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Doctors-Nurses-Midwives, Public Health Specialists

What is the situation of midwifery in India?

Midwifery in India is either a debatable topic (in public health and Safe Motherhood circles), or of no consequence (in the ways most middle and upper-class women give birth). First we must define the terms of those who attend birth, as they exist in India today.

Midwives are all nurse-midwives educated in a bio-medical (anatomy and physiology) understanding of pregnancy, birth and postpartum. They are qualified as both nurses and midwives and attend only 12 percent of births in India, according to the latest (1999) National Family Health Survey. These are almost all in institutions of some kind

Dais (or Traditional Birth Attendants) and ‘other women’ attend 57% of all births. In rural India 83% of births are at home. Although they are referred to as TBAs, and not midwives, and assumed to be unskilled, they are the inheritors of India’s midwifery skill, knowledge and ritual heritage.

Doctors, or other ‘medically trained,’ staff attend the remainder. However, due to the stated government policy of institutionalized birth for all and the status afforded hospital birth, women are increasingly turning away from traditional handling of birth to medical establishments. In hospitals, birth is most commonly under the control of doctors and not midwives.

Auxiliary Nurse Midwives (ANMs) are supposedly the government’s front-line village maternal child health workers. This cadre of health workers was created after India’s Independence and at first its emphasis was on midwifery and MCH. In the 1970s, however, with the push for population control, the ANMs’ role became motivating and handling ‘family planning cases’ and her role at birth or as an MCH provider was limited. As a ‘multi-purpose worker’ now she is supposed to carry out innumerable tasks at the local level: nutrition and MCH programs, refer cases for abortion and family planning, give treatment and educate about communicable diseases, maintain records of vital statistics and pre-natal mothers and provide primary medical care to populations of up to 5,000 people, as well as train dais. Her role in maternal child health has been diluted beyond recognition by bureaucratic bungling and she is almost never found at a birth.

Increasingly, Registered Medical Practitioners (RMPs), Compounders, Vaidyas, almost exclusively male, will be called to a laboring woman’s side to give an injection of pitocin (a synthetic oxytocic) to speed up labor. These pharmaceuticals are found in the most far-flung villages—however practitioners formally educated in their use, are not.

Cord-cutters and Postpartum Workers in some parts of India do a set of specific tasks at all household births, as well as some in local clinics. This work involves tasks which others (including, usually, the person who delivered the baby) do not perform: cutting the umbilical cord, removing trash and offal, rubbing the baby with dirt, massaging the baby and mother, and bathing the infant when the first period of confinement ends. These women remove pollution from the home by removal of trash and by way of payments (coins, grains placed under the baby). On the final day, and with little ceremony, they ritually progress the baby into the next stage of its life: decreased pollution and entry into its social world.

This work is based on untouchable status and they are always from the lowest ranked untouchable community within a village. They work as agricultural laborers, though their caste-based work is associated with bodily processes and substances, death, animal butchery, and trash-work. These castes include Pasi (pig-herders), Chamar (leather-workers, removers of the carcasses of dead animals), Dom (funeral workers), and what in Sitapur are called Dhanuk or Bakshur (basket weavers and sweepers). (Courtesy Dr. Sarah Pinto)

Terracotta Image of an infant placed in a winnowing basket immediately after birth (honoring the fertility of both mother and earth). Note that the placenta is still connected to the baby at this point.

Safe Motherhood programs advocate skilled attendance at birth. Shouldn’t all women be attended by ‘skilled birth attendants’? Most dais aren’t trained. Doesn’t every woman have the right to a safe birth?

The obstetric model of childbirth, is based on a complex and resource intensive web of inputs: infrastructure (buildings, medical technologies, cold chain); highly skilled medical personnel (obstetricians-gynaecologists, paediatricians, anaesthesiologists, etc.) and pharmaceuticals. Efforts to provide quality maternal care for the vast numbers of India’s poor in resource-starved public facilities requiring highly skilled personnel are bound to face difficulties.

One of the cornerstones of “Safe Motherhood” efforts in India, and globally, is “skilled attendance at birth.” The term “skilled attendant, according to these public health groups concerned with reducing maternal mortality and morbidity among the poor, refers exclusively to people with midwifery skills (for example, doctors, midwives, nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose or refer complications to a higher level of care. This means that those attending birth should be able to provide “essential” and now the newly introduced term is “emergency” obstetrical care. In order to do this the Government of India, lobbied by such international NGOs as the White Ribbon Alliance for Safe Motherhood, Unicef and the World Health Organization, has rolled back prohibitions against the use of such pharmaceuticals as misoprostal, methergin, pitocin, antibiotics, anti-convulsants allowing certain cadres of government workers, Auxiliary Nurse Midwives (ANMs), Lady Health Visitors, and the like to use these drugs.

