At the policy-making level what can be done to strengthen the dai tradition and link it to government health services and providers.
The dai tradition, dais, and birth spaces generally are inextricably interwoven with ideas of caste, purity and pollution. In many areas of North India the term for dai is chamain, or female Chamar belonging to the caste which were leatherworkers, handled dead animals and thus were considered ‘unclean’. It is important to recognize that efforts to link with dais face the quadruple aspects of discrimination against these women: caste, gender, class and literacy. MATRIKA analyses lead us to believe it is for these reasons dais have been consistently devalued, and deskilled.
This, in essence, means that many hierarchies will need to be challenged in order to link with dais, enhance their status, improve their skills, and bring them into the fold of health care providers on an equal footing.
Nothing speaks like money in today’s world. Although often dais say their work is ‘sewa ka kam’ they are poor and the women whom they serve are the poorest of the poor. One dai in our workshop said she even brought old cloth and oil from her own home as there was nothing in the jacha’s house.
This means a stipend/payment must be instituted for each birth handled by a dai—and an infrastructure created for executing this. Some states have moved in this direction but it should be a national initiative. The real problem in operationalizing this idea is the corrupt infrastructure which would dispense this compensation. So the problem lies not with the dais but with petty functionaries who siphon off funds meant for the poor.
Most scholars of the history of medicine on the Indian subcontinent agree that hands-on local health traditions (massage, bonesetters, herbalists, snake-bite specialists, and dais) had their origins in tribal peoples and scheduled castes or Dalits. Dais are mostly Dalits, inheritors of an often sophisticated, caste-based body knowledge and skill which differs radically from allopathy but is congruent with Ayurveda and other Asian systems of medicine.
Some policymakers and funders are now talking about the problem of ‘social exclusion’—the fact that some scheduled caste/scheduled tribe people are prevented from accessing government health services (PHCs, subcenters, ANMs, Anganwadis) because of their caste status.
State health cadres’ recognition of and dialogue with WOMEN’S indigenous health knowledge and practitioners could be an important step in overturning hierarchies and moving toward a cooperative model of maternal health care. Building linkages between obstetrical practice and that of dais could be a component in enhancing the status of dais and poor, traditionally oriented women in the eyes of government health personnel. As this website makes clear, from British colonial bias, through allopathic medical dominance, as well as years of ground level humiliation of indigenous caregivers by functionaries such as ANMs (where a woman who has attended no births is instructing women who have attended thousands) dais have faced scorn. Government policies have contributed to this. However, as one Tamil woman vaidya, Dr. PLT Girija, said, “Dais are the obstetricians of Ayurveda.” They should be recognized as such—and their communities would benefit from this reversal of hierarchies of knowledge.
AYUSH has been created to deal with indigenous systems of medicine (ISM). Hasn’t it been active in maternal health?
The Ministry of Health and Family Welfare founded a Department of Ayurveda, Yoga and Naturopathy, Unani, and Homeopathy in 1995. It was renamed later as AYUSH and has a portfolio of developing educational systems within these medical traditions, development of institutions, hospitals and dispensaries as well as drug quality control.
The dai tradition is not textually based, has not been formally incorporated into any educational or institutional setting. It has not found a place within AYUSH. However there are currently moves towards mainstreaming AYUSH and pressure for developing an ISM approach to women’s health. A document prepared by Dr. Mira Sadgopal for the 'National Dialogue' on Women, Health and Development, Mumbai, 23-25 November 2006 states
For the 11th Five Year Plan period (2007-2013), the Planning Commission has called for 'mainstreaming of the AYUSH systems in Government health policies and programmes'. While words were voiced in this direction in the 10th Plan, too, it made little headway. The National Rural Health Mission is now seen as the main field for operationalisation of this aim. Recently as a member of the Planning Commission’s 'AYUSH' steering committee, I could see that the Terms of Reference lacked a focus on women's health but I think space was made for it to evolve. Planning Commission Member and Committee Chairperson Dr. Syeda Hussain was supportive. Dr. Leena Abraham was member-secretary for the ‘Public Health’ Sub-Committee, and I was member-secretary of the Sub-Committee on ‘Local Health Traditions’ (LHTs). Dr. Vasantha Muthuswamy, currently Senior Deputy Director General of ICMR (Indian Council of Medical Research), was another supportive member in the 'LHT' sub-group. Among the many problems related to implementing the intention of 'mainstreaming' AYUSH, in looking at its implications for women's health and women's access to health care we enter an area of public health where there is little substantial data and scant research-based analysis to rest on.
Research does, however, indicate that one of the barriers to accessing health care services is a providers’ attitude. If the provider is respectful and somewhat knowledgeable about indigenous medicine, he or she will be much more culturally accessible to poor and marginalized communities.
What about the policy of “skilled birth attendants”?
This website reflects the best of the dai tradition. Unfortunately doctors working in rural areas rarely see the best, they see the worst-the 'botched cases' which are referred to them. When considering TBAs the most common program 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. This would be a more effective capacity-building approach. If 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 feels the GOI MoHFW should put forward a case for an integrated and coordinated system, building on what exists-rather than attempting to replace it. Global experience may not fit the Indian situation because of resource constraints and large requirements of
medically (or pharmaceutically) qualified personnel.
