Shenaz Hamid Khan lives in a small one-bedroom apartment --about 300 square feet-- in Govandi, an overcrowded government resettlement slum on the outskirts of Mumbai, with 15 other people from her husband's family.
Her household includes her husband's parents, their four other sons; three sons' wives and seven grandchildren. To sleep at night, they stretch out on the floor or outside on a balcony that they share with 11 other housing units on this floor.
Nineteen-year-old Khan, a new mother to one of the grandchildren playing on the floor nearby, doesn't talk much. She sits on the floor of the apartment letting her mother-in-law, Farzana Khan, answer most of the questions.
Farzana Khan says her daughter-in-law's recent pregnancy was physically draining. She often carried water up all seven flights of stairs to their apartment, and the climb alone would exhaust the younger woman, she says.
Shenaz Hamid Khan had suffered from tuberculosis three or four years before, and she relapsed after her daughter, Alisha, was born eight months ago. She "let herself go," Farzana Khan says.
Now, Farzana Khan makes sure the young mother has enough to eat, makes her doctors' appointments and takes her medication.
She also answers questions about family planning for her daughter-in-law, who moved to coastal Mumbai, the largest city in India, from a village in the central state of Madhya Pradesh for her arranged marriage at the age of 16.
When Shenaz Hamid Khan is asked if she will have any more children, her mother-in-law once again takes over. Farzana Khan says she will take the new mom to be sterilized once she recovers from tuberculosis.
Beside Shenaz Hamid Khan sits her 22-year-old sister-in-law, Samina Sher Khan, who was also sterilized after the birth of her twins.
"But do you want more children?" I ask, looking straight at Shenaz Hamid Khan and pressing the question.
The 19-year-old hesitates. Then she looks at her mother-in-law and shakes her head no.
"This is the other way around," says Dr. Ravikant Singh, president of Doctors for You, a nonprofit with branches in six Indian states that offers free medical care to the 20,000-plus residents of this slum.
Most mothers-in-law pressure their daughters-in-law to produce as many grandchildren -- particularly grandsons -- as possible, Singh says.
But while Farzana Khan's decisions may be unusual, her dominance over her daughters-in-law is commonplace.
"In India, especially among rural and urban poor, mothers-in-law exercise a great degree of control over the health choices of their daughters-in-law," says Singh.
In his experience, that means making the crucial decisions about immediate postnatal care of the baby, such as breastfeeding practices and family planning measures.
This power can be harnessed for good. Mothers-in-law can guide responsible family planning decisions, including long-term pregnancy prevention measures.
But some public health officials would like to see daughters-in-law gain more autonomy over decisions concerning their own bodies, since many mothers-in-law push for larger families and don't always support younger women in making their own decisions about health.
Farzana Khan seems to pride herself on her progressive stance toward grandchildren. Rather than pressuring her daughters-in-law for more grandsons, she is firm about taking them to be sterilized. And she seems to have good intentions; her care of Shenaz Hamid Khan during her bout with tuberculosis seems tender and thoughtful.
But if Shenaz Hamid Khan had different ideas about her own body it would be hard for her to do much about it.
Singh says the women whom his project supports -- and, indeed, throughout India, particularly in depressed socioeconomic areas--receive no support from government agencies or nongovernmental organizations when their in-laws attempt to control their reproductive health. There are no hotlines or support groups for Shenaz Hamid Khan to consult if she wanted to.
A 2005 law, the Protection of Women from Domestic Violence Act, accords women more power to level accusations against domestic violence threats, including from their mothers-in-law.
However, especially in situations where in-laws exercise absolute power, many young women may be reluctant to raise criminal charges or may believe that their case does not constitute violence.
With such legal limits in mind, some health researchers are looking for changes in the way mothers-in-law relate to the reproductive health of their daughters-in-law, beginning at home.
Dil Mil Research
Suneeta Krishnan, a researcher with the nonprofit RTI International who splits her time between Bangalore, India, and Berkeley, Calif., published the results of a trial program last year that fostered group discussions among mothers- and daughters-in-law on matters of family health and violence.
She calls the program Dil Mil, an abbreviation of "Daughters-In-Law, Mothers-In-Law" that also means "hearts together" in Hindi.
The Dil Mil discussions took place in pilot programs at local health clinics in southern India and focused on "women's power within marriage and implications for health, domestic conflict and violence-related triggers, sources of support and community norms," Krishnan writes.
Researchers provided transportation, refreshments and a small stipend (about $2). They also provided antenatal care to DILs and aging-related health care to MILs, which encouraged attendance and openness.
The DILs in the program asserted that it is the "right" of the MIL to intervene in family matters, Krishnan reports.
Future programs, Krishnan writes, might channel that dynamic so that MILs take a leadership role that relies on their DILs' feedback and desires.
After going through the program, MILs and DILs reported that their relationships changed; they were more likely to see one another as allies than adversaries.
Krishnan believes that the program would be beneficial in all regions of India, especially in low-income urban settings and in communities where MILs still exert a great deal of authority. She hopes to expand on her findings and offer more programs in many different regions.
Currently, she says, there is no other program like this in India. Women often bear abuse and unequal power dynamics within the family in silence, since they are viewed as personal matters.
However, since the Dil Mil pilot focused on familial tension in the context of family health, participants were more likely to open up. Expanding current doctor-patient relationships will help women understand how family dynamics affect their health.
Singh's group, meanwhile, is doing something similar in Shenaz Hamid Khan's Mumbai neighborhood.
"We try to overcome these challenges by spending more time on the counseling of both mothers- and daughters-in-law together whenever possible," Singh says.
Doctors for You often requests that new mothers bring their mothers-in-law for their child's immunizations and follow-up visits. That way, doctors have more access to those making important decisions in a child's health, which all too often fall outside the purview of the mother.
"We also organize awareness drives in the community on various issues like breastfeeding and immunizations, where all women--young, old, pregnant and adolescents--can join in a health talk," Singh says. Openly discussing the role of extended family in childrearing and reproductive decisions can ensure that soon-to-be mothers and their children receive adequate medical care.
"But lots more needs to be done," says Singh.