When Survival Gets Mistaken for Choice

It took five hours by road from Dhaka to Sirajganj, and then another hour by boat and motorcycle, to reach BRAC's Shushasthya Primary Health Care Centre in a char (riverine land) of Ghorjan union.

It is unsettling to consider that this is the distance a woman would have to travel in the event of a serious medical emergency.

That distance, abstract in description, becomes tangible upon arrival.

Tucked away in an unassuming part of the char, a green, tin-roofed house stands as the Shushasthya centre. Inside, lines of women wait patiently to see the doctor, while expert midwives, clad in pink and wearing bright smiles, move briskly between rooms.

One of the midwives, Tahrima Khatun, a woman in her early twenties, shares something that unsettles me more than any statistic could. Among women who now come to the centre to deliver, many ask to leave almost immediately after childbirth, even though, ideally, a woman should be monitored for at least six hours post-delivery. Here, reaching home before nightfall often takes precedence over afterbirth care.

I had arrived with the assumption that suffering here would be visible, articulated, named. Women would speak of pain, risk, or fear. Instead, what I encounter is a striking nonchalance. The urgency is not about medical observation, but about making it home in time.

The quiet acceptance I witness feels at odds with the physical violence childbirth inflicts on the body.

Childbirth is not a neat or sanitised process. Every contraction comes at a cost. The body is torn open, leaving behind a wound roughly the size of a dinner plate. Safe delivery requires skilled medical expertise, effective medication, timely intervention, and functioning equipment. These are not privileges; they are the minimum standard of care. Standing on a riverine island where access itself is precarious, one question becomes unavoidable – how much of this is realistically available here, when geography dictates everything?

Most women in these areas give birth at home. Pain is narrated the way one narrates the weather – something expected, endured, and rarely questioned. There is little language for complaint, and even less for indignity. That silence is often mistaken for acceptance.

This is where the idea of resilience becomes dangerous.

If you are born in a storm, violent weather begins to feel normal. Over time, risk blends into routine. What should alarm us instead reassures us. We begin to admire adaptation rather than question why adaptation is necessary in the first place. We frequently praise the resilience of char women, framing endurance as empowerment. Yet resilience, when born out of structural neglect, is not strength. It is a coping mechanism.

Home births in chars are often explained away as cultural preference. This framing is both convenient and misleading. Preference assumes choice, and choice assumes options. What does choice mean when accessing a clinic requires crossing a river? When labour begins at midnight? When weather determines whether a boat can move?

When reaching emergency care takes hours, home birth is not a preference; it is a survival strategy.

The real issue is not why women choose home births, but why we have collectively accepted conditions where childbirth must be negotiated with geography. The normalisation of this reality allows us to remain comfortable. As long as women adapt, the system appears to function.

However, adaptation often signals something else entirely. It signals lowered expectations. Once pain becomes routine, it stops being reported. Once risk becomes familiar, it stops being treated as urgent. Normalcy and peace begin to take on very different meanings, shaped by what is available rather than what is acceptable.

During the visit, I find myself wondering what would happen if these women were ever allowed to unlearn this normalisation. If they were told, clearly and consistently, that this is not how it has to be. That dignity in childbirth, access to pain management, and timely medical intervention are not luxuries reserved only for urban women.

That question leads to another, more uncomfortable one – do urban, middle-class women really respond so differently?

We have information. We understand rights-based language. We read studies and attend discussions. Yet many of us have learned to stay quiet in medical spaces. Long waits, dismissive attitudes, pain brushed off as "normal" – these are experiences shared across geography. To add insult to injury, there are numerous studies on male-pattern baldness, but far fewer effective ones on endometriosis, for instance. Women's pain, whether in a char or in a city hospital, is still treated as secondary.

The difference may not lie in awareness, but in permission. Permission to complain. Permission to demand better. Permission to label something unacceptable even when it has always been that way.

Maternal health discussions in Bangladesh often rely heavily on numbers. Mortality rates, facility counts, and coverage percentages dominate the narrative. These metrics are important, but they flatten lived experience. They do not capture the humiliation childbirth can involve when pain is unmanaged, when help is delayed, and when endurance is the only available option.

Survival should not be the benchmark. Dignity should be.

Christa Teston reminds us in Doing Dignity that dignity has historically been tied to autonomy, rationality, and social worth – prerequisites that have systematically excluded women, the poor, and those on the margins. When dignity is treated as conditional, it becomes easy to withhold it from those already expected to endure.

When we celebrate resilience without interrogating the conditions that require it, we absolve systems of responsibility. We turn admiration into excuse. Calling char women strong without addressing the structural failures shaping their reality allows us to look away from difficult questions about access and infrastructure.

If maternal health is truly a priority, we must stop mistaking endurance for empowerment. We must stop romanticising women's ability to adapt to broken systems. We must also be honest enough to acknowledge that resilience, when celebrated too easily, often becomes a justification for inaction.