Abstract: This paper explores indigenous Indian concepts of power, satta and Shakti, working with data, specifically dai interviews, generated by the Jeeva Research Project. From the dais’ own words it attempts to discern and present the differences between satta and Shakti in order to nuance out the very different qualities and manifestations of power and capacity that are being enacted in the handling of childbirth in poor and rural areas of India.
Keywords: power, governance, provider sensitivities, social empathy, cultural rootedness of traditional birth attendants, childbirth skills, Jeeva Research Project, National Rural Health Mission Policy Scenario (NRHM), satta & shakti, accessibility, continuum care
In the Hindi language two words signify ‘power’. Satta carries the meaning of authoritative power and influence. Shakti on the other hand denotes power known as energy, potency and ability. (McGregor 2009; Kumar & Sahai 2013). Satta gives a sense of political power, associated with governance and influence. It is substantial, able to be seized, controlled and executed. Shakti is fluid, more associated with a cosmic energy that enlivens the world and flows through all natural phenomena. It is said that Shiva without Shakti is shav or a corpse. Shakti is associated with goddess mysticism and thus some feminists are reclaiming this uniquely South Asian concept to include creativity, agency, capacity and liberation. (Chitgopetkar 233)
Introduction: the Jeeva Project, Dais and the National Rural Health Mission Policy Scenario
The Jeeva Research Project is a research initiative of a collective of researchers interested in both ‘public health’ and ‘indigenous knowledge’ aspects of the traditional skills, knowledge, roles and contemporary dilemmas of indigenous midwives or dais1. The Jeeva fieldwork has been carried out over 2½ years in four diverse field sites in Jharkhand, Karnataka, Maharashtra and Himachal Pradesh. The study examines the application and effects of the current health policy thrust to ‘institutionalise childbirth’ that emerged from concern about high mortality among birthing women.
Dais are indigenous health care providers for women in India. Traditionally they offer available, affordable and culturally acceptable midwifery services during and after childbirth. No accurate estimates of their numbers exist, but roughly assuming an average of 1 or 2 dais per village there may be a total of about six hundred thousand practicing dais in rural and urban India. At one time they served all sections of society in their vicinities. In an effort to discover the reasons why dais still are popular among the poor, we took up the Jeeva research.
The Government’s ‘flagship’ programme, the National Rural Health Mission (NRHM) was initiated in 2005 largely to implement measures for ‘safe motherhood and child survival’ through its Janani Suraksha Yojana (JSY) scheme. Uncannily the NRHM and JSY ignore the vast reserve of traditional knowledge and skill held by dais, and rely instead on hi-tech biomedical facilities and personnel trained to practice only within hospital or ‘institutional’ settings. However, given the diverse terrains and unequal distribution of health services, such facilities are often not available or accessible to the marginalised and remote communities.
The urgency of policy makers and medical administrators to meet globally fixed targets by 2015 blindly pushed them to ban the dais from the NRHM without ever assessing the dais’ existing skills and potentials
– despite little or no training – in the deprived contexts of their work. Current health policy seems to have no clue that the dais’ cultural rootedness makes them a potential ally rather than adversary of the public health system. And so the policy environment actively discourages their work, attempting to root out what are seen as outdated and hazardous traditional practices that ‘lack any evidence base’.
In this paper we explore some of the narrative data generated through the Jeeva study against this background scenario and in light of the two indigenous South Asian concepts of power, satta and shakti.
In four States – Jharkhand (Jh), Karnataka (Kr), Maharashtra (Mh) and Himachal Pradesh (HP), we selected four study sites in backward districts, composed of population clusters of around 10,000 population each. We identified a total of 368 dais and interviewed 120 of them (15 ‘popular dais’ + 15 ‘other dais’ per site). The aim was not only to understand their knowledge, skills and outlook but also the socio- economic contexts within which they work and their relationships with the families whom they serve, as well as their relationships with the other formal and non-formal providers of childbirth care.
Hence the Jeeva methodology was layered, initially employing sample households’ survey to understand community perceptions regarding childbirth assistance. The other providers were surveyed carefully to assess their roles, relationships with and views on dais. The women who had given birth in the past two years in the sampled population were interviewed, as well as those who gave birth prospectively (i.e. in year 2013). The field researchers were trained in qualitative research methods for interviewing the dais, noting relevant issues in the environment, direct observation of birth events and developing case studies. During the 2½ years of field work the research teams lived in the study areas, building up rapport and always seeking the consent and convenience of the respondents. Thus the trust they built up in the communities allowed them to achieve depth, reliability and validity in the data.
