted, being
suspected of child abuse or in the worst scenario a baby may be taken into protective
custody by the public authority. According to Ichikawa, this way of birthing is estimatedto be very rare, around 0.035% of all births and those who have practiced it call thisway of birthing “ a private birth” instead of unassisted birth ( 無 介 助 分 娩 in Japanese)(Ichikawa 2021), because they are assisted by a partner or friends both mentally andphysically.10）The fact that private birth is considered as unassisted birth despite being
surrounded by close friends or family members means that only medical professionals
are recognized as the right people to assist in delivery. Nonprofessional assistance isseen as equal to unassisted and dangerous in Japan. However, it must be noted that
one of the reasons that a private birth takes place is because a midwife’s presence
is not easy to obtain due to the guidelines regulating midwifery practice, such as
geographical distance or an approval from a back-up doctor in charge of the midwife.
In other words, a private birth is generated in an environment where a choice of normal
birth at home with a midwife’s attendance is hard to realize. There is a contradiction
between the idea that medical care is an obligation and the institutional inadequacy
which does not provide women who want a homebirth with midwifery assistance as an
option. The following narrative by one woman depicts that medical care is taken for
granted and it is very difficult to imagine a world without medical care.
“Because I had ‘a natural delivery’, I was physically and mentally devastated.
My labor pain was weak, I was put on drugs to speed to the delivery, accelerating
drip. Then severe labor pains came every minute. Excruciating pain lasted for 9 hours
without any effect and the doctor said “let’s stop here and try inducing the delivery
again tomorrow”. I told him I would die if I had to go through this again. Somehow

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（特殊）Is Health Care a Right or an Obligation: An Exploration of Medicalization of Childbirth in Rural Bangladesh and in Japanmy baby came out a few hours later. But the next day the bottom of my body was
numb, so I needed to use a wheelchair the whole day. If somebody asked my advice, I
would say do not exhaust yourself in birth because you need to take care of your baby
afterward.

(38 years old first-time mother, interviewed in 2022)

Although she called it a natural delivery, it is not natural because she was on drugs toaccelerate labour. What she meant by natural delivery was, in fact, birth without pain
relief and she regretted not utilizing it, because the birth was very damaging to her both
physically and mentally. She said she would advise people not to exhaust themselves
and only rely on an epidural for pain relief.
Very often people look toward de-medicalization due to a very bad birthexperience caused by medical intervention. For instance, people who had a traumaticbirth previously may want to deliver at home or at maternity home run by a midwife
the next time round. However, contrary to this direction, this woman wants to havemore medical intervention in order to overcome previous bad experiences. In this caseshe thinks she should have an epidural delivery the next time. Although the proportionof epidural delivery is very low in Japan compared with the west, it is increasing
steadily to reach 8.6% in 2020. 11）It is interesting to explore why two types of reactions
are seen; one type seeks to avoid medical intervention after suffering from it previously,
while the other looks for more medical intervention despite previous suffering. In Japanthese two attitudes toward medical care are observed and in recent times the latter isgaining ground. My assumption is that because medical care is already part of our daily
life and a basic infrastructure of our living, it is difficult to imagine a society without
it. For most people to think of avoiding medical care in any aspects of life, including
maternity care, would be unplausible and unrealistic.

Discussion
In this section I would like to discuss four points. The first point asks if it is rightin assuming that Bangladesh lacked health care in the first place. The second questionis what is a driving force of a rising cesarean section rate in Bangladesh. The third
point deals with two different attitudes toward medical care and reasons behind these
attitudes. Lastly, I would like to reflect on the notion of health care as defined in the
Declaration of Alma-Ata and health care as practiced in Bangladesh and in Japan.
Firstly, is it correct in assuming that people do not have access to health carein rural Bangladesh? The results of questionnaires and interviews conducted show thatwomen had a variety of people to talk to such as TBA, village doctors, 12）Kobiraj13）
and health workers during pregnancy and whenever help is needed. In Bangladesh the

