By Ranjit Devraj
NEW DELHI, Dec 16 2004 (IPS)

Although she lives within a stone’s throw of some of the finest medical facilities in the world, Sumitra preferred to deliver her baby boy, now six months old, in the familiar surroundings of her own modest home at Okhla, an industrial suburb in the Indian capital.

”I knew that I would be safe with a ‘dai’ (traditional midwife) attending to me and my husband was ready to fetch a doctor or rush me to a hospital in case there were complications,” a contented Sumitra, who only wanted to be known by her first name, told IPS.

The choice that Sumitra made is not unusual in India where two-thirds of all births happen at home although the vast majority of the country’s estimated one million ‘dais’ operate in rural areas rather than in urban settings.

According to a study, earlier this year, released by the International Institute of Population Studies, less than 16 percent of all rural births in India were conducted in hospitals or clinics. The high cost of medical services is probably a contributory factor on why hospitals are shunned.

Also, the personalised care provided by the ‘dai’ at home has meant that many women in urban areas are still prepared to take risks of their labour going wrong due to last-minute complications.

Sumitra said one of the reasons that she preferred not to go to a hospital when her time came was the general belief that doctors and obstetricians tend to be ”scalpel-happy” and resort to caesarian deliveries at the slightest excuse.

Surveys carried out in privately run maternity homes show that at least a third of births are done by caesarian section leading many obstetric specialists to talk about a ‘caesarian epidemic’ in the capital.

Because caesarian section deliveries can be timed, maternity hospitals that have limited staff find the procedure convenient when having to deal with simultaneous deliveries at the same time. But post-operative care and costs are another story.

Said Premvati, the ‘dai’ who attended to Sunita, ”I don’t mind waiting for hours or days before the birth occurs and from experience I can tell in advance whether the services of a qualified doctor are going to be required or not.”

Premvati who has attended to 300 deliveries over the last 20 years said she has never attended to a single case in which the mother has died, although there have been several still-births and a few infant mortalities.

”Unlike what most people think, we use gloves and new blades to cut the umbilical cord and tie it with clean thread,” she told IPS in an interview.

Added the traditional midwife: ”We also know how to wash up with easily available antiseptic lotions. Anyway there are doctors or para-medics available in reasonable time to give the mandatory tetanus shots if things go wrong.”

But according to official figures each year more than 100,000 women die in childbirth and the blame is being laid on the humble ‘dai’ who usually comes from a low caste in India’s hierarchical social system.

Most of the deaths, however, are from excessive bleeding, eclampsia, difficult labour and anemia from which 75 percent of Indian women suffer. And such complications can hardly be laid on the ‘dai’ when the nearest hospital or doctor may take at least a day or so to get to in the vast rural areas.

The symptoms of eclampsia include raised blood pressure, abnormal swelling (oedema) and protein in the urine. This poorly understood condition can affect up to approximately 10 percent of all pregnancies to some degree or another, although its severity varies from woman to woman.

Since 2002, the Union Ministry of Health and Family Welfare, as part of a drive towards safe motherhood, has been discouraging deliveries at home in favour of births in hospitals and clinics – although many experts say this is not practical.

‘Dais’ have been delivering babies for generations, and the ‘hunar’ or the art they have, is usually passed down from mother to daughter. And they, too, have many supporters.

Among them is Janet Chawla who runs the voluntary agency ‘Matrika’ an acronym for Motherhood and Traditional, Resources, Information, Knowledge and Action but which also means model in the Hindi language.

Matrika has built up an indigenous database on the female physiology and birth process. The database includes perinatal rites – which are the rites of passage of birth and the joys of parenthood – and commentaries by traditional midwives and their experiences in different parts of India.

As part of its advocacy activities, Matrika disseminates its findings and networks with groups that promote safe motherhood that is compatible with ground realities in India.

”The fact that ‘dais’ are being increasingly marginalised in modern medical systems which refuse to recognise their skills keeps us going,” said Chawla.

These traditional midwives have, over the years, developed skills suitable to their particular environment.

For example, in the desert state of western Rajasthan they attend to births with the mother lying on a bed of warm sand which foments her body and absorbs blood and other waste. The sand, then can be disposed off safely.

Immediately before delivery, the ‘dai’ massages the vagina of the mother with ghee (clarified butter) to relax her and ease the delivery. She may stay on to attend the mother’s needs for days at a nominal cost.

”I charge 15 U.S. dollars for a delivery and about two dollars for every extra day I stay with the mother or attend to her,” said Premvati.

The skill of the ‘dai’ is acquired through long years of apprenticeship with an older practitioner and this includes knowledge of traditional herbs and local materials that ease the pangs of birth and help the mother towards quick recovery.

Premvati has already passed her skills on to Sunita, one of her three daughters, and is planning to return to her village of Badayun in northern Uttar Pradesh state where she will continue to serve women, who unlike her urban clients, have less choice and are generally poorer.

‘Dais’ all belong to the areas where they share deep ethno-cultural ties with the women there. In the rural areas, they are mostly paid in kind because in the villages cash is hard to come by.

Sunita, who is 25 and has already attended to 15 delivery cases on her own, plans to enroll for a formal training course in midwifery that has become available for ‘dais’ as part of the government’s safe motherhood programme.

”Normal deliveries can be safely conducted at home by ‘dais’ provided they are trained properly,” said Saroj Pachauri, the regional director for Population Council, an international non-governmental organisation that works to improve the well-being and reproductive health of current and future generations.

According to Pachauri, India still finds it difficult to provide affordable institutional care for all births even if it is the country’s desirable goal. ”The strategy should be to effectively integrate traditional and modern health care systems so that maternal mortality can be prevented,” she told IPS.

Excerpt: