Way to healthy delivery

Dais have been an important part of the process of childbirth. However, the trend of institutional deliveries has sidelined them. These traditional midwives can be trained for a role in the national rural health scheme to lower the rate of maternal mortality, writes Usha Rai

There are over 10 lakh dais or traditional birth attendants serving rural and urban communities in the country and for centuries they have been delivering babies in return for a coconut, a sari or sums as small as Rs 50 or 100.

According to the National Family Health Survey (2005-2006), an overwhelming proportion of births, especially in the high focus states of the National Rural Health Mission (NRHM), still take place in homes. Till 2005, when`A0NRHM came into existence, there was constant training and retraining of trained birth assistants (TBAs) and dais to ensure a continuum of care for pregnant women and lactating mothers.

The NRHM, however, made the mistake of equating safe delivery with institutional delivery. But it is not as if hospitals or health centers have brought about a revolutionary change. On the contrary health experts have pointed out that now the site of maternal deaths has shifted from homes to medical institutions. Though the concerns of the NRHM are justified as India has the highest maternal mortality rate in the world yet the manner in which it has gone about solving this problem is questionable.

Contradictions

According to National Family Health Survey (NFHS) figures released recently, in Uttar Pradesh alone as many as 40,000 pregnant women die every year. It was in a move to bring down this number that the NRHM focused on institutional deliveries with Rs 1,700 being given to every mother post delivery under the Janani Suraksha Yojana.

The statistics released by the NRHM, however, present a different picture. Dr Abhijit Das, Director of the Centre for Health and Social Justice, points out that figures from Andhra Pradesh show that 93 per cent of the deliveries in February 2008 at the primary health centres (PHC) were normal and 83 per cent of the patients used referral transport provided by the nearest government facility.

But there is another side of this story. The number of nurses in the labour rooms in primary health centres in Andhra Pradesh is as low as 19 per cent and the number of auxiliary nurse midwives (ANMs) trained as skilled birth attendants (SBA) is 35 per cent.

Uttar Pradesh claimed 99 per cent normal deliveries in its PHCs. This, Dr Das found difficult to accept since the number of trained SBAs present was 4.5 per cent, medical officers available at the PHCs was 1.5 per cent, trained nurses 3.8 per cent and ANMs available 4.5 per cent.

So the question arises — who does the delivery? Is it done by the non-existing doctor or some skilled attendant like the dai.

Janki Bai, a dai from Khargone, Madhya Pradesh, says she had helped in delivering a baby whose head was elongated. Since it was an abnormal delivery, she referred the case to the hospital but the baby died there and its body was cremated there quickly before the family returned to the village.

Looming threat

The NRHM is in its third year of operation and the TBAs are feeling threatened. Both the ASHA programme and the emphasis on institutional delivery have had an impact on dais and their traditional roles as the midwives of their villages.

Ideally, the dais should have been integrated into the NRHM, as they are deeply respected in their villages. Many of them have shown leadership qualities and have got into village panchayats.`A0This potential should have been tapped to make them service providers and health educators. Some dais have even become ASHAs, but because of their low literacy level very few could make the grade. This has led to a direct conflict with those lucky enough to get into the system.

The dais are generally from the lower castes (removal of placenta etc is seen as dirty work in many states), poor, widowed and often single women but all these are no reflection on their skills. They are a part of the caring and nurturing backup of the village and their work is round-the-clock all through the year. It does not begin and end with the birth of a baby.

Dais and auxiliary nurse midwives are the mainstay of delivery huts like the one at Neval village, 10 km from Karnal. These delivery huts offer a ray of hope to expectant mothers. — Tribune photos by Ravi Kumar

Recently, dais from different parts of the country gathered in Delhi to seek recognition for their work and a place in the NRHM. They spoke of their concern for the village women. While claiming that they had nothing against institutional deliveries, they pointed out that many of the primary health centres were not operational, doctors were unavailable and transporting a pregnant woman for an institutional delivery was often a Herculean task.

They cited several instances of women delivering on way to a health facility and the dai being their only hope for a safe delivery in transit.

Government figures indicating`A0100 per cent round-the-clock functionality of the PHCs in Madhya Pradesh were challenged by Janakibai of Khargone district of MP. She said three of the 10 PHCs in her area were not functioning and none of them remained open 24 hours.

Instead of respecting their contribution, their time-tested skills and knowledge and upgrading their skills and knowledge, there is an attempt to by-pass them in many parts of the country. Worse, they are being blamed for the continuing high maternal mortality in the country though it is a well-known fact that emergency obstetric care is not available in a large part of the country.

Dai sangathan

In Gujarat the Dai Association was established in 2005 by the dais and civil society organisations to increase their visibility, capabilities and to advocate for a more significant role in the public health programme.

The Gujarat government has recognised their role and 8,000 dais and 18 NGOs are associated with the Dai Sangathan. Babiben Parmar, President of the sangathan, in fact spelt out their role in promoting immunisation, tuberculosis and HIV prevention and treatment in addition to facilitating childbirth.

In fact, the sangathan is playing a major role in providing health insurance to rural women.

Despite the large turnout of dais, civil society health professionals and foreign donors for programmes to reduce maternal mortality at the national consultation, the government representation at the meeting was limited to the Assistant Commissioner from the Ministry of Health and Family Welfare Dr Manisha Malhotra. She, however, did indicate that the NRHM had not disowned the dais. It had left it to the state governments to innovative and integrate dais into health programmes.

However, instead of aping the West, India needs to realise the ground reality and recognise the role of dais. There is a need to find a proper place for them in the NRHM as active partners with ASHAs, ANMs and anganwadi workers. The rich traditional support that the dais provide through counseling, massage, delivery by squatting, traditional medicines and nutrition needs to be documented and recognised.

There is also a need for an accreditation council to train dais and ensure quality service.