In the triage room of a public hospital in Lahore, a woman in active labour lay on the hospital bed for over an hour while the delivery room behind her remained vacant. A nurse appeared only after the woman’s relative slipped a crumpled five-hundred-rupee note into her hand, and the newborn was finally wrapped in a soiled cloth to be taken to the nursery. Meanwhile, outside the building, a speaker announced repeatedly: “Hospital ke amlay ko kisi kisam ki bakshish ya rishwat dena mamnooh hai” (Giving any kind of gift or bribe to hospital staff is forbidden).

What struck us the most about this observation during our fieldwork was not that a rule was broken, but how smoothly, unremarkably, the transaction unfolded. Care moved not through medical urgency or formal entitlement, but through informal negotiation - and the woman whose preferences the system had least accommodated was the one whose body was at its centre.

Our research, conducted across fourteen reproductive healthcare facilities in Lahore, finds that this displacement is not incidental. It is structural. A woman’s standing as the primary subject of her own care: her right to be consulted, informed, and treated as the person whose agreement is necessary before anything is done to her body, is not uniformly denied. It is stratified, quietly and consistently, according to two intersecting variables: her ability to pay and the formality of the institution she enters.

In public hospitals, her autonomy is absorbed by institutional informality, displaced onto the attendant beside her and the husband whose signature the house officer collects as a matter of routine. In private hospitals, money purchases back some degree of procedural recognition, though it does not purchase freedom from patriarchal mediation entirely. And for women for whom the formal system is too expensive, too surveilled, or too dependent on a consenting husband, the alternative is Safiya clinics¹ or other quack clinics, where consent is not documented but absorbed into the transaction itself.

The place where this stratification is most physically legible is the patient's consent form. Across the facilities we studied, forms did not merely vary in quality - they mapped, with a precision difficult to attribute to coincidence, onto the ability-to-pay gradient.

In public hospitals, printed consent forms exist in principle, somewhere in a filing cabinet, and are frequently referenced by doctors as official procedure. Yet when asked to produce one, staff often struggled to locate it. The ward’s modus operandi is not a printed form but a plain sheet of paper, scribbled in Urdu by a house officer. Of the handwritten forms we reviewed, very few contained space for the patient’s own signature; her husband’s mark, however, appeared on nearly all of them.

As you move toward private facilities, the printed form begins to appear - structured, standardised, with a dedicated signature line for the patient. At the higher end of the private tier, the form splits into two documents: one for the attendant, one for the patient - her legal personhood given its own page.

In Safiya clinics, the form disappears entirely, not because consent is assumed but because documentation is precisely what women here are paying to avoid. The monetary transaction itself - shaped by shame, fear, stigma, and the urgency of secrecy- stands in for everything the form would otherwise record.

However, the law imagines a different subject. Across the Mental Health Ordinance 2001, the PMDC Code of Ethics, and the Punjab Healthcare Commission’s Minimum Service Delivery Standards, the same principle holds: no provision in Pakistani civil law grants a husband automatic authority to override his wife’s medical consent when she is conscious and competent. Pakistani courts have increasingly engaged Montgomery v Lanarkshire [2015 SCMR 663], which holds that the disclosure standard is set not by what a doctor deems necessary, but by what the patient would consider material. Under this framework, performing a procedure without her explicitly communicated consent is battery, and battery is committed across Pakistan every hour.

The problem, then, is not ignorance. The healthcare system knows exactly what patient-centred consent looks like; its own frameworks encode it. The problem is that this knowledge is activated selectively, appearing where institutions are formal, resourced, and accountable to a paying patient, and receding where they are overcrowded, under-resourced, and socially habituated to treating the family as the operative unit of decision-making.

What fills the gap is not a legal framework but a risk management logic. The husband’s signature protects the doctor from future dispute, reassures the institution that someone socially recognised has accepted responsibility, and allows the family to retain authority over the woman’s reproductive future. Her consent, legally sufficient on its own, becomes contingent until ratified by kinship - an arrangement never written into any law or policy, which is precisely why it never has to defend itself.

This logic is sustained by a legal architecture that is itself fragmented. The most explicit provincial legislation on reproductive consent: the Sindh Reproductive Healthcare Rights Act 2019, does not apply in Punjab, and the Punjab Healthcare Commission’s standards rarely reach ward-level practice. The CNIC requirement most starkly reveals who bears the cost: with one, a woman’s signature is legally sufficient; without one, authority passes to the closest male relative.

The population most likely to lack CNICs (young, unmarried women, rural migrants, rape survivors) is precisely the population with the greatest reason to avoid family involvement. In one case from our fieldwork, a woman sought an abortion for her niece - above eighteen, raped by her stepfather, and without a CNIC. The closest male relative was the perpetrator; the formal system would have handed authority over her body to the man who had assaulted it. So instead, they went to a Safiya clinic, where the fetal disposal fee could not be paid, and the aunt carried the fetus home in her chaddar, disposing it at night in a garbage dump while police patrolled nearby. This is not a failure of informal care. It is what the formal system is produced by functioning exactly as designed.

The same logic runs through the hidden economy of public hospitals. Formally free, they function through informal payments that accumulate from entry to discharge, structuring access to care, speed, and dignity. The public hospital is not a lower-quality version of private care; it is governed by a different economy, one whose formal rules prohibit bribes while its wards accommodate them, whose legal framework recognises the patient while its paperwork records the husband.

Private hospitals did not eliminate patriarchy either. Husbands remained central, and doctors often preferred to involve them in reproductive matters. But private care created procedural room, and the woman’s disagreement, even if eventually overridden, had to be encountered. What class buys is not autonomy but legibility: a private room, a printed form, a signature line, and a sequence in which the patient is addressed before the family is activated.

The husband’s signature condenses this entire structure into a single mark. It is proof not that someone agreed, but that the institution considered his agreement safest. How the law’s language of adult consent is overtaken by the ward’s language of protection and social legitimacy, and how a woman can be present and still absent from the record of her own care.

In Lahore’s reproductive healthcare system, how far she is moved from the centre depends not only on patriarchy in the abstract, but on the material route through which she enters care: public ward, private file, or informal clinic. In one space, her signature disappears beneath her husband’s. In another, it is restored to a separate page. In the last, the page itself vanishes.That disappearance is the finding. Autonomy is not only denied when a woman is told no. It is denied when the system never creates a place for her yes.

Hamna Mahmood is a final-year Economics student at the Mushtaq Gurmani School of Humanities and Social Sciences. Her research examines the politics of economic policymaking in Pakistan, particularly how external financial pressures shape taxation, exchange rate policy, and state autonomy. Her broader interests include political economy, informal labour, development, and state capacity.

Aleeza Maryam is a fifth-year law student at LUMS. She has interned at Mandviwala & Zafar, Haidermota & Co. and served as Regional Head of Marketing & PR for AIESEC in LUMS. Currently a Teaching Assistant at LUMS, her broader interests span law, literature, leadership, and social impact.

1. The term ‘Safiya clinics’ (also rendered ‘Safia clinics’) refers to informal, unlicensed reproductive health facilities operated in Lahore by midwives and unqualified practitioners outside Pakistan’s regulated healthcare sector, providing clandestine abortion services, principally to women unable to access formal care.