‘Popular dais’ were those most frequently mentioned by families in the four study areas. Consecutive in-depth qualitative interviews with each were conducted with the help of interview guides, use of active listening2 and by focusing on their childbirth experiences, practices, knowledge and interactions. The 120 dais interviewed were located in the districts of Kangra (HP), Bokaro (Jh), Bellary (Kr) and Nandurbar (Mh).
The methodologies used in Jeeva’s field research sought to invert various hierarchies by listening carefully to the dais, foregrounding their worldviews, body knowledge, skills and socio-economic realities. In some places this was initially difficult as communities suspected all outsiders to be pro-establishment and dais felt threatened. It was really only towards the second year of fieldwork that the dais would speak to the researchers freely, assured of being listened to.
This paper looks at dais’ interview narratives seen alongside the dual concepts of power, satta and shakti. As our analysis method we first read and reread the qualitative data to evolve six broad categories in the dais’ narratives, namely of i) birthing practices: change over time; ii) support and caregiving they provide; iii) accessibility and continuum of care; iv) childbirth and postpartum skills; v) the local practice of ‘injection’, and vi) attitudes towards money and reimbursement. From the dais’ own words we have attempted to discern and present the differences between satta and shakti. This approach allows us to use indigenous categories of power to nuance the very different manifestations of power and capacity enacted in the handling of childbirth of the rural poor in these diverse parts of India.
Our working hypothesis in this paper is that the indigenous categories of satta and shakti are relevant to birth practice. Shakti allows us to recognise and value the dais’ congruence with natural phenomena even in the increasingly degraded natural environments which they inhabit. Furthermore it highlights how their skills utilise tools of warmth, oil, their own hands and herbs. Dais possess emotional, physical, social and cultural skills of negotiation that allow them to tap support from families’ resources and nourishment and utilise the home environment’s tools optimally, as contrasted with the stark, pain-filled environment and institutional procedure in hospitals. The satta that women experience is reflected in the dais’ frequent perceptions of government providers and biomedical services as heavy-handed and controlling. The power of the government apparatus that demeans and denigrates the dais as care providers is also apparent. We do emphasise that the interviewed dais and their selected narratives represent the best of the dai traditions. We also acknowledge that dais generally, and these dais specifically, serve the poorest of the poor, women whose health is often compromised before they even conceive.
Change over time
Dais speak articulately about changes in the handling of birth over time and how birthing women and themselves are affected by the changes. Usually information on maternal mortality and childbirth is set in a framework of numerical calculations that obscure the women’s experiences and realities. Below is a representative sampling of the dais’ statements.
Earlier no one went to a hospital. Women used to do a lot of work before herige (childbirth) and it used to happen without much effort. Now in the month that seragu (menstrual period) stops they go to the hospital. I have done all deliveries at home. If it was not possible at home, only then would I send the woman to hospital. Now women think they have found out everything and that we should not create a problem by doing herige at home. If the anganwadi teacher, doctor and all give support (to homebirths) then even now I could do it at home. At home there will be hot water, warm gruel, bed and curtain – it will be better than what they give in the hospital. In hospital the food is not timely or good – one may have to get it from outside. It is difficult there. – Rati Naagamma (Kr site)
Now the Government people don’t give much importance to our work. They remember us when there is a need and once that need gets fulfilled they forget us. The Anganwadi Sevika gives value to us only at the woman’s home, but after reaching the davakhaana she does not give us value. I tell her “I can’t speak Marathi, so at least you tell them.” [The dai speaks Pavri, a tribal language quite different from Marathi.] But she says ‘yes’ and then forgets me. – Gugli Paavra (Mh site)
Nowadays doctors do all the births. Earlier I used to take the puaati (birthing woman) for childbirth to the PHC (Primary Health Centre) at Chandankiyari. But I stopped going there since the Sahiya3 was appointed for this. I don’t go because it is the Sahiya’s work, not mine. When the Sahiya was new she used to take me along to the PHC. Now since she has learnt I have stopped going with her anymore… [about care at the hospital]
See, the birthing passage is delicate. That’s why porsav (childbirth) has to happen slowly and smoothly. The doctors don’t do it slowly and they torture the woman. That’s why most people in villages don’t want to go to the hospital for porsav. At home we allow it to take its time. – Chabbi Sahis (Jh site)
