This article seeks to enhance our understanding of childbirth-related practices among rural women in Jharkhand and the obstacles they face in seeking appropriate care. It documents women's experience of childbirth from their own perspectives, and the perceptions of providers regarding birthing practices. It also describes women's perceptions of complications experienced during childbirth and the actions taken to address these problems, and explores the obstacles women face in accessing appropriate and timely care. The findings are intended to bridge the gap between policy and programme makers (and implementers) on the one hand, and poor, rural women - for whom the services are provided - on the other.
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly62Women’s Experience of Childbirth in Rural JharkhandLindsay BarnesThis article seeks to enhance our understanding of childbirth-related practices among rural women in Jharkhand and the obstacles they face in seeking appropriate care. It documents women’s experience of childbirth from their own perspectives, and the perceptions of providers regarding birthing practices. It also describes women’s perceptions of complications experienced during childbirth and the actions taken to address these problems, and explores the obstacles women face in accessing appropriate and timely care. The findings are intended to bridge the gap between policy and programme makers (and implementers) on the one hand, and poor, rural women – for whom the services are provided – on the other.The government of India is committed to the Millennium Development Goal of reducing the maternal mortality ratio by three-quarters by 2015; specifically to less than 100 per 1,00,000 live births by 2010 (from 540 in 1998-99) [IIPS andORC Macro 2000]. A key strategy to achieve this goal would be to ensure that “all women have access to high-quality delivery care… namely, a skilled attendant at delivery, access to emergency obstetric care in case of a complication and a refer-ral system to ensure that women who experience complications can reach life-saving emergency obstetric care in time” [MOHFW 2005: 103]. The goals of India’s National Population Policy, 2000 are to achieve 80 per cent institutional deliveries and 100 per cent deliveries by trained birth attendants by 2010.However, these goals need to be contrasted with the reali-ties on the ground. Significant proportions of rural women in India continue to face enormous risks during pregnancy and childbirth due to obstacles experienced in obtaining timely and appropriate care. Evidence, for example, from Jharkhand though sparse, supports the finding that the majority of rural women in India do not receive quality care during pregnancy or childbirth. In 1998-99 only 7 per cent of rural deliveries in the state took place in institutions and 11 per cent of rural births were assisted by trained health professionals [IIPS andORC Macro 2001]. The situation is compounded by women’s poor health status; 73 per cent of rural women in the state are anaemic and 43 per cent are chronically energy deficient [IIPS andORC Macro 2001].1There is a need to better understand the factors influencing healthy pregnancy outcomes. While the clinical causes of ma-ternal mortality in India are well known [RGI 2000], it is clear that childbirth-related practices and beliefs, such as the use of oxytocin2 to augment labour, perceptions of heavy bleeding as normal, delayed initiation of lactation and starvation of the new mother, also have the potential of compromising healthy preg-nancy outcomes. The objective of this paper is to enhance our understanding of childbirth-related practices among rural women in Jharkhand. It documents women’s perceptions of complications experienced during childbirth and the actions taken, and explores the obsta-cles women face in accessing appropriate and timely care. It also explores the perceptions of providers regarding birthing practices. BackgroundTo understand the complexity of the obstacles that inhibit rural women from obtaining necessary and appropriate care for pro-blems during childbirth, the “delays” framework is useful: that is, I am grateful to Dinesh Agarwal, Pertti J Pelto and Leela Visaria for valuable comments. Lindsay Barnes (janchetnamanch@rediffmail.com) is project director, Jan Chetna Manch, Bokaro.