The main differences between dais and "SBAs" seem to fall in these categories:
- Literacy- Dais are not literate in that they can't fill out forms but that does not mean that they do not know a mother's health status and history, progress in labour, etc. Nor does it mean that they cannot be skilled providers of emergency obstetrical care. Conversely 10th Pass young women are not necessarily going to be the best 'midwives' nor are communities likely to accept them. These 'community midwives' having been trained, if they find private practice in rural areas difficult, are likely to get jobs in cities or private clinics-thus not serving the population they are intended to serve.
- Pharmaceuticals- Basic to the enterprise of SBA is the use of pharmaceuticals. Experienced older dais do not advocate the use of oxytocin injections to stimulate contractions. Increasingly they are pressured by families to refer cases to the compounder, RMP or they themselves use injections. We can say that these 'quacks' should not use pharmaceuticals, but they are doing so-everywhere-because doctors, nurses, hospitals are not available but pharmaceuticals are.
- Accountability- The question arises: "Who is the SBA accountable to?" and the answer is "The bureaucracy"-which in reality is an obscured system of accountability. Dais, on the other hand, are responsible to the families and communities whom they serve. They have a reputation to guard and are usually known and trusted. They, in our data, feel personally involved and care deeply about the birth process-and they are deeply spiritual, see themselves in partnership with, and accountable to God or Goddess.
Dais themselves acknowledge that some dais are very experienced and skilled, and others are not. Sometimes these 'skilled' dais are known to have specialties, like removing a retained placenta. Our informants, especially those confident of their skills, spoke highly of the life-saving tools available in hospitals with doctors. They also told of their financial, geographical, cultural and attitudinal difficulties in accessing them.
In our data analysis and advocacy efforts we point out that dais hold their knowledge in a radically different language and knowledge system than obstetrics-and that this indigenous system can be benchmarked with other Asia specific health knowledge. MATRIKA maintains that skills assessment in Safe Motherhood programs has been based on an obstetric model of 'skills' and makes invisible the expertise of the dai tradition.
Many analysts have pointed out the problems associated with overburdening front line maternal-child health care providers with too many, and too diverse, tasks. Dais and 'other' women are attending births in part because this is their focus of attention. They often see ANMs, nurses, etc. as involved in other work, with other agendas. Cadres of maternal-child or reproductive health workers have been responsible for birth control, malaria programs, RTIs and now AIDS prevention and birth registration-thus diluting their ability to be responsive to maternal child health needs.
Why do we have such negative views of dais?
The historical reason is rooted in the ideology of colonial India. The British often liked to justify their rule in India in terms of the scientific advancements they brought, particularly in terms of medicine and engineering. Historians have generally been more skeptical and pointed out that these developments were designed more to benefit the British themselves with any incidental benefit to the Indians very much as an extra. In fact, hundreds of lady doctors, not allowed an easy access to practice in the UK because of gender bias, came to work in India.
The issue of high maternal mortality also the supposedly barbaric hygiene and birth customs of dais and women themselves came to grip the imagination of British abroad and English-educated Indians themselves. So popular was the Countess of Dufferin’s Fund in the 1880s, which established maternity hospitals and wards throughout India, that big fund-raising events were held in Oxford and at the Mansion House in London, as well as in India. It was truly a cause celebre. We have inherited many of these views. (See “Mother India” by Katherine Mayo” in Featured Articles section)
A more positive view is often held by many older middle and upper class Indians whose ancestral homes in villages allowed them exposure to these birth traditions and dais personally. Also dais are often regarded highly by the women and families whom they have served. Much anecdotal and scholarly evidence suggests that local women avoid public health facilities for a variety of complex reasons. Unfortunately this research has not influenced the Ministry of Health and Family Welfare’s RCH 2 (Reproductive and Child Health) current policy.
Utilizing dais discriminates against the poor. We’re supposed to promote health through modern medicine. Doesn’t every woman have the right to a safe birth?
Dr. Jo Murphy-Lawless, an Irish sociologist and analyst of childbirth globally, writes
Proposed solutions to problems of maternal mortality have flowed from advanced economies and global institutions like the World Health Organisation and have tended to reflect models of health care that are heavily influenced by the politico-administrative apparatus of the wealthy modern industrial/post-industrial state. In the World Health Organisation, whose professional core is made up of medical doctors, the issue of appropriate maternal policies and model-building for Safe Motherhood programmes, has been caught between the structures and systems in wealthy countries that produce their medical elite and the circumstances of poor countries, where maternal health and well-being are threatened by the problems of extreme poverty.
Murphy-Lawless points to the difficulty in transferring resource-intensive technological and pharmaceutical based models in increasingly unsecured social and economic conditions. She questions their applicability amid the increasingly extreme conditions created by the impact of globalisation on poor countries. She also asserts the violence behind the erasure of indigenous birth practices and practitioners in the Bolivian context.
More critically still for women in Bolivia, the WHO has taken a particular stance on the issue of skilled attendance in childbirth. In 1992, the WHO drew a line under indigenous midwifery, categorising it as an unsafe traditional form which must be replaced with a full modern health care system (WHO, 1992). Leaving aside this policy as a violation of indigenous rights, it was a potentially disastrous decision from a practical point of view, given the still large percentages of women in parts of the world who give birth reliant on local indigenous midwifery and who do not have access to formal health care systems…