ISSN (Print) - 0012-9976 | ISSN (Online) - 2349-8846

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Global Health Initiatives and Local Challenges

Maternal Deaths

Childbirth in South Asia: Old Challenges and New Paradoxes edited by Clémence Jullien and Roger Jeffery, New Delhi: Oxford University Press, 2021; pp 342, $75 (hardback).

I have known Roger Jeffery and Patricia Jeffery for about three decades, first as scholars whose empirically rich work I read and taught. Later, they were friends whose friendship I value indeed. They were both visiting professors at the Centre of Social Medicine and Community Health, where I taught for three decades. They lectured in our centre, over the years, on various themes they had researched in a village in Uttar Pradesh (UP). They were, what we called, old India hands. I have had the privilege of working with them over many years, and Roger and I have been partners in a project out of which emerged the wonderful book edited by William Sax and Claudia Lang (2021), The Movement for Global Mental Health: Critical Views from South and Southeast Asia (Amsterdam University Press), among other remarkable publications. We also hosted a workshop together Safe Motherhood Initiatives: Contributions from Small Scale Studies.

Childbirth in South Asia: Old Challenges and New Paradoxes is extremely important because India continues to have an unconscionably high maternal mortality rate, made probably worse during the COVID-19 lockdowns.

In 2015, India still accounted for more than two-thirds of the total maternal deaths in the region, or 17 per cent of global maternal deaths. (p 10)

While the maternal mortality rate has indeed declined around the globe, it is not clear how much this has been because of programme interventions. As the editors point out in their Introduction,

Bangladesh has lower levels of institutional delivery than India and Nepal, yet MMR has declined more quickly. (p 12)

There are so many other factors involved—maternal nutrition, physical infrastructure, roads and ambulances, human resources, effective referrals, and, above all, emergency obstetric care at the institution. All of these need sustained and significant investments in public health and not the divestments we have had.

Institutionalisation of Childbirths

In an absolutely brilliant Introduction, the editors point out what the global policy framework has been, what policy interventions have been advocated, and what the problematic underlying assumptions are. For instance, it was assumed that the institutionalisation of childbirths would translate into better natal and neonatal care. This institutionalisation was to be achieved through both demand and supply initiatives—the former through cash incentives and the latter through improving facilities.

Across South Asia, these measures have seen sharp increases in institutional births. Yet,

maternal care particularly suffered because of lack of trained human resources … poor referral and blood bank linkages … and major deficiencies in physical resources. (p 19)

One of my students did a study of the Janani Suraksha Yojana (JSY) in rural UP with a sample of about 172 pregnant women (Verma 2015), predominantly from the lower castes and classes who had availed of the scheme. Not one of them have had their blood pressure taken, or abdomen palpated, or urine tested by the local auxiliary nursing midwifery (ANM) or accredited social health activist (ASHA), and 158 of them had been referred to private ultrasound facilities for ultrasound screenings. This “normalisation” of unnecessary techno­logy not only leads to increasing costs but also clandestine sex selective abortions despite the Pre-Conception and Pre-Natal Diagnostic Techniques Act, 1994 and a further skewing of the sex ratio at birth. This gets reflected in the child sex ratio too that declined from 927 girls per 1,000 boys in 2001 to 919 girls per 1,000 boys in 2011 in India.

Thus, an institutional birth does not necessarily amount to good quality care. As the editors note,

In India, for example, Dalit and Adivasi women, along with poor Muslims, are particularly likely to experience poorer quality of care and treatment. (p 20)

This compels the editors to raise the issue of obstetric violence with pregnant and birthing women reporting both physical and verbal abuse.

The medicalisation of childbirth has also meant an enormous increase in cesarean sections (C-sections).

In 1998–89 only 7.1 per cent of all births in India were C-sections. This increased to 9 per cent in 2005–06 and then shot up to 18.1 per cent in 2015–16. (p 20)

This figure elides the sharp differences between the public and private sectors in C-section rates. In some high-end corporate sector hospitals, C-section rates exceed 70% of all births. Does the performance of unnecessary C-sections amount to obstetric violence?

The volume comprises 12 essays in addition to the Introduction. The authors are all well-known historians, anthropologists, and medical sociologists from India, Pakistan, and Bangladesh. Why Sri Lanka is left out in a volume on South Asia is a mystery. The essays are uniformly well-researched and well-written, with a careful scrutiny of the relevant primary data.

Obviously, I cannot comment in detail on all the essays in the volume. There are essays by anthropologists on birthing in rural Pakistan, “Forms and Ethics of Baloch Midwifery: Contesting the Violations of Biomedicalized Childbirth in Pakistan” by Fouzieyha Towghi and in urban India, “‘Since It’s a Pleasure to Save Somebody’s Life,’ I Do This: Midwifery and Safe Motherhood Practices in Urban India” by Helen Vallianatos, and “Childbirth in Transit: Motherhood and Migration at Taljai, a Slum in Pune” by Deepra Dandekar, which show striking similarities. One is the continuing relevance of the so-called tradi­tional birth attendants (TBAs). While a general shift has taken place to institutional births, people are acutely aware of staff shortages, the lack of medicines and infrastructure, and the costs of such care even in public institutions. Those who can afford it, therefore, prefer private institutions. Not that it guarantees quality of care as is revealed in another chapter of the volume. The poorest, of course, cannot access these services. Thus, even as there are efforts towards institutionalisation, there are simultaneous efforts to train TBAs (see “Training Birth Attendants in India: Authoritative Knowledge, Social Forms, Practices and Paradoxes” by Pascale Hancart Petitet) for home births. At the same time, elites in urban areas access birthing salons for natural births. A water birth in one of these costs a minimum of 1.25 lakh. Sadly, there is no chapter on this.

