This case study describes the efforts of medical educators of the Department of Obstetrics and Gynaecology of the Aurangabad Medical College to create gender-sensitive practices in patient management and to incorporate gender-sensitive attitudes amongst doctors at all levels, including professors, lecturers, residents, and interns. Nurses and the support staff were later included as well.
Aurangabad is the fifth largest city in Maharashtra, with a population of over one million. The Aurangabad Government Medical College Hospital (GMCH) is one of the premier medical colleges in Maharashtra and the biggest tertiary care hospital in the state, administered by the Directorate of Medical Education and Research (DMER). The hospital has 1,177 beds. The average monthly patient flow was approximately 58,000 outpatient visits in 2017.
The case study shows that medical educators — when convinced of the need to incorporate gender considerations in medical practice — can bring about major changes by establishing and providing gender-informed services, despite a large patient load, poor infrastructure, and inadequate staffing. Champions of the initiative such as the head of the department (HOD) and his OB-GYN team demonstrate how they have brought about remarkable changes in the functioning of the department.
The background on social determinants of health
Public health in the last two decades has seen the emergence of approaches that take into account social determinants of health. The World Health Organisation’s Commission on Social Determinants of Health, (2005– 2008) has defined the social determinants of health (SDH) as “the conditions in which people are born, grow, live, work and age” and as “the fundamental drivers of these conditions.”
In other words, these are the factors apart from medical care that influence the health outcomes of the population. There now exists a huge body of literature that talks of the causal, if indirect relationship, between various socioeconomic factors and health. Health inequity, which is the unjust and systemic difference in the health status of different population groups is the consequence of social factors. It is important to address these factors to achieve the equitable distribution of various health targets across diverse population groups.
It has been well established that public health interventions that fail to consider the social context and conditions of patients do not contribute to the reduction of mortality and morbidity rates. National-level data from the National Family Health Survey (NFHS) clearly indicates that diarrhoea, anaemia, infant mortality, and maternal mortality are far more prevalent in households with low socio- economic indicators. The literature on the role of social determinants in influencing health outcomes has identified gender as an important factor leading to inequities in health. The distinction between sex and gender is increasingly being made by advocates of women’s health to emphasise its consideration in the development of public health programmes and interventions.
In South Asian settings, including India, the life expectancy of women is lower than or equal to the life expectancy of men. Several studies have highlighted the impact of gender roles on women’s health. Pregnancy and childbirth are conditions that are unique to women and are normal biological processes, but carry a significant risk to women’s health. And owing to their restricted gender roles and lower status in society, women also have poor access to healthcare and less power to make decisions about healthcare utilisation. In the Indian context, several studies have highlighted gender disparities in the incidence of diseases and their treatment, pointing to the need to address gender disparities by public health interventions in order to improve the health of the population and to achieve global targets.
Gender inequity has significant implications for health in the field of medicine. Medicine as a field is frequently critiqued for not taking into account gender in clinical practice, research, health programme delivery, medical education, and other relevant domains. It is male biased, as the available knowledge is focused on males and is often generalized t women, thus ignoring women’s unique physiological makeup. It does not consider the aspect of gender inequity that creates additional barriers for women in accessing health services. Women’s health issues are often relegated to reproductive matters and pregnancy-related problems, thus ignoring the other health needs of women, including their mental health needs.
In short, there is no distinction between biological and social factors in terms of health disparities between men and women when seen through the lens of gender analysis. Gender role ideology, which is defined as the attitude of healthcare providers (HCPs) towards male and female patients, accentuates these disparities. Women patients are viewed as more demanding, as they are seen to seek too much information and their health problems are attributed to uncontrollable factors like behaviour and emotions. The negative attitude of HCPs towards women acts as a deterrent for women seeking healthcare. This lack of gender perspective in the field of medicine has a negative impact, on of the provision of, and access to, healthcare services to women. The family planning programme in India has not been able to integrate gender equity in its services because of the limited involvement of men and the negative attitude of HCPs towards women accessing abortion services is one of the major barriers faced by women in accessing safe abortion services .
