Matrika (Motherhood and Traditional Resources, Information, Knowledge and Action) began a as 3-year research project focused on North India’s traditional midwifery practices. Matrika’s methodology ventured outside of the government’s medicalized training models to explore the enthnomedical knowledge of the Dai through interviews, workshops, legends and songs. I highly encourage everyone to spend some time reading through the information on Matrika’s website: http://www.matrika-india.org/
This blog post contains a summary of key concepts Matrika has used to illuminate the enthnomedical world of the Dai.
Conceptual Pillars of a Dai’s Perspective on Childbirth and Health:
1. Microcosm-macrocosmic view of world - patterns of life and health mirror the minutia of our cosmos. The microcosmic-macrocosmic understanding of the world is founded on philosophies of equilibrium, life energy and harmonious attraction.
2. Concept of Jee – force or energy of life. Although Jee transcends the realm of physical sensations, it is often allied with heat and can be physiological defined as a pulse or rhythm within the body. Physical and emotional health is a product of unobstructed Jee. In India, the flow of Jee is regulated by many traditions such as massage and yoga.
3. Narak – The meaning often rendered by Narak can be translated as the hell or domicile of demons, although the Dai often illustrate Narak as a place deep beneath the earth where the energy of life and the body reside. The Dai’s perspective of Narak, as sacred and nurturing, diverges radically from that of the Pundits, holy texts and caste-oriented people, who identify Narak as “filth” or “pollution”. For many people the concept of Narak encompasses both birth and menstruation; thus menstruating women are prohibited from visiting temples, mosques and interacting with holy texts. Nanak’s association with pollution lends insight into why most Dai come from low caste backgrounds. Since the Dai often deviate from polluting concepts of birth, for them, Narak represents the time in which a women’s body is “open”, preparing for birth though releasing of bodily fluids and lochia. Matrika says that Narak, “Signifies the inner world of the body, which is invisible to the human eye.” The aim of many of the Dai’s therapeutic practices are to positively influence the inner-body without compromising the outer-body. Non-threatening techniques include massage, herbal therapies, and alternation between hot-cold foods/poultices and enforcement of privacy. Matrika also sights that postpartum discharge is connected to the concept of “bad blood” - blood that the Dai believe nurtured the baby and, now with its task finished, must leave the body after the birth. Matrika is keen to point out that skilled Dai can plainly distinguish between normal amounts of discharge and postpartum hemorrhage.
4. The cosmic significance of the Mother-baby umbilical cord connection - postponing cord cutting, until after the placenta is released is a strong tradition, imperative among most Dai. The Dai believe that severing the cord directly after birth or before it stops pulsating aborts the important flow of Jee between Mother and the baby. Many Dai often claim that the baby’s life source is housed in the placenta; when a baby has problems breathing the Dai sometimes rouse the flow of Jee by placing the placenta on a hot surface.
Some traditions regarding the placenta often seem contradictory.
Due to caste and gender inequalities, tasks related to the placenta are sometimes assigned to a woman who hails from a caste lower than the Dai. Some communities honor the placenta by burying within in the home and praying to incur health and prosperity for the child.
All the Dai I have interacted with completely discount biomedicine’s practice of immediate cord cutting. The Dai from Asha NGO have commented that delayed cord cutting helps the child breathe and decreases the amount of shock they experience. In their support, there is actually no scientific reason to explain instant cord cutting - many doctors and midwives have begun to delay cord cutting until after the cord stops pulsating to ensure that the child receives an optimal amounts of blood and oxygen. In 2007, the American Medical Association published a study which found that delaying cord clamping for a minimum of 2 minutes after birth has both immediate and delayed benefits for the baby. For babies born at term, both newborns and infants reaped the benefits of an increased blood volume and iron status. (http://jama.ama-assn.org/cgi/content/full/297/11/1241).
5. Hawa-Gola – Though often used as a pair, the colloquial translations of Hawa and Gola are ‘wind’ and ‘round’. Burra Hawa, or bad wind, pertains to the activity of damaging spiritual forces. Though many Indians laugh because the chapattis I roll are not ‘goli’, within the Dai’s context, gola has come to describe energy (which was believed to have formed the baby) leaving the body in the form of ‘bad blood’, known in biomedicine as postpartum hemorrhage. The Dai consider postpartum retention of Hawa-Gola extremely dangerous, they describe a retained placenta by saying the placenta has “moved high into the body”. Often pain after childbirth is attributed to the gola searching the womb for the newly born baby. Symptoms of this ‘searching’ are identified as the sudden cold or shakes women typically experiences after their warm child is leaves their womb. Many Dai control shakes and cold by feeding the mother warm food and placing a heated clay pot on her abdomen.
6. Bemata – Among Dai, Bemata is conceptualized as an old women who resides underground, sculpts babies out of the earth and inscribes futures on children’s foreheads after birth. Bemata posses a dual power to harm and nurture: she grows and protects the baby in the womb but becomes the cause of complications if she does not flow away with postpartum bleeding within six days postpartum. Matrika describes Bemata as “diagnostic tool” used by the Dai to evaluate the postpartum health of the baby and mother, as they do not posses biomedicine’s practice of Apgar scoring etc.
The Shortcomings of Traditional Midwifery are Multifaceted:
Matrika has made it a point to examine the common notion that traditional midwifery practices are always unsafe and the cause of birth-related complications. Matrika wisely points out the Dai typically serve sections of the population victimized by poverty, malnutrition, polluted water (approx. 6-70% of India’s water is severally polluted!), lack of resources and violence related to caste-gender inequalities. Matrika calls for the grip of poverty to be held as equally responsibly for maternal complications as the guiding hand of the Dai.
The question is not whether or not the Dai and poverty stricken mothers reject emergency procedures but whether or not they even have access to life saving services. When we take this view, the problem becomes focused on what the Dai do or do not do and more focused on the access and lack of resources. Matrika illustrates this problem by saying that even if a medical practitioner – trained in all the latest life saving procedures – was present at birth, they would not be able to implement most their knowledge sans the assistance of proper equipment and a surgical environment. I have seen that the policy of institutionalized birth fails when even when women are institutionalized in hospitals, as many government hospitals lack the resources necessary to perform life-saving procedures!
Besides poverty, another impediment to the call for “Safe Motherhood for All” stems from the fact that WHO and Unicef do not include Dais in the category of “Skilled Birth Attendants”, defined as a person who is capable utilizing pharmaceuticals during birth. There has been little attempt to partner with or educate Dai, even though they are largely responsible for all the births in rural and slum areas. Dais are considered unable to obtain qualifying skills due to the fact that they are often illiterate and come from low castes and socioeconomic standings. The situation is worsened by the fact that Dai are often blamed and insulted by medical staff when they bring woman to a hospital after identifying a complication.
Since Asha has recognized the fallacy of position held by most policymakers and caregivers, they have worked with the government to provide many Dai with training and delivery kits. Giving Dai acess to resources and information has helped them identify and eliminate detrimental practices and work more smoothly with the medical system when problems arise.
Hopefully, advocates of Safe Motherhood will dig deeper into the social/economic reasons behind maternal deaths and will come to see the Dai as one of the missing links to increasing the efficiency of their initiatives.