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proportion of formal medical personnel including doctors, dentists and nurses is only
5%, and the other 95% consists of paramedics, traditional practitioners, TBA, village
doctors, drug sellers, homeopathic doctors, ayurvedic doctors and so forth (Bangladesh
Health Watch 2008: ii; Ahmed et al. 2011). As these figures are based on 2007 researchand recent figures could be different with fewer TBA or village doctors, and yet despitea belief that Bangladesh is lacking in health care, there are plenty of people whom
women can rely on. They are exactly “first level contacts of individuals, the family andcommunity” as stated in the Declaration of Alma-Ata, in other words, they are primary
health care providers of the village people. Rural women may feel reluctant to access alicensed medical doctor, but they feel much more comfortable to visit these health careproviders who live in their vicinity. Thus, if health care is defined broadly to include
non-biomedical care, Bangladesh has many of those health care providers.
Here, it is noteworthy to mention Arthur Kleinman’s work on medical pluralism.
He is a well-known medical anthropologist and psychiatrist with research experience in
Taiwan who said that health care in any cultures consists of plural sectors（Kleinman
1981）. One is a professional sector made up by licensed doctors who are trained
biomedically. The folk sector consists of traditional practitioners and healers of different
backgrounds who are granted skills in specific cultures. The popular sector consists offamily members and other lay people who are not healers but consulted for help ineveryday living. In Bangladesh the folk-sector is very large whereas the professional
sector is extremely small, only 5% in 2007. Kleinman says that in any culture, healthcare consists of plural sectors with a variety of people involved. If attention is paid to
only formal sectors, Bangladesh may lack resources for health care, but it has abundant
health resources when health care is defined in wider terms.
Also, there is a hierarchy where the professional sector comes out on top, andthe folk sector is treated as an informal sector with their knowledge devalued. Althoughboundaries between the formal sector and the informal sector are not clear, the informal
sector emphasizes its proximity to the formal sector, whereas the formal sector tries toascertain its legitimacy distancing itself from the informal sector（Cross & MacGregor2009). A village doctor in Bangladesh represents a very good example. Despite a lack offormal medical training, a village doctor diagnoses, prescribes medicine and is called toa delivery at home as he has won the trust of many women. Pinto argues that althoughformal sectors may try to express distance from informal sector by saying that theirknowledge is irrational or based on lack of evidence, what the formal sector does is,establishing hierarchies between the two sectors (Pinto 2004). Grasped in this broader
perspective, to look at Bangladesh as lacking in health care is based on a biomedicallydominated perspective which may overlook some of the important health resourcespresiding in Bangladesh. Having said that, it doesn’t mean that Bangladesh does not

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（特殊）Is Health Care a Right or an Obligation: An Exploration of Medicalization of Childbirth in Rural Bangladesh and in Japanneed to implement health care systems based on biomedicine. The fact that maternalmortality is still high means that it needs to employ emergency obstetric measures tolower the rate to less than 100 per 100,000 births. What I want to stress here is that
health care other than the professional sector needs to be given the same amount ofvalue as the professional sector, because both the folk sector and the popular sector
successfully treat a percentage of people. Kleinman says 70-90% of symptoms are dealt
with in the popular sector without being seen by the doctor. From this, it can be said
that framing Bangladesh as lacking in health care is a narrow perception deriving froma biomedically dominant viewpoint.
Next, I would like to consider the driving force of the rising cesarean section
rate. Indeed, the increased proportion of facility births has resulted in the increased
cesarean section rate nationally. But as shown in BDHS (Bangladesh Demographicand Health Survey), not all facilities have a high cesarean section rate. For instance,in Rajoir Upazila, the cesarean section rate of the public hospital was 43.5% in 2017,27.3% in 2018 and came down to only 10 % in 2019. This big discrepancy between
public and private hospitals reveals that private hospitals have exceptionally highcesarean section rates, suggesting some of them are unnecessary. Dependence on
the private sector is a necessary evil considering the limited practicing hours andghost doctors in public hospitals (Chaudhury et al. 2003). However, considering theeffects of profit-driven private hospitals on the health of women, regulations must be
implemented so that women’s bodies are not cut for the sake of profit. In the longrun, the effects of cesarean section may contribute to worsened maternal mortality.
As private hospitals are built for business purposes, perpetually seeking out patients,
they became a driving force to move health care from a right to an obligation. My
assumption is that profit motive and medicine as an industry are the driving forces of
medicine moving from rights to obligation.
Thirdly, I would like to discuss the reasons behind the two contradictory
attitudes toward medicalization of childbirth, one seeking more medicine and theother trying to avoid it. As I wrote in the previous section, the 38-year-old woman
was thinking of using more medicine (in this case anesthetic) after she had a very
painful birth due to the acceleration of labor. She wants to solve the problems causedby medicalization by relying on further medical care. But she could take a completely
opposite direction that is to avoid medical care the next time. Here, I would turn to asociologist named Chang Kyung-Sup whose theory may be applied. He used the word
first modernity and second modernity (equivalent to postmodernity or late modernity)
and wrote that in the second modernity people attempt to avoid risks generated in
the first modernity (Chang 2010). Applying his theory to the trends in childbirth, thefirst modernity refers to the period when birth moved from home to hospital, andGender and Culture in Asia Vol.7, 2023