REPRODUCTIVE HEALTHEconomic & Political Weekly december 1, 200763the delays in recognising life-threatening complications, making the decision to seek care, reaching a health facility and receiving quality care at the facility [Ransom and Yinger 2002; Thaddeus and Maine 1994]. Several studies in India have highlighted one or more of these delays as affecting safe pregnancy outcomes. A study in Andhra Pradesh, Madhya Pradesh and Orissa, for example, concluded that the delay in recognition of complications and the failure to obtain timely treatment were major factors underlying mater-nal mortality [Murthy and Barua 2002]. Studies in Tamil Nadu showed that rural women expressed fears about delivering in hos-pital, including being alone without family, being scolded for ex-pressing pain, having to accept family planning measures against their will, and being questioned about their post-partum beliefs; women also reported apprehensions about hospital procedures and forced surgery [Ram 1998; Van Hollen 2003]. In contrast, a home birth was perceived to be associated with comfort and lack of fear; and studies have noted that traditional birth attendants provided much-valued support to women in labour [Patel 1994; Pinto 2006; Sagar 2006]. The adoption of “modern” dangerous practices in home deliv-eries, in particular the use of oxytocin injections, has been noted in numerous studies [Jeffery, Jeffery and Lyon 1989; Sharan, Strobino and Ahmed 2005; Van Hollen 2003]. Evidence suggests that rural women with the financial means often resorted to prac-tices such as oxytocin injections because they wished to deliver at home rather than in a hospital or health centre, while taking advantage of what they perceived were the benefits of modern medicine [Sharan, Strobino and Ahmed 2005; Van Hollen 2003].Studies show that facility-level practices are not always safe. For example, a study of delivery practices in rural Karnataka concluded that although most deliveries occurred at facilities be-cause of complications, no more than 30 per cent of the women were delivered by a physician; moreover, the majority of wom-en in labour were administered oxytocin to hasten the process and were discharged a few hours after delivery with little or no advice [Ganapathy, Ramakrishna and Mathews 2000]. Maternal Health in JharkhandSince the creation of the state of Jharkhand in 2001, the state government has made efforts to improve maternal healthcare services. Doctors have been employed on a contract basis and posted in rural health centres, labour rooms have been built and the health budget has been substantially enhanced. Several national and state level programmes have maternal health components and aim to increase institutional deliveries as a fast track towards reducing maternal mortality. These programmes, however, do not take into account the ground realities in such poorly developed states as Jharkhand and are not always sensitive to the realities facing women in the state, such as the paucity of institutions to cater to maternal health needs, the lack of affordable services and the perception of poor perceived quality of care in facilities. Moreover, programmes pay little attention to diet and nutrition, traditional pregnancy-related practices (both harmful and beneficial), or the fact that women themselves have little say in decisions concerning their own lives. In addition, few programmes build awareness at the community level of the possible dangers associated with preg-nancy and delivery. Study SettingThe study was located in Bokaro district, Jharkhand, where the facilitating community-based organisation, Jan Chetna Manch, Bokaro has been working for over a decade. Jan Chetna Manch’s activities include helping women set up self-help (savings and credit) groups, now numbering more than 350 in 75 villages. The federation of these women’s groups runs a women’s health centre where antenatal care and other health services are provided. The centre also houses a birth centre where trained village women health workers conduct normal deliveries.The study was conducted in Chas and Chandankiari, two poorly developed blocks in Bokaro district. Although located close to large urban, industrialised centres, most villages in these blocks do not have electricity, tarred roads or a regular supply of drinking water. Compared to many districts in Jharkhand, there are fewer scheduled tribe households in this area. Villages are largely populated by scheduled caste and backward caste Hindus, and Muslims. Most people work as marginal farmers, casual manual labourers or in small family businesses. Women are predominantly poor, marginal farmers.While little is known about maternal health in this setting, a few studies have been conducted by Jan Chetna Manch. Findings suggest that rural women are reluctant to access institutional care during childbirth. Some women had accessed delivery care from the women’s health centre, but the vast majority preferred to call the village “doctor” (rural medical practitioner or RMP) and deliver at home even during emergencies [Barnes 2003; Barnes and Datta 2004; Jan Chetna Manch 1997, 1998, 2002]. In-formalassessments show that while more women are accessing antenatal care in villages where women’s self-help groups exist, their health remains poor. A random sample of 100 women who had accessed care at the women’s health centre from the fifth to the ninth month of pregnancy showed that 83 weighed less than 45kg during the fifth month of pregnancy (42 were less than 40 kg) and 47 weighed less than 45 kg during the ninth month of pregnancy (14 were less than 40 kg). Similarly, another random sample showed that 66 out of 75 women who registered during the first trimester of pregnancy at the women’s health centre had a BMI of less than 18.5 kg/m2, signifying severe chronic energy deficiency [Barnes 2003; Barnes and Datta 2004; Jan Chetna Manch 1997, 1998, 2002].Women’s compromised health is compounded by the limited and poor quality public sector facilities available in the study areas. Although both blocks have primary health centres (PHCs), few deliveries are conducted in these facilities. The referral hos-pital in Chas does not have facilities for emergency obstetric care. Private healthcare, available in the neighbouring cities, is expen-sive and used only in emergencies. Accessing referral hospitals is difficult as most villages are connected only by mud roads and some are completely isolated. Public transport facilities are limited and while private transport is available, it tends to be expensive, especially in emergencies.