Dais do not get any recognition nor any facility. That is why younger women are not ready to learn the work. In our village all of the dais are old now and nobody is learning. Women today say they don’t want to mess in other’s filth, that it’s dirty work to do prasooti (childbirth) … I have never been to a hospital nor have I seen one. I’ve heard from others that at the hospital they do prasoota lying down. Then they shout, ‘Push, push!’ We don’t do it like that. If the woman’s pains don’t get stronger then we give her a herbal decoction, we make her walk and then she gives birth in a sitting or squatting position. These are old-time methods that we keep doing in our own way… [on why she feels dais’ care is better] When childbirth happens normally in the dai’s hands then why go to a hospital? If a baby is aarda (crosswise in the belly) then operation (C- section) is a must. But doctors operate even for a normal baby and cut without reason. This is not right. Even if delivery is normal, they surely cut and stitch. This isn’t right either and it can be avoided. Doctors need to understand how much trouble women have afterwards to sit, stand, walk and pass urine. We don’t like it at all. – Jhaandri Devi (HP)
These dais continually express care, concern and an intimate ability to perceive the woman’s sensations and experience of birth-giving. With deep intuitive understanding of the innate shakti of the woman, the dai facilitates the physiological process of labour and postpartum. When Jhandri Devi states that in hospitals control is exercised in the command ‘Push-push!’ she refers to satta in the form of external control as opposed to facilitation. This finds a contrast in Chabbi Sahis’s firm assertion that at home a childbirth takes its time. Interestingly, some western scholars and advocates of ‘natural childbirth’ have termed this hurry as a kind of ‘industrial model of childbirth’.
The dais quoted here are also critical of the lack of concern for the woman in institutionalised medical care. And although within their interview narratives some dais mention cooperation with government providers like Anganwadi workers (AWWs), Auxiliary Nurse Midwives (ANMs) and ASHA workers like Sahiya, they mostly express a sense of exclusion, of being manipulated and ignored. Thus the traditional skills and relationships of Dais with families get erased with the rise of satta.
Support and Caregiving
Dais are generally sensitive to women’s emotional, physical and social needs during labour and childbirth. The dais’ existence is embedded in the social, familial and cultural and religious affairs of their communities. They know how to negotiate these realities as they impinge upon maternal wellbeing.
If a woman is giving birth for the first time she may get scared. We have to tell her that nothing wrong will happen. We tell her how to breathe when the pains come. We ask her to lie down. But elder women of her family need to stay near her, because such a young woman is often shy with us. In the last birth I attended her mother-in-law and other women were there to care for her. – Saku Ismal Pavra (Mh site)
When they call then I go because of a loving bond between us. I think it is better if childbirth happens at home. Why make them spend money by going to a hospital? What will the poor people do if they don’t have money! Anyway recently I heard from two dais in about their experience in the Sadar Hospital in Purulia. They are my sister-in-law’s relatives. They were forced to hold the puaati (woman in labour) while the nurse beat her and gave her so much trouble. How can we do such things at home? At home we have to give them courage. – Puran Devi (Jh site)
Children are not born just like that. Women shed tears. When children are being born it may take 3 to 4 days. During labour they complain to us, ‘Who are you? You are troubling me!’ The dai sometimes gets the brunt of a woman’s discomfort in labour. I just stay with her and do the delivery. I don’t give an injection or anything. – Sunanda Bai (Kr site)
If the pains don’t get stronger, we bring water and sheru (mustard seeds) from the chela who has blown a mantra over it. We give it to the birthing woman to drink. We also have her drink a simmering decoction of jaggery and chhuaare (dry dates). At her time of pains a woman needs a lot of support. I speak lovingly and encourage her. Then the birth happens quickly. – Shanta Rajput (HP site)
Each area has its own ritual methods of facilitation (shakti). Common to homebirths in each of the study areas are the opening of hair, the taking off of jewelry and the opening of doors and locks. Anthropologically one might see in this that in this way the woman is gets moved from the identity of a bound and obedient daughter-in-law (i.e. ‘culture’) into the space of an open, fertile and strong birthgiver (i.e. ‘nature’). These rituals of opening in the immediate environment mirror the opening of cervix and birth canal in the woman’s body. In contrast the hospital or ‘institutional’ environment takes the woman to a separate room, restricts her family’s access and lays her on a high table in a cold and lifeless setting, her arm tied down with an i/v line in it, where masked aproned strangers who are her only company, touch her with gloves.