Integrating gender in medical education: The need for change
Revamping medical education provides an important opportunity to transform the provision of healthcare in India by integrating social determinants of health in the medicine curricula of MBBS. Gender-informed curricula can help HCPs be more aware of the impact of gender on health and integrate it into clinical practice — as well as class, caste, religion and sexuality. Despite the importance of this issue, the scope of undergraduate medical education in India is limited to a biomedical model of medicine with an emphasis on proximal determinants of health like pathogens and treatment modalities.
The Indian experience
In 2002, WHO made a commitment to implementing a gender policy to mitigate gender inequities in health. A consultative meeting of leaders in the field of medical education was convened which concluded that the key to achieving gender equity in health was to integrate gender considerations into pre-service training curricula. There was a consensus that the gender perspective should be integrated in all the disciplines of medical education and that continuous training should be provided throughout the professional life of medical practitioners. Developed countries like the USA, Canada, and Australia adopted initiatives to integrate gender considerations in the pre-service training of HCPs. Developing countries, including the Philippines and Thailand, adopted similar initiatives.
In India, an initiative to integrate gender in medical education was introduced by the Achutha Menon Centre for Health Science Studies of the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum in 2002.
CEHAT (Centre for Enquiry into Health and Allied Theme) was one of the partners in this initiative. Under this three-year project, different activities were undertaken, such as formulating training modules for gender sensitisation, developing criteria for a gender-sensitive setting for imparting medical education, organising gender-sensitive trainings for medical college teachers, and reviewing Indian medical textbooks through a gender lens. The project led to the creation of a pool of trained medical educators who carried out short trainings and orientations in their respective disciplines in medical colleges.
CEHAT has also led several initiatives on the in-service training of medical professionals to respond to the issue of VAW and demonstrated evidence-based health systems models for responding to domestic and sexual violence. Dilaasa, a hospital-based crisis centre, was a joint initiative of the MCGM and CEHAT, established to sensitize HCPs and to train them to consider domestic violence as a health issue. In 2014, the National Urban Health Mission (NUHM) replicated this model in 11 hospitals of Mumbai. Other states have also adopted the model of Dilaasa. This experience of working with the health system on handling gender-based violence was a crucial
background for initiating the project on gender in medical education.
About the project
The Integrating Gender in Medical Education (GME) project was implemented in select medical colleges in Maharashtra. The aim was to sensitise medical faculty and medical students to gender equity in health which would subsequently lead to gender-informed health services. The aim was to achieve gender sensitisation and awareness of public health issues such as gender/sex differences, sex selection, access to abortion, and VAW by integrating gender perspectives in the MBBS curriculum.
The programme aimed to build the capacity of medical faculty on gender perspectives and women’s health issues through training of trainers, and facilitate the teaching of gender perspectives to MBBS students. At the conceptualisation stage, a consultation workshop on
the GME project was organised in September 2011 with senior officials from the Department of Health and Family Welfare, DMER, MUHS, the State Women’s Commission, and the Indian Council of Medical Research (ICMR) along with academics, activists, and organisations working on gender and health. At the workshop, several key recommendations regarding the GME projects emerged. One recommendation was the development of a ToT programme that focused on five departments: Forensic Medicine and Toxicology (FMT), Medicine, Preventive and Social Medicine (PSM), Obstetrics and Gynaecology (Ob-Gyn), and Psychiatry. These disciplines were chosen because they form a large part of the undergraduate education.
At the inception of the project, medical educators were trained on specific elements such as understanding the differences between sex and gender, recognising the role of gender in health-seeking behaviour, and understanding how health is experienced differently by men, women, and marginalised groups of men and women (transgender, intersex, sexual minorities). The aim of the training was to understand the relationship between communicable diseases like sexually transmitted infections (STI), reproductive tract infection (RTI), and human immunodeficiency virus (HIV) and their links to gender. Considerable attention was also paid to recognising the signs and symptoms of VAW and the many ways in which the consequences of VAW are reported to and within the health system. These critical components are currently missing in the MBBS curriculum despite their crucial linkages to health.
As the teaching of the gender integrated curriculum by medical educators was underway, medical educators of the OBGYN department began seeing their clinical practices more critically. They started questioning several existing clinical practices. There was a recognition that while the teaching of gender integrated modules is underway, medical students would be able to imbibe such a perspective only when they observed changes in clinical care offered to women at the department. This led to step-by-step changes made at the level of the department.