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly64Table 1: Socio-Demographic Profile of Respondents NumberTotal respondents 32Caste/community Scheduled caste 10 Other backward castes 9 Scheduledtribe 4Other Hindu castes 2 Muslim 7Main economic activity of household head Cultivator 6 Marginal cultivator/agricultural labourer 12 Artisan (potter, carpenter, basket-maker) 3 Others* 11Landownership status Owns enough land to produce sufficient foodgrain for the year 6 Own enough land to produce sufficient foodgrain for part of the year 18 Landless 8Education status of respondent Non-literate 22 Literate, informal education 2 Class 1-4 4 Class 5-9 4 Class 10 (matriculation) and above 0Education status of respondent’s husband Non-literate 11 Literate, informal education 0 Class1-4 2 Class5-9 13 Class 10 (matriculation) and above 6*Includes non-agricultural wage work (e g, drivers) or work in a small business/shop, the steel plant, mines and the government. The study was entirely qualitative and comprised focus group discussions, key informant interviews and in-depth interviews. The sample was obtained from villages with self-help groups. A total of 10 villages were selected. Study DesignFive focus group discussions were conducted with women from selected villages to identify potential key informants, learn about local birthing practices and inform the community about the project. In-sights from these discussions helped to shape the content of key informant and in-depth interviews. Fifteen key informant interviews were held with ‘jankar burhis’, ‘dais’ and RMPs (also known as ‘gaon ka daktar’ or ‘jhola chap daktar’) (five each), using a semi-structured guide. As trained nurses, midwives or quali-fied doctors (with anMBBS degree) were not present during most deliver-ies, they were not interviewed.Finally, in-depth interviews were held with randomly selected pregnant and newly-delivered women from the 10 villages, irrespective of whether or not they were members of self-help groups. Care was taken to ensure that women of all major castes and communities from the study villages wererepresented. In all, 32 currently pregnant women and 32 women who hadrecently delivered a live birth (less than six months earlier) were interviewed. In addition, 12mothers-in-law and 12 husbands (not of the women inter-viewed)were interviewed. Interviews were conducted from ApriltoSeptember 2005. Each woman was interviewed twice within a month.This paper is based on 32 interviews with women who had de-livered a live birth during the last six months; 16 of whom had delivered for the first time (referred to as first-time mothers) and 16 who had experienced three or more deliveries (referred to as third-time mothers). These accounts are supplemented with information provided in key informant interviews. The names of all the respondents have been changed. Study FindingsRespondents were largely from poor, scheduled caste or other backward caste families, and were generally engaged in agricul-tural activities (Table 1). Pregnancy-related Practices: The Last DeliveryPlace of Delivery: As can be seen from Table 2 (p 65), none of the respondents had delivered in a hospital during the last pregnancy. Among first-time mothers, eight delivered in their maritalhome, five in their natal home, two in the women’s healthcentre and one at an aunt’s home. In contrast, almost all third-time mothers (14/16) delivered in their marital home. When asked about their preferred place of delivery, the dis-cussion usually revolved around the natal home versus the marital home rather than home versus hospital delivery. Many women said they would have felt more comfortable in their par-ents’ home, but did not want to burden their families with the responsibility and expense of childbirth: “A woman who is preg-nant forthe first time is not allowed to go to her parents’ house during her pregnancy. If anything happens to the baby there, her parents will be needlessly blamed; moreover, they [the girl’s parents] will have to man-age everything themselves. It would be like carrying someone else’s bur-den” (SD, first-time mother).Beliefs and practical considera-tions also determined the location of delivery. For example, if the baby had died in the natal or marital home after a previous childbirth, the death would be attributed to evil spirits re-siding there, and the woman would try to avoid delivering there in the next pregnancy. Practical consid-erations included distance from a healthcare provider or to the nearest town, issues about who would bear the cost of delivery and the availability of family members to take care of other children. “I asked my husband what we would do if something happened to me at my in-laws during delivery. He said, “I will send you to your mother’s”. My mother had told him to take me there as doctors are available even at night. There are also more vehicles for transportation. Here [in-laws’ house] there are private hospi-tals but the treatment