Accessibility and Continuum of Care
Dais are available and devoted to the care of the mother and newborn. Although all of the dais attended to other work, from farming to shop-keeping to cooking and other house work, they readily leave that when called to a childbirth. Theirs is an abiding presence at the woman’s side during labour and most often they continue this caretaking in the postpartum days. Below a dai speaks of her own daughter-in-law’s difficulty in accessing medical care when it became necessary.
My daughter-in-law had pains the whole night but the baby was not coming. We decided to take her somehow to the davakhaana (Rural Hospital, Dhadgaon). It was rainy season and the Udai River was flooded so we could not cross it. What could we do? We carried her in a cloth sling, walking carefully along the muddy footway near the river bank until we could cross and climb up and across the steep hills to find a commander jeep. In that we reached Dhadgaon, hours after we had started. But that day was Sunday and the government hospital staff was on holiday. We had to take her to a private doctor. – Hunaidi (Mh site)
“Her aunt and mother are not there,” a neighbour said to me. “It is just happening like that, come and see.” It was 10 at night. I went and found that really no one else was there. How to manage? She said, “It’s my first childbirth.” I told her, “You must give pains properly and I will handle your delivery.” She said she had eaten supper. I made her a cup of coffee and then walked her all over the house. I made her lie down and then get up. The pains grew stronger. After midnight, exactly at 12:30 am, she gave birth. … After the birth I go there for up to 5 days. I bathe the baby and mother. After the bath I give warmth and smoke to the woman. She spreads her sari and legs wide apart and squats over the fire while I drop dried neem leaves, garlic peels, carrot seeds or raagi seeds into it. The healing smoke and heat should reach her vaginal place. The warmth of the fire is good to ease her aches and pain. If, while squatting, she takes the warmth on her hands and heats her legs and her face they will not swell. Whenever she bathes, giving the fire’s smoke and warmth should follow it. – Rati Nagamma (Kr site)
When family members come at night to call me I go with them. If it is in another village I stay over there and come back in the morning after finishing all the work. Next day in the morning I go there again to give seva (service) for mother and baby. I apply sek (dry heat) with a poultice of bheri leaves wrapped in cloth. To do this first I tend the poski (fire over the buried placenta). I massage the baby’s whole body and specially give sek to the navel and cord stump. Here, I will show you. [Lighting a diya (small oil lamp) on the floor she first heated her thumb and forefinger. Then she dipped them into warm oil and applied it on the baby’s cord stump. She repeated this 3 times.] I also clean the place and wash the soiled clothes of mother and baby. – Raashi Devi (Jh site)
Skills and Experience
Dais’ methods are high-touch and not high-tech. In medical practice too, clinical examination using a physician’s senses used to take precedence over diagnostic technology. Without recourse to modern medical tools and drugs, dais still rely on their sensory perceptions, on locally available resources and on their experiences of births. This starkly contrasts with obstetricians’ reliance on diagnostic tools, measurement parameters and complex medications that mediate the doctor-patient relationship.
Experienced dais use their hands skilfully, particularly in massage during and after birth and occasionally even late in pregnancy. Their hands ‘see’ and can intervene, finding the baby’s position in the belly and if needed repositioning it in the womb.
Nothing gets cut at home. I have done the delivery for so many women. With only hands it comes neatly with no tear. I told one woman I would do her delivery, but she wanted to go to the hospital. We took her there and a boy baby was born. But the staff had taken a blade and cut her. The places where sandaas (fecal matter) comes out and baby is born became one. – Sunanda Bai (Kr site)
In my sister’s delivery the cord was wound around her baby’s neck. When the head came out, I saw it was like a noose around the neck. I held that girl’s head and removed the cord from around her neck, over her face. I have done 3-4 deliveries like that. – Giriyamma (Kr site)
A pregnant woman from the upper village of Sangred went to a private clinic at Joginder Nagar. There the doctor told her she had twins in her belly and both babies were ulte (breech). He asked her to get admitted 15 days before due date. I met this woman coming back from there. She said she feared the hospital and asked me to do her check-up. The woman and babies seemed fine. I asked her to call me at the time when her peerd (pains) start. When her family called me I went and did her prasoota easily. Of the twin babies, one was puttha (breech) and the second was seedha (straight, head-first). – Bimla Devi Rajput (HP site)
In the eighth month (of pregnancy) a woman who carries heavy burdens finds that her baby moves here and there inside her belly. Sometimes it gives her pain. Then I massage her belly with mustard oil and move the baby back into its right place. Whatever I do, I do with my hands. If somebody has a puttha (breech) baby or an aarda (crosswise) baby then in her 7th or 8th month I straighten the baby by massaging her belly. In the 9th month one cannot straighten the baby as it gets set in its place. – Anarkali Rajput (HP site)
A private MBBS Doctor in the Himachal site confided to the research team that he feels dais are skilled but need more ‘technical knowledge’.