However this remains on the policy (and ideal) level. Many well-intentioned policies cannot be implemented for a variety of reasons. India is an immense and diverse country with scant resources. Corruption in the public health sector is rampant; drugs for public distribution are sold on the open market; doctors posted at Primary Health Centers collect their salaries but live elsewhere—and doctors prefer lucrative salaries in urban areas or abroad. Many Obstetricians and Gynecologists are young women and custom and safety prohibits their living alone in remote areas.

Everyone says that dais are not skilled birth attendants and yet MATRIKA claims they are—how come?

Good and experienced older dais who have been practicing for years in their communities usually do fit the definition of someone with midwifery skills. Let us look at the Ministry of Health and Family Welfare’s Skilled Birth Attendant checklist.

Good dais (midwives) are able to
  • provide preventative care to pregnant women,
  • detect abnormal conditions in mothers and infants,
  • assist women through labour and delivery
(All within an indigenous medical framework. Certainly these skills can be enhanced and supported by medical referral services. What the dais can't do is prescribe essential drugs. Many studies point to the absence of social and psychological care in health facilities and dais are almost always appreciated for this.)

Dai training has never focused on obstetric-based emergency
management of complications or Home Based Life-Saving Skills. Dais do have ways of handling complications utilizing locally available resources and indigenous medical skills. (Dais, herbalists from Bangalore, use of the same herbs used for jaundice in cases of pre-eclampsia-symptoms. These herbs were understood de-toxify the body. Eclampsia is a toxemia-reaction calling for cleansing of the system. Throughout India dais use the placenta, stimulating it by heat, as a resuscitation device for asphyxia.)

We can compare MATRIKA’s assessment of skilled dais with the WHO description of a Skilled Birth Attendant

Experienced Dais have a basic ability to perform the following skills,
although within an indigenous knowledge system and within a supportive and feasible referral environment:
  • Take a detailed history, assess the needs in pregnancy, give appropriate advice and guidance, and be able to calculate expected date of delivery.
  • Provide minimum essential care in pregnancy
  • Assist pregnant women and their families in Birth preparedness and complication readiness including arrangement of money and transport
    should a need arise
  • Educate women and families on self-care during pregnancy and birth
  • Recognize pregnancy related conditions and illnesses that require first line management and referral for specialist medical care
  • Perform vaginal examinations, ensuring safety for the women and themselves
  • Recognize onset of labor
  • Provide minimum essential care in labor and during delivery
  • Monitor maternal and fetal well being during labor
  • Recognize delayed progress in labor and take appropriate action
  • Manage a normal vaginal delivery
  • Provide minimum essential newborn care to ensure safe transition to extra-uterine life
  • Recognize and conduct first line management of conditions
    detrimental to the health of newborn at the time of birth
  • Assist women and newborn in initiating & establishing breastfeeding
  • Provide minimum essential care to women and newborns in the postnatal period
  • Recognize and conduct first line management of pregnancy related conditions detrimental to the health of women and newborns in the post-natal period.
(MATRIKA has data to support the above)

They do not have the following skills
  • Active management of third stage of labor and rational use of oxytocics
  • Able to use the partograph (although they usually have an indigenous tracking system)
  • Recognize and conduct first line management of hemorrhage and hypertension in labor.
Why hasn’t dai training worked to improve Maternal Mortality Rates?

The primary reasons poor women die having babies are because they are malnourished, overworked, live in degraded environments and are often victims of violence—not because they are having babies. Good medical referral systems, policy change directed towards these problems, and a respectful attitude towards dais and women seeking formal health care are the best approaches to reducing maternal mortality rates.

Also dai training programs are dominated by a Western biomedical approach and dais are perceived as unskilled. The lack of understanding of and respect for indigenous birth knowledge by formal sector health care planners and personnel has prevented the development of culturally appropriate, sustainable and affordable training methodologies and cooperation between formal and informal health care providers.

Ayurvedic knowledge has the capacity to ‘validate’ and provide an explanatory framework for dais’ understanding of female anatomy and physiology. The use of an Ayurvedic conceptual framework could facilitate communication and mutual learning between maternal health care providers. A complementary and cooperative approach recognizes and dialogues with informal sectors of home-based maternal health care

This website reflects the best of the dai tradition. Unfortunately medical personnel working in rural areas rarely see the best, they see the worst—the ‘botched cases’ which are referred to them. The first message in any dai training syllabus is “train TBAs to avoid harmful practices during delivery”. The “appreciative inquiry” methodology is proactive, first drawing out what is helpful, building on that and then finding out what is dangerous would be a more capacity building approach. If first and foremost in the trainers and policymakers mind is dangerous practice, no wonder that is what they see and know.

MATRIKA advocates a pragmatic approach of capacity building of caregivers already in place and puts forward a case for an integrated and coordinated system building on what exists—rather than attempting to replace it.

For a critique of this model see “Over-medicalisation of Maternal Care in Developing Countries”, by Pierre Buekens, in Studies in HSO&P, 17, 2001
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