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the second modernity may refer to the period when the natural childbirth movement
became active, because this movement can be seen as an attempt to avoid risks causedin the first modernity, such as too much pain coming from induction or accelerationof labor, injuries caused by vacuum or cesarean delivery, exhaustion from anesthetics
or other drugs, and bodily discomfort and loss of autonomy in the course of delivery.
This direction of the second modernity in the area of Childbirth happened in 1980’s
in Japan. However, in recent times a different type of the second modernity is gaining
ground, a direction to overcome the risks of the first modernity by the use of more
medicine as exemplified in epidural delivery and cesarean section on demand. In otherwords, risk of medicalization is going to be solved by over medicalization rather thande-medicalization. Granted that these two contradictory responses exist in the second
modernity, what are the reasons behind? I would argue that biomedicine becoming
more and more dominant and obligatory, there is no way to avoid medicine in the latemodernity. As medicine is now a norm of behavior and point of reference in Japan, demedicalization may be labelled as either anti-social or a thought of some elites. For
most ordinary people over medicalization is an easier way out to medicalization and its
concomitant risk.
Lastly, I would like to go back to the notion of health care in the Declarationof Alma-Ata and compare it with maternal health care provided in Bangladesh and inJapan. Health care defined in the Alma-Ata Declaration is very broad and not limited tobiomedical care. Health care may include a variety of support such as moral support byfriends, encouraging words or warm touch by people, traditional knowledge of healing,
culturally inherited method of alleviating pain and many others. But the wealth of thesemeasures for health care are less visible now due to the dominance of biomedicine(Illich 1976, Katz Rothman 2021). If we understand that health care is much broader
than biomedicine, we might have more alternatives to choose from. For instance, the38-year-old woman may have more choices apart from anesthetics; warm touch by a
midwife, walking to accelerate labor, taking a warm bath or just having somebody staywith her. These things may make a big difference. But when health care is reduced tobiomedical care, many culturally important types of ‘care’ may be lost or devalued.
Although biomedicine is an important part of health care, there must be
reasons why the Declaration of Alma-Ata kept using the word health care and health.
My assumption is that the WHO took a position that health should be considered notjust from a biological point of view but also from sociocultural contexts and that healthshould not be reduced to biomedicine. Within the WHO there was always tensions
between social and economic approaches to population health and technology or
disease focused approaches (Brown et al. 2006: 66). In fact, in 1979, the next year
when the Declaration was established, a group of people proposed a more disease-40

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（特殊）Is Health Care a Right or an Obligation: An Exploration of Medicalization of Childbirth in Rural Bangladesh and in Japan

oriented approach to health care, called selective primary health care（Walsh &Warren 1979）. The Alma-Ata Declaration was criticized for being too broad andidealistic and having an unrealistic timetable. Instead, selective primary health care wasintroduced which aimed to tackle the main diseases of developing countries in moreinterventive ways (Cueto 2004). These tensions clearly depict two contrasting ideasthat see health as a result of people’s knowledge and choice and one that believes inmedical and technological intervention. For the former, medical intervention is only one
option and often not the most appropriate（Rifken & Walt 1986）.

Conclusion
It is noteworthy that there were always tensions about ideas of health andhealth care within the WHO. However, childbirth is not a disease but an importantlife event of women which takes place in their everyday living. Consequently, it isimportant to provide maternal health care not in a disease-focused way but a way inwhich a woman can choose according to her lifestyle and values. It will be important
to go back to the idea of health care in the Alma-Ata Declaration and regain a broader
view of health care where biomedicine is only one part of it. By so doing women canbroaden their perspectives to include knowledge from the past, knowledge that comesfrom the folk sector, or many other health resources within their reach. Knowing that
pregnancy and childbirth are not a disease, they should be considered in a frame ofhealth care rather than of medical intervention.

Acknowledgement
A part of the study was conducted with support of Grants-in-Aid for Scientific
Research (B) 15H05170 (2015-18) and 19H01390 (2019-21). I express my gratitude
to MD Nurul Islam and Rokeya Zevin Kaisari for collecting data by conducting
questionnaire and interview research. My gratitude also goes to the women of thevillages for sharing their birth experiences. Finally, I send my appreciation to Dr Sharon
Hanley for useful comments and editing of my manuscript.