Big, very experienced gynaecologists also accept that dais in earlier times used to tell by touching the abdomen if a baby is straight or breech. We do appreciate them for this skill of theirs. Sometimes a pregnant women comes to us and says that the dai had told them the baby is breech. In such cases, we ask them to go for ultrasound and that confirms it. But I feel that, apart from this, dais can’t do anything else as they don’t have technical knowledge. (Gautam, Varkey & Sadgopal 2014)
One categorical statement can be made about dais that holds true across the vast area of the South Asian subcontinent: dais never cut the umbilical cord before the placenta comes out. Many reasons are given by the dais for this: that the placenta is more easily delivered when still attached to the baby; that the baby’s life is in the placenta so don’t separate them quickly; and that the placenta (with cord still uncut) can be used to revive a seemingly lifeless baby. Below are examples of what we call ‘placental resuscitation.’
The people of the house all started to cry… I saw every part of the baccha’s body. It felt warm and I could also sense light phus-phus nikaas (light exhaling of air). Then I put the phool (placenta) in warm water. After some time and a lot of effort the baccha (baby) started to cry. But this whole procedure took about three to four hours. I was paying attention back and forth between the baccha and the phool. I did it like that and I got tired out constantly rubbing the cord. After a long time that baccha started crying. – Nirodha (Jh site)
If the baby is lying there without crying then the cold water is poured over the placenta with the baby kept there. Cold water and warm water are put over its chest alternatively while patting it. A person standing by the side will take a pounding stick and beat the floor slowly beside the baby and placenta while the dai keeps softly patting the baby’s chest. After an hour the baby begins to cry, “Aaaa… aaa…” Then we know that life has come. I tie the thread and cut the cord. – Hullema Bi (Kr site)
A senior ANM at a PHC in the Jharkhand site, in her Provider’s Survey interview, said,
I know dais revive the baby with the phool (placenta) by milking the cord but I don’t know whether she warms the placenta. Here we give suction if the baby doesn’t cry and also give oxygen and keep the baby in an incubator. The dai does not help here. Nowadays she sends everybody here. Here we cut the cord immediately after the baby is born. The dai does not cut the cord until the placenta comes out. The dai lights the poski (fire) and similarly we sterilise here. Things are similar, only the dai is doing it from before and we do it according to science.” (Gautam, Varkey & Sadgopal 2014)
Placental stimulation has not been subjected to scientific research. But in recent years researchers have found that ‘delayed cord clamping’ reduces the risk of iron deficiency anaemia in early infancy as it allows for the passage of blood from placenta to the newborn. (Vain et al, 2014; Dash et al, 2014) In India where anaemia is endemic these findings are very relevant. What dais have been doing for centuries is only now being validated scientifically.
Traditionally oriented people view childbirth as a time of ‘heating’ in the body. Heat-producing drinks are given to stimulate contractions of the womb and facilitate opening of the body. They are also felt to give a woman the strength to push out her baby.
To increase the pains I ask them to give her hot water, hot tea or hot maand (rice starch). If the baby is still not getting born then I light the fire, give sek on the belly. As her belly gets warm the puaati says, “Hold me, hold me – the pains are strong!” – Karuna Sahis (Jh site)
Her pains stopped as her jeeva (life force) had grown cold. To revive her pains we made hot and sweet tea for her and I had her drink that and it warmed her body. – Lotardi Pavra (Mh site)
A reason why most doctors (and policy-makers) do not appreciate the skills of dais is the fact that their respective knowledge systems are contained within entirely different frameworks of meaning, or epistemes. Local health traditions in India, along with traditional midwifery, operate within an episteme that is completely at odds with modern bio-medicine’s technical terminology, as one physician-researcher suggests.