Colonial Legacies

Samiksha Sehrawat’s astonishing essay “Colonial Legacies and Maternal Health in South Asia” explains how the afterlife of colonial policies continues to shape policy and practice in the countries of South Asia. She argues that

the medicalization of childbirth in the 1920s and 1930s took place amidst rising concerns regarding conditions of childbirth in eugenicist and maternalist ideologies internationally. (p 41)

The other two features that shaped policy was “scientism as a sign of modernity” ushered in by medical professionals in international health organisations. Thus, it was agreed that the high maternal mortality rate was a result of the deplorable cultural traits of the people and the dirty and ignorant dai who conducted childbirths. Colonial policy that caused poverty and hunger, along with the lack of investment in health, were effectively whitewashed away as causes. The Association of Medical Women in India (AWMI) came up as a solution to the problem of unemployment among women medical doctors in Britain but contributed to tropes that represented “the medical needs of ‘dumb’ Indian women oppressed by Indian patriarchal traditions” (p 46).

In the post-independence period, the new civilising mission was led by the United States (US) initiatives in development, hand-maidened by the Rockefeller Foundation, among others. Indeed, the discipline of tropical medicine was viewed as a “proof of the benefits of Western imperialism” (p 49). In short, in addition to scientism and cultur­alism, we have technological solutions to social problems.

Two essays discuss technology in childbirth. One is an ethnography of in-vitro fertilisation (IVF) in Bangladesh, “Discourses of Childlessness in Bangladesh: Power and Agency” by Mirza Taslima Sultana, which reveals quite a high failure rate. The second important finding is the aversion to third-party assisted reproduction as in surrogacy. We do know of course that Bangladeshi women, like Indian women, are moved to Nepal for surrogacy. The other paper “Digitalizing Community Health: Mobile Phones to Improve Maternal Health in Rural India” by Marine Al Dahdah and Alok Kumar takes us to a natal dystopia where a mobile phone with pre-recorded messages replaces a health worker.

The essay on Nepal, “Politics of Childbirth in Nepal: The Case of Maternal Mortality Ratio” by Jeevan Sharma and Radha Adhikari has something salutary for the rest of South Asia. Nepal only legalised abortion in 2002 (India did in 1971), largely driven by population control considerations. Nepal is the only country offering abortion irrespective of age or marital status. This is something India urgently needs to emulate. Illegal abortions in India are estimated to contribute 8% to the maternal mortality; a substantial number of these would be young unmarried women.

Three essays discuss issues related to doctors, especially the problem of getting doctors to work in rural India. One of these essays, “Care’s Precarity and Professionalisation of Health Workers in Private Maternal Clinics in Rajasthan and Uttar Pradesh, India,” reveals that private nursing homes, run by entrepreneurial doctors, are in fact staffed by unqualified nurses and orderlies, some of them with fake degree certificates. Indeed, in one case, births are conducted not by the doctor running the enterprise but a ward cleaner. Yet, these doctors claim victimhood.

One of the best essays in the volume, based on extensive ethnographic work at multiple sites, is Neha Madhiwala’s “Protocols and Set-Ups: Producing Professional Obstetrical Knowledge in the Periphery of Mumbai, India.” Reservations have meant that “high quality medical education has become accessible for disadvantaged students” (p 212). But lacking financial and cultural capital, the “challenge of facilitating their assimilation into historically upper-caste metropolitan sub-culture of education remains” (p 214). One extremely important finding is that once they obtain admission, the students in the reserved category do as well as those so-called merit students. Interestingly, Dalit and Adivasi students

agreed that discriminatory attitudes among senior faculty, which they encountered in regional colleges, were not in evidence in Mumbai. (p 223)

Armed with good degrees, “a lack of fluency in English and a discomfort with the ‘suit and tie’ culture” (p 236) made them hesitate to go into metropolitan private practice where they would confront “modernized forms of untouchability” (p 234). But most of them did indeed want to set up their own nursing homes, when they could afford to do so, acutely aware of the difficulties in competing with corporate hospitals. This is an extremely rich and nuanced study that merits a monograph in itself.

Another ethnographic study, “Outsiders in the Village: Class, Space and the Shortage of Women Doctors in Rural Rajasthan” by Jocelyn Killmer has a young woman doctor explaining why she cannot work in rural Rajasthan. She says,

You can’t find people who have similar thoughts to you. You spend time with village people and you become jangli [wild or uncivilized] within six months. (p 180)

A fascinating paper, “Son Preference in India: Stigmatisation and Surveillance in Maternity Wards in Jaipur, Rajasthan” by Clémence Jullien finds pervasive son-preference among both the patients in a maternity ward and the staff. Women are taking help from priests and unofficial doctors prescribing injections to conceive a male child. The paper concludes,

though doctors systematically mention son preference as a shameful attitude of the lower social classes, the medical community is more involved in the phenomenon of son preference and the practices of sex-selective abortion than they appear. (p 254)

The volume is a veritable feast of information and acute analysis. It is a must-read for all medical students, students of public health, policymakers, workers in maternal and child health, and anthropo­logists and sociologists of health and gender studies. All of us reading this book will come back immensely enriched.

Reference

Verma, Chandrika Prasad (2015): “Access and Barriers to Institutional Birth Schemes: A Study of Janani Suraksha Yojana in Sultanpur District, Uttar Pradesh,” unpublished MPhil dissertation submitted to the Centre of Social Medicine and Community Health, School of Social Sciences, Jawaharlal Nehru University, New Delhi.

 

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Updated On : 1st Aug, 2022
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