Increasing use of prenatal care in Ladakh (India): the roles of ecological and cultural factors.

Attempts to manage the outcome of pregnancy are ubiquitous among human societies. Those practices are becoming standardized as prenatal care under a biomedically trained practitioner has come to characterize the formal management of pregnancy. However, many women do not seek biomedical surveillance of their pregnancies, and, in many contexts, particularly in 'modernizing' or rural communities, prenatal care facilities are often poorly coordinated and under-utilized for a variety of reasons. This report illustrates widespread and increasing usage of biomedical services for prenatal care and birth among women in Ladakh, India, over the course of the past 20 years. This trend is at odds with that typical of other parts of South Asia, and can be attributed to the unique ecological, cultural, and historical characteristics of this region. These include the hypoxia of this high-altitude region, which poses substantial problems for successful birth outcome, along with the socio-ecology of maternal diet and work patterns that further compromise birth outcome. These risk factors exist in the context of the absence of involvement of traditional institutions such as Tibetan medicine or traditional birth attendants (TBAs) in pregnancy and birth, and government-sponsored efforts to establish institutions of modernity in Ladakh such as biomedical facilities. Hence, the penetration of biomedical services into the domain of reproductive health has been facilitated. Idiosyncratic aspects of the obstetrics practice itself, particularly the social position and personality of the obstetrician, have also played an important role in recruiting women to make use of hospital-based prenatal care and birth. However, despite broader usage of prenatal care and hospital births by Ladakhi women, there is little indication that birth outcomes have improved significantly. Reasons for this lack of measurable success are considered.