… the battle to be fought within academic medicine and their many constituents and representatives, may be between the tendency to maintain a hegemonic epistemology and the need to stretch currently accepted epistemological frameworks in an effort to understand medical traditions that lie outside biomedicine on their own terms. (Cohen, 2007: 155)
The Jeeva field teams attempted to comprehend dais’ narratives by paying close attention to their words and how they used them. The dais appeared to think analogically, i.e. connecting what they knew of the natural world with organs or processes in the body. Prime among these is the placenta.
All dais and local women in Jharkhand call the placenta ‘phool’ meaning flower. They explain that the placenta is the flower and the baby is the fruit, drawing the analogy from nature. On a visit to the Mh site as I reviewed the Local Terms Register I was uncomfortable that the only words for placenta were kuchru (in Pavri) or kaachro (in Bhili), both meaning waste. During a discussion in the team, a young Pavra adivasi field research assistant said, “Yes, there is another older word for placenta, ‘saatardo’. The word saatardo also means ‘beehive’.” It is interesting to see the analogy between the placenta and a beehive that makes honey (a baby) and is a site of activity. Significantly the structure of a hive resembles the cotyledons on the maternal side of the placenta. It seems to be another example of keen observation and parallel representation of a natural phenomenon and the inside of the maternal body. This kind of language conveys an appreciation of and congruence with the energetic natural world (shakti).
Garam Sui and Rural (or Registered) Medical Practitioner
Throughout most of India, even in small and remote villages, rituals to facilitate labour are being replaced with the sui or injection of oxytocin to stimulate womb contractions. As the body gets ‘heated’ during childbirth it is called the garam sui or ‘hot injection’. Thus beliefs in deities overseeing the domain of birth and ritual custom, often deemed ‘superstitions’, are getting replaced by modernity, technology and pharmaceuticals. The sui is a new modern ritual.
The baby moves fast after giving a garam sui. Sunil doctor told me, “You surely can do the prasav (childbirth), but now don’t do it because these people will not give you any money. Let me do it and give the sui – I’ll take money from them and give a bit of it to you.’ – Manji Devi (Jh site)
Women who are weaker, cannot give pains, or the pains don’t come or come only after a gap, then some people call the private doctor to give a teeka (injection). In none of the prasoota that I’ve done have I given an injection. For increasing the pains it should not be given. It is not good. Our hilly people who have gone to hospital when the pains were weak have seen them fill a glucose bottle with medicine and give it. In village it is given straightway. This can be harmful to both mother and baby. I just see that the pains come. – Jhandhari (HP site)
Jhandhari says that she ‘just sees that pains come’. After reviewing the early dai interviews, we encouraged the researchers next time to ask ‘before the sui how did you get the pains to come?’ Only then would dais talk about the various ways to facilitate labour, e.g. rituals, warmth, movement, herbal medicines, allowing time and so on.
We inhabit a materialistic culture that is generally interested in identifying, naming, obtaining and controlling – the satta approach. Dais even in other parts of India, whose voices I have documented over the last 25 years, repeatedly spoke of their birth work as seva ka kaam or ‘service work’, often with overtones of the sacred. That dais respond to women in the creative process of birthing, not for money or material gain, indicates the shakti of ability, capacity, skill, time and energy. A dai is motivated not by money but by the appreciation they receive from the woman and her family and the joy of being of use in a time of need.