is not good. And there aren’t many doctors” (GB, first-time mother).Delivery at a hospital or nursing home was rarely a preferred option. Women feared that it would lead to unacceptable costs: “My mother-in-law and sister-in-law said that taking me to hos-pital would be expensive. Where would we arrange the money?” (KD, first-time mother).Moreover, an institutional delivery was perceived as threat-ening, particularly among those who had prior experience of pregnancy-related hospitalisation: “Everyone is scared in hospi-tal about whether they will cut open the belly or not” (AD, third-time mother). “I had problems when the [earlier] delivery took place in a hospital. They tied my legs to iron rods. When there was pain I would shake, and all the nurses would abuse me. In hospital nofamily members are allowed in the room” (KB, third-time mother).Even a woman who had been admitted to a nursing home following sepsis during her earlier delivery because of the unhygienic manual removal of the placenta by a jankar burhi
REPRODUCTIVE HEALTHEconomic & Political Weekly december 1, 200765preferred a home birth with the same woman rather than return-ing to hospital.Attendance at DeliveryDeliveries were conducted by traditional attendants (jankar burhis and dais) and “modern” providers (RMPs). As Table 2 shows, almost all women who delivered at home were attended by an elderly woman, a relative or a jankar burhi, especially if a dai was unavailable. The dai was also called for almost every de-livery; in 14 cases she was called prior to the delivery and in 17 cases after the delivery. Third-time mothers were more likely to call the dai prior to birth (10/16) than first-time mothers (4/16).The division of work between the jankar burhi and the dai is often hazy. Typically, while both provide the mother support and encouragement by giving her oil massages and monitoring labour,includingassess-ing the dilatation of the cervix, the jankar burhi also provides other assistance such as calling the dai or RMP when required. Both the jankar burhi and dai remain with the woman throughout labour and delivery, palpating the abdomen to assess the posi-tion of the foetus, pouring oil on the navel to monitor the direc-tion of its flow, encouraging the mother-to-be to move around, squat and bear down, ensuring that she keeps drinking hot, sweet drinks or eating hot rice-gruel, helping the mother expel the placenta, cleaning the baby with oil, and bathing and wrap-ping the baby up. However, it is the dai who actually cuts the cord (with a blade) and ritually buries the placenta where delivery has taken place, gives the mother ‘mathvasi’ (presses her head into the mother’s belly whilst the mother is standing, to expel blood clots post-delivery) and ties the mother’s abdomen after delivery. While the jankar burhi may visit the mother for several days and accompany her to the hospital if necessary, the dai attends to her for six days following delivery, massaging her, giving her a hot compress with castor leaves and fomenting the baby’s cord with heat from a wick lamp. On the sixth day she helps the mother bathe in the pond and perform the ghat puja (prayers). A total of 20 women were provided services by the RMP dur-ing labour; 12 first-time and eight third-time mothers. An addi-tional six women (and their babies) were given only post-delivery tetanus-toxoid injections by the RMP. The RMP mainly adminis-ters oxytocin injections to speed up delivery or/and gives teta-nus-toxoid injections to the mother and baby after the birth; he also provides a saline drip if the jankar burhi, the dai or fam-ily members so prescribe. Some RMPs are present at the time of the birth, but typically they remain outside and do not assist the woman during the actual delivery. In most cases, the RMP is not expected to examine, attend or assist the mother-to-be. Although sometimes the RMP is permitted to conduct internal examina-tions, narratives highlight women’s resistance to this practice: “My husband wanted me to go to “doctor” S [RMP], but I do not like him. He was called for some deliveries, and the first thing he did was to stick his fingers into the woman’s private parts. He has no shame. Every time I see him I feel angry, so I did not consult him. After a whole night of pain, the dai told my husband to call “doctor” R [anotherRMP], he doesn’t examine women. He gave me four injections and waited outside” (AB, third-time mother).The ‘ojha’ also plays a role during childbirth, but his impor-tance is waning due to the growing popularity of allopathic medicines. He does not usually visit the mother during labour, but water or oil is taken to him to perform rituals, which is then given to the woman to drink or to apply. The ojha is generally the last resort, and consult-ed when the dai and RMP are ready to give up on the delivery. In only four cases was the delivery at-tended by a trained attendant: two women were attended by the government auxiliary nurse-midwife(ANM) who