Notes――――――――――――

1）The Declaration of Alma-Ata was adopted at a conference joint hosted by the WHO and UNICEF from
September 6 to 12, 1978. The Declaration of Alma-Ata can be accessed below:chrome-extension://efaidnbm
nnnibpcajpcglclefindmkaj/https://cdn.who.int/media/docs/default-source/documents/almaata-declarationen.pdf?sfvrsn=7b3c2167_2 (Accessed January 27, 2023）
2）The translation of the Declaration of Alma-Ata referred to in this paper is the work of Friends of WHO Japan

Gender and Culture in Asia Vol.7, 2023

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アジア・ジェンダー文化学研究【第 7 号】2023( 公益社団法人日本 WHO 協会 ) and was translated by a group of medical students. There are several versionsof the Japanese translation apart from that of Friends of WHO Japan.
 https://japan-who.or.jp/about/who-what/charter-2/alma-ata/（Friends of WHO Japan） https://amda.or.jp/old/contents/database/1-1/1.html (translation by AMDA) https://navymule9.sakura.ne.jp/150102Alma_Ata_1978.html (translation by Mitsuho Ikeda)
3）It is worth noting that the word ‘traditional practitioners’ is translated as “ 伝統的医療者 (traditional medical
practitioner)” in this version.
4) Maternal mortality ratio is the number of women who die from pregnancy-related causes while pregnant orwithin 42 days of pregnancy termination per 100,000 live births. (Definition by The World Bank). The MMR
in Bangladesh was estimated to be 173 in 2017 (The World Bank). In comparison, the MMR in Japan in 2019was 3.3 per 100,000.
5）The WHO defines a skilled birth attendant to be an accredited health professional - such as a midwife,
doctor or nurse - who has been educated and trained to proficiency in the skills needed to manage normal(i.e. uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification,
management and referral of women and neonates for complications. Traditional birth attendants, whether
trained or not, are excluded from the category of "skilled attendant at delivery".
 https://www.who.int/data/nutrition/nlis/info/births-attended-by-skilled-health-personnel
6）The project was called Demand Side Financing (DSF), because it funded money directly to the women’s side(demand side) rather than to the facility side (supply side). The project, sponsored by the Government of
Bangladesh and WHO, began in 2007 and was gradually extended to include more sub-districts. The resultsby Schmidt et al. showed that in those sub-districts covered by this scheme, both the rates of facility births
and cesarean section increased, the former 2 to 2.5 fold and the latter 3 fold（Schmidt et al. 2010）.
7）The research was conducted by research assistants in Bangladesh who had a background in anthropology
in two villages (Union) in Rajoir Upazila (sub-district) during 2016 and 2017. The questionnaire data wascollected by visiting and asking questions in each household. The interview with women about their birthexperiences was done on a one-to-one basis in the Bangla language by domestic research assistants.
8）Research conducted in the same unions, five years later in 2021, revealed that the proportion of home birth
decreased to 33% and facility birth increased to 67%. TBA assistance was reduced to only 12% and cesarean
section rate rose to 60%, out of a total of 626 women. It is obvious that these 5 years have led to extensivechanges in childbirth.
9）It is said that private hospitals hire a broker called ‘dalal’ to solicit more patients. Dalals talk to TBA, SBA andother health related workers who have contacts with pregnant women and encourage them to send women
to the private hospital that employs them. One TBA said in an interview done in 2019 that she gets 500 taka(around 750 yen) for a normal birth and 1000 taka (1500 yen) for a cesarean section from a private hospital.
10）I chikawa defines ‘private birth’ as one that a woman intentionally chooses to deliver in a private
environment and one that she prepares for with careful thought (Ichikawa 2021).
11）The Ministry of Health, Labour and Welfare collects data in September every three years in their Survey ofMedical Institutions ( 医療施設 [ 静態 ] 調査 ) and uses figures obtained in this way as figures for that year. Ratesof cesarean section and epidural delivery excluding cesarean section, (the term ‘painless delivery 無痛分娩 ” isused in the statistics but it means epidural delivery in most cases) in 2020 were calculated to be 21.6% and8.6% respectively by this method. As the rate of anesthetic deliveries in 2016 was estimated to be 6.1% by
the Japan Association of Obstetricians and Gynecologists, the proportion of ‘painless delivery’ has shown agradual increase.
12）Village doctor (gram doctor, usually a male figure) is not a licensed medical doctor (doctor with the official
medical license is called MBBS doctor in Bangladesh) but he is trusted by villagers. Some village doctors not
only see patients and prescribe medicine, but also administer labour accelerating drugs, perform episiotomy
and conduct minor surgery.
13）Kobiraj is a practitioner of Ayurvedic medicine and usually gives herbal treatments.

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