The money given to the doctor could be used to give something to eat to the prasoota. If somebody has devotion then they give something to me. If somebody wishes then they give, like in that house over there they gave me 100 rupees. They said we can give you only this much. I tell them to give me only what you can. Poor people do give as much they can. I can’t say to people that they should give me as much you paid the doctor! – Ratna Devi (Jh site)
After doing a childbirth they give me grain for 3 months – whatever is in the house, jowar, wheat or raagi. Or they give me cash – 50 or 200, 300 rupees. If they are rich they give 200-300 rupees and I take whatever they give me. Those who are rich have money and can give. In the hospital they tell you to bring money beforehand and they won’t see you until you give it. If the life is going out of the woman they still say bring the money first. In the hospital you also have to give money to the woman who takes and buries the placenta, to the one who fills the blood, to the person who has given an injection – a share to be given to each of the hospital staff. They say it is better in hospital. But hospital is not for the poor. It is for the rich. – Seetha Bai (Kr site)
In some homes I don’t take anything. If they are very poor, then can I take from them!? God has blessed me with meals at both ends of day and that is enough. Poor people should be helped. Some people give a cloth piece, or a suit, but not money…. A woman in our village was about to give birth. The doctor at Lohardi PHC urged her to have her childbirth there only and told her about the (JSY) money she would get. That woman outright said, “I don’t want to have my prasoota at the hospital.” In our village most of the births happen at home. Nobody has got money. Even though the hospital facilities are available now, and one gets money for having the birth there, and the vehicle will drop you up to your home, still nobody from our village goes to the hospital since they feel it is fine at home so why go to hospital? – Suman Rajput (HP site)
The lure of money results in some strange birth scenarios as Valli Bai relates below. What a dilemma this presents for the dai who is perfectly capable of completing the birth and cutting the cord! However she knows of the financial need of the family so sends them off to collect, baby still connected to the placenta. The research team in Jharkhand says the same thing also happens in their area.
If the birth is about to happen then I tell them to call the ambulance, but once the delivery took place before it reached. So I tied the cord but didn’t cut it, put the maamsa (placenta) in a bag and sent them like that in the ambulance. We must not reveal that the birth took place in the house or they will not get the Bhagyalakshmi benefits (from the Government). If I had cut the cord they would not have got anything, so I sent mother and baby like that. – Valli Bai (Kr site)
The dais own words convey their energy, potency and ability (shakti) in serving women under the most difficult circumstances. They are consummately ecological cooperating as they do with maternal bodily processes. Facilitating with herbs, warmth, ritual and hands during labour, birth and the postpartum period, they generate no waste. They willingly clean up the products that have come out and often reverently bury the placenta. The placenta is handled with respect as it has functioned as a conduit for survival and sustenance to the baby.
Through the Jeeva study we have found the biomedical and institutional spheres of the Government to be plying their influence through financial enticements, trained health cadres and often inappropriate and interventionist handlings of birth. These findings should not be read as arguing against the provision of good and necessary medical care for poor and rural areas. Rather as a plea for recognition of indigenous midwives, their skills, caretaking and ethno-medical practices and integration of their good practices within service-delivery systems.
1 ‘Dai’ is the generic term officially recognised in India and some other South Asian countries for the indigenous traditional midwife. In the regional sites of this study, however, the people use their own local terms for the dai, e.g. kusraain or dhaai (Jh); sulageethi or janaaiwaal (Kr); huaarki, suaarkin or suin (Mh); and daai (HP).
2 ‘Active listening’ is an important interviewing technique in which sometimes an interviewer responds to the Dai, repeating what she has understood in her own words. This gives the Dai a chance to correct any misunderstanding and lets her know that the interviewer is sincere, so the Dai may be encouraged to go on and explain in more detail about the topic.
3 Sahiya is the term used in Jharkhand for ASHA, a paid part-time community health worker appointed on a large scale by the Government under the NRHM. Her main role is under the JSY (Janani Suraksha Yojana) schemeto escort women in labour from home to the nearest PHC or CHC hospital and to make postpartum visits.
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JANET CHAWLA. Is an activist, childbirth educator, scholar and founder-director of the NGO, MATRIKA. She researches, writes and lectures on traditional midwives (dais) and indigenous body knowledge. She has written and lectured on indigenous concepts of reproductive health nationally and internationally as well as contributed to edited volumes, produced a play a documentary film, Born at Home on childbirth in rural India. She was Scholar in residence at the Five Colleges Women’s Studies Centre in Massachusetts. Also active in the movements to humanise over-medicalised hospital childbirth Ms. Chawla is a founder member of Delhi Birth Network, a group devoted to advocacy for natural and midwifery-attended birth. Her current involvement is with qualitative research of the Jeeva Project- gathering data from families, dias and other providers in 4 remote areas Kangra District in Himachal; Bokharo in Jharkhand; Nandurbar in Maharashtra and Bellary District in Karnataka. Ms. Chawla’s most recent paper, ‘Oucats Women- cast out Birth Knowledge’ appears in Multiple voices and stories: Narratives of health and illness edited by Arima Mishra and published by Orient Black Swan. The MATRIKA film Born at Home can be viewed on youtube.