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I visited India earlier this year to study maternal and adolescent anemia and childbirth practices in rural Rajasthan. In Rajasthan and much of India, maternal mortality continues to be a leading cause of death amongst young women, such that India and Nigeria alone contribute to one third of all maternal deaths worldwide. (1) Between interviews and hospital visits, I spent much of my time with Dhuli Bhai and three other Traditional Birth Attendants or Daimaas, village level women who have been respected in their communities for centuries for their understanding of rudimentary medicine and birthing skills.
As India has progressed, their role and, in many ways, their stature in the eyes of the Indian government has diminished. (2) Many Daimaas have been marginalized and have been viewed as lacking adequate medical training and formal education. Additionally, India has pushed for the modernization of childbirth, has encouraged institutional deliveries, and even has implemented programs, such as the Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram, which incentivize women to visit local institutions for their delivery, rather than conduct deliveries at home under the attendance of a Daimaa.
Yet in the villages of rural Rajasthan, the role of the Daimaas remains fixed and powerful. Dhuli and other Dai’s are revered in their communities and villagers visit them to receive remedies for anything, from a common cold to postpartum complications.
One morning at 3:15 am, I woke up to the sound of Dhuli Bhai’s* voice. “Wake up, Priya. Woh thayaar hain.” This meant that “she,” one of the neighborhood women, was ready for her delivery and we needed to go with her to the hospital. I rubbed my eyes groggily, quickly changed my clothes, and off we went.
That morning, I watched Dhuli serve as a guide for maternal health – bringing a young woman to the local hospital for her delivery and later providing her with post-partum care. I walked with Dhuli through a rock-studded path in the mountains. She carried a large bag with her which contained emergency birthing equipment.
It was still dark outside, with the hush of the night interrupted only by the rustling of the corn fields and it took us forty minutes to reach Meera, a twenty-year old woman who was about to deliver for the first time. As we walked, I spoke to Dhuli about the process of childbirth in her community and what it was like to be a Daimaa. Did she enjoy taking women to the hospital? How did she decide whether to go to the hospital or to conduct the delivery at home?
Dhuli bhai peered back towards me with a wise and forgiving smile, and replied, "I always encourage women to deliver at the hospital, as this is what the government suggests. But Priya, always remember that having a hospital doesn’t always mean much. Hospitals are far away and not always great, and women sometimes deliver on the way there.” She paused momentarily to catch her breath. “If the delivery takes place at night, people fear that they will be beaten or murdered on the path to the hospital by “gundas” (thugs).” As she said these last words, I looked up at a dark, starry sky and a sliver of fear encircled me.
When we finally arrived at Meera’s house, we were greeted by her mother, father, siblings and her husband. Everyone had a cup of chai in their hands and anxiously paced around the front of the house anticipating the arrival of Meera’s child. Meera lay on a cot outside resting.
As we waited, I sat down next to her holding a maternal health textbook in one hand which Dhuli Bhai curiously peered towards. She noticed a picture of the birth canal and confidently went on to describe the process of implantation and embryogenesis as she had seen in the field. Her words were a reminder to me that a woman who had had less medical training than I had, still knew so much.
In the next hour, we waited for five or six more family members to arrive and, finally, all eleven of us made our way in a tempo to a government hospital in the neighboring state, Gujarat. When we finally arrived several hours later, the hospital was packed with throngs of women waiting for a delivery bed, a few nurses in white coats moving between rooms, and a small child cleaning the floors. Dhuli Bhai noticed quickly that Meera was ready for her delivery and rushed to inform one of the nurses.
We were allowed to skip a long line and Meera was then brought to a bed where she was given half a tablet of misoprostol to promote forceful and faster contractions. Her delivery was then conducted hastily by a nurse-in-training without the use of anesthetic, and Meera was told not to cry.
All the while, I watched as Dhuli held Meera’s hand, rubbed her forehead, and later rejoiced when the baby was finally born. However, unlike many deliveries I had witnessed in the United States, there was no mother to fetus interaction or bonding and the little boy was whisked away to another room surrounded by family members who dressed and played with him.
Meera, Dhuli, and I remained in her delivery room where the mood was somber. Meera remained in pain. I looked at her and tried to smile, but she did not smile back. “Can I have some water?” she asked. I quickly poured a cup for her, she gulped it down, and then closed her eyes. Meera and her new baby boy would meet a few hours later to begin breastfeeding and for a “check-up” by the attending doctor who took a quick look at Meera, asked when she delivered, and left. This was in stark contrast to the way Dhuli Bhai spent many hours speaking to Meera about how to care for her baby and sharing ways to take care of her own health post-pregnancy.
In watching Meera's delivery that day, I realized that birthing practices, even in a private hospital setting, did not meet my expectations and that conditions were often hurried and painful. Despite these conditions, Dhuli Bhai and the other Daimaas provided support and a last resort when the hospitals weren’t working.
As a future physician, I recognize that global health delivery is complicated. Physicians and public health practitioners grapple with encouraging women to go to a hospital where they may receive less than optimal quality of care or stay at home where they might face the risk of a complication. At the hospital level, there is also a constant economic conundrum as to whether it is better to hurriedly perform 100 or more deliveries in a day to meet the vast demand, or to take time and give each woman quality care. Essentially, while India has progressed in enabling women the opportunity to deliver at hospital, quality still often lags behind.
In the interim, as we develop healthcare infrastructure and increase the excellence of hospital care, one thing we can do is partner with women like Dhuli Bhai who are intelligent, compassionate, have immense hands-on knowledge, and are willing to learn and improve the care women receive. Training Daimaas is especially important given than nearly 60% of deliveries in India continue to occur at home, despite India's push for hospital-based deliveries. Ultimately, a Daimaa may be the only person to provide medical assistance. (3)
According to a recent UNFPA study, trained midwives have the unique capability to fulfill 87 percent of essential interventions needed by mothers and newborns. In a study based in Pakistan, Jokhio et. al found a 20% reduction in perinatal death when traditional birth attendants were trained appropriately. (3) Additionally, it has been noted that a 25% increase in effective midwifery can reduce maternal mortality by 50 percent. (4) In light of these findings, we must capitalize on the contextual knowledge that Dai’s possess and provide them with appropriate and safe midwifery training that builds on their existing knowledge. Instead of discarding the role of Dai’s, we must empower and provide them the tools to improve the delivery of care.
Throughout the world, child birth is not equal; it is contextually defined, and bound by access to quality healthcare and trained health personnel. In spite of these complexities, by forming partnerships with the right people, there is a path forward.
Priya Shankar is an MD/MPH candidate at the Boston University School of Medicine and Harvard School of Public Health.
*Names have been changed to protect patient identity
(1) Maternal Health in1990-2013. World Health Organization. http://www.who.int/gho/maternal_health/countries/ind.pdf?ua=1
(2) How Midwives Can Answer the World’s Maternal Health Woes. May, 26 2015, The Wilson Center New Security Beat. http://www.newsecuritybeat.org/2015/05/midwives-answer-worlds-maternal-h...
(3) Madhivanan, P et. Al. Traditional Birth Attendants Lack basic information on HIV and safe delivery in rural Mysore, India. March 2010. BMC Public Health. http://www.biomedcentral.com/1471-2458/10/570
(4) Kennedy, Holly. The Lancet Series: The intersection of global and local midwifery.