1. Replacing the archaic medical examination proforma with
a gender-sensitive medico-legal proforma for sexual violence
As a part of gender integration, they had taught students to look at rape or sexual violence not merely as a legal issue but also as a critical health problem, because unwanted pregnancies, STIs, injuries, and other
forms of trauma are a consequence of it.
2. Respecting the patient’s privacy during the medical examination
The examination of patients in the presence of a group of medical students is a “given” in all medical colleges as this is how practical teaching has been conventionally carried out in India for several years. However, in all this, very little thought is given to the privacy of the patient. Gender integrated training has enabled medical educators to entrench the notion of “privacy” across all arenas in their department.
3. Collaboration with the burns department to provide
comprehensive care to burns patients
Thanks to understanding and imbibing a gender perspective, medical educators of the OBGYN department now recognise the need to assess pregnant women reporting burns as possible cases of domestic violence.
4. Creating a protocol for the identification of, and the response to, victims of domestic violence.
Medical educators of the department are sensitised and trained to handle cases of violence. Violence in pregnancy has a profound impact on maternal health and pregnancy outcomes, and doctors now routinely enquire about it when providing antenatal care (ANC).
5. Establishing women-centric comprehensive abortion services.
In most government hospitals in India, access to medical termination of pregnancy (MTP), also known as abortion, is not easy. The MTP law allows adult women to access abortion services. Conditions such as obtaining the signature of the husband or the mother-in-law, making a police complaint if the woman is unmarried, and denial of abortion services to women under the age of 18 years are rampant. Additionally, women who reach the hospital in an advanced stage of pregnancy (second trimester) are suspected of seeking sex selective abortion in a desire for a male child. Some hospitals even have an unwritten rule of “No contraception, no MTP”.
Aurangabad Medical College has adopted several positive changes and replaced archaic and defensive practices with more women-centred and gender-informed services. There is no conditional access to abortion services in the OBGYN department
One of the most significant changes was renaming the department. The name of the department was changed from the Family Planning Department to the Comprehensive Contraceptive Services for All Centre.
Experience of implementing gender-sensitive clinical practices
The change in clinical practices has meant the developing of standard operating procedures, the promotion of evidence based practice, and generating evidence to show impact.
Medical educators stated that they had to be true to the gender integrated content taught by them to medical students. Clinical changes were essential. Once they made changes in clinical practice, they saw that their peers and students accepted and imbibed them. The approach was not top-down, but rather it was inclusive.
These are important lessons for introducing sustainable changes in clinical practice. In this regard, the HOD, OBGYN, Aurangabad Medical College said, “In case of repeated reproductive infections, clinicians used to advise women hysterectomy or used to tell them that it is a psychological problem. Now these problems are viewed through the gender lens and students are taught to take women into confidence and explore the underlying reasons.”
He described his earlier practice when no attempt was made to look at clinical conditions through the gender lens: “I would often chide women seeking abortion more than once and ask them why they didn’t use contraceptives.” The other educator from the department who is an associate professor said, “Earlier, I wouldn’t pay attention to the vague complaints made by some women. But I can now sense instances of domestic violence.”
The improvement in the quality of care can be measured by the impact of changes at the facility level. There has been a decrease in caesarian sections and unnecessary interventions during labour. There has been an increase in the number of deliveries, early initiation of breastfeeding, and better pregnancy outcomes.
The initiative to implement gender-sensitive clinical services has been acknowledged by various international organisations. It has also been recognised by the Government of India.
- Developing gender-based analytical tools for understanding and treating various diseases
- Recognising gender stereotypes held by HCPs and developing gender sensitivity in addressing health concerns
- Developing an in-depth understanding of the concept of sexuality
- Providing gender-sensitive reproductive health services for people from diverse groups (men, women, transgenders, people in same-sex relationships)
- Inculcating gender sensitivity in abortion service delivery for women and girls
- Being sensitive towards the sexual healthcare needs of different groups
- Recognising and responding to gender-based violence (GBV) in a sensitive manner
Post the training, medical educators along with experts reviewed the curriculum to assess how and where to include gender aspects in teaching undergraduate students. This humongous task was undertaken for all five disciplines, namely gynaecology and obstetrics, forensic science and toxicology, community medicine, psychiatry, and internal medicine. The medical educators were of the firm opinion that along with teaching the academic subjects to students, it would be critical to assess them in clinics and in their practical lessons where they interact with patients.