provides services on a private basis; and two women were at-tended by trained personnel at the women’s health centre. Planning for ChildbirthPlanning for childbirth was rare. Women re-ported that they did not feel the need to plan ahead, that their families would somehow arrange things, that they put their trust in God or considered it inauspicious to plan in advance. “My husband and I didn’t plan where I would deliver. We thought we would see to that when the time came” (LD, first-time mother).A few women reported that they had arranged for money, from either their parents or husbands, in case of an emergency. Theamount was never more than Rs 500, not even enough for anormal delivery in a city hospital or to hire a vehicle to get there. None of the women had considered arranging a vehicle in advance. Indeed, all the mothers in this study had “planned” a home birth. Typically, mothers do not participate in delivery-related decision-making: “If the need arises to go out for the delivery, my brother-in-law and husband will decide where to go. They are the main people in this family. As long as they are there, they decide” (SD, third-time mother).Family SupportThere was a clear demarcation between the kinds of support pro-vided by senior women and men of the family. Women largely provided support within the home. For example, mothers-in-law called the jankar burhi, dai or even the RMP, and attended the delivery along with them or assisted them. They also assist-ed the woman following delivery, cooking for her or caring for her children. Indeed, as many mothers observed, the support of women in the family helped them cope with the pain of labour. “The delivery took place at night. My mother-in-law and sister-in-law were with me. When I was in pain they gave me a lot of support” (MD, third-time mother).By and large the “outside” tasks, including calling the RMP, arranging for a vehicle to transport serious cases to hospital, Table 2: Characteristics of the Last Delivery (N = 32) NumberPlace of last delivery Home 30 Women’s health centre 2Attendance at last delivery* Jankar burhi or elderly relative 29 Dai 31 RMP 36 Health worker in women’s health centre 2 Auxiliarynurse-midwife 2When dai was called for delivery Prior to delivery 14 Afterdelivery 17 Not called 1When RMP was called for delivery Prior to delivery (for oxytocin injections) 20 After delivery (for tetanus-toxoid injections) 6 Not called 6* More than one attendant reported.
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly66purchasing medicines, informing relatives about the birth or ar-ranging finances, were performed by the men in the family. Some tasks, such as buying blades, calling the dai and accompanying the woman to hospital, were performed by both men and women. In a few cases, mothers-in-law/mothers also arranged money, if needed, especially if they were members of women’s self-help groups. While husbands did not provide much support at the time of childbirth, especially in extended households where otherfemale members were present and willing to help, some husbands had accompanied their wives for antenatal check-ups, or helped in the housework, looked after the children, or brought special foods for the mother post-delivery. “For 25 days after de-livery he [husband] did everything. He even washed the blood-stained cloths. He bathed the children, fed them and washed their clothes. My mother-in-law and sister-in-law live separately” (MD, third-time mother).Problems during ChildbirthGiven this scenario, and combined with the poor nutritional sta-tus of women and conditions of general poverty, many women had experienced pregnancy-related complications. Following from the general perception that pregnancy and childbirth are normal events, women’s own assessment of complications expe-rienced tended, by and large, to underestimate their seriousness, although the likelihood that a few may have exaggerated their symptoms cannot be discounted. Rather than depending on women’s own assessments, resear-chers chose to classify, on the basis of a study of women’s narra-tives, the level of seriousness of the complication suffered during delivery. Based on this classification, a number of respondents – 22 of 32 – were reported to have experienced the following pregnancy-related complications:(a) Nine women experienced serious complications, of whom the majority experienced two or more potentially life-threatening complications, such as heavy bleeding and retained placenta, pro-longed labour and heavy bleeding, or prolonged labour and birth asphyxia. Not a single woman experienced eclampsia or fistulae.(b) Thirteen women experienced somewhat problematic but not life-threatening complications, such as heavy bleeding unaccompanied by other problems.(c) Ten women experienced unproblematic deliveries.Although a number of women reported serious complications, it would not be appropriate, with this small sample, to draw conclusions about the magnitude of women experiencing com-plications. We reiterate here that this study is not an attempt to measure the extent of childbirth complications, but rather to understand women’s perceptions of complications experienced and actions taken, which are discussed in the following section. Heavy BleedingHeavy bleeding was the most common problem experienced. Seven of the nine women experiencing life-threatening con-ditions reported that they had bled heavily. Threeofthefour first-time mothers reported that they had also lost conscious-ness. Six of the 13 women who experienced some problems also reported heavy bleeding. All 22 women reported that following childbirth they had experienced weakness, and at the time of in-terview many showed symptoms of severe anaemia and vitamin deficiency. While most women who experienced heavy bleed-ing were given mathvasi by the dai, two women, who had lost consciousness, reported that mathvasi was not done. Although women did express concern about heavy bleeding to their birth attendants, irrespective of whether the attendant was a dai, a jankar burhi or anRMP, heavy bleeding was considered necessary and not a danger signal. “After the delivery I lost a lot of blood. When I told the doctor [RMP], he said that it was dirty blood, and it was better if it came out of the body. He said if he gave medicines to stop the flow, I would face problems later” (RB, third-time mother).Despite probing, providers could only vaguely indicate when they perceived heavy bleeding to be a danger signal. Indeed, some providers believed that the quantity of blood expelled depends on a woman’s physique. “If the blood flows far away, then I understand that too much blood is being lost. If there is heavy bleeding and two clots of blood come out, this is good. If these clots stay in the uterus they will cause stomach ache” (CD, jankar burhi). “There is no harm in more bleeding because it will dry the wounds faster” (BD, dai).Jankar burhis and dais, on probing, admitted that too much blood loss can be fatal; however, few took prompt or appropri-ate action. Most indicated that they would refer a woman with excessive bleeding to anRMP; only one dai reported that she would refer the mother to a hospital. “Yes it [excessive bleeding] is harmful. The woman becomes weak, her body may swell up and she may have little blood left in the body” (SD, jankar burhi).“If the bleeding does not stop, then I know she is having exces-sive bleeding. I place a ball of cloth at the mouth of the uterus and make her sit on a gunny bag. If the bleeding does not stop even then, I tell the family members to take her to a reputed doctor” (PD, dai). “If excessive blood flows out from the body, then a woman caneven die. That’s why I tell them to call the “doctor” [RMP] (KD, dai).RMPs were only slightly better informed about excessive bleed-ing. Several reported the need to cleanse the uterus of dirty blood. They often relied on the assessment of the dai or the woman giving birth. If haemorrhage was suspected, all RMPs re-ported giving methergine3 injections, often along with other in-jections and medicines; however, they did little else to stop the bleeding: “Sometimes the mother has stomach pain after deliv-ery. I give a methergine injection for that. All the dirty blood in the uterus comes out after this injection” (“Dr” S, RMP). “If I see blood is dripping under the bed, I know too much bleeding is tak-ing place. Then I give a methergine injection, a saline bottle, a vitamin injection” (“Dr” D,RMP). RMPs also referred cases that they could not manage. Two RMPs reported that a woman they had treated had died from excessive bleeding, and one noted that he had learned the importance of prompt referral: “A woman was having intense labour pains but was not able to deliver. I did an internal examination and found that the mouth of the uterus had opened only a little. I gave her seven injections, and then the delivery took place. But she started having continuous profuse bleeding. I asked the family to take
REPRODUCTIVE HEALTHEconomic & Political Weekly december 1, 200767her to Jharia. Unfortunately she died on the way. Now I check excessive bleeding. If a bowl of blood is lost then I give injections. If it doesn’t reduce even then, I refer the case” (“Dr” B, RMP).Birth AsphyxiaFive women reported that their babies were born with severe birth asphyxia – i e, they were born with a bluish colour, did not breathe immediately and did not cry for at least 10 min-utes. In addition one woman reported symptoms of mild birth asphyxia in her infant. Of the 20 births that were preceded by an injection of oxytocin by the RMP, four infants experienced severe birth asphyxia and one experienced mild birth asphyxia. In contrast, of the 12 cases in which oxytocin was not adminis-tered, only one infant was reported to have experienced birth asphyxia (severe).Although these figures may not be statistically significant, they do suggest that birth asphyxia, a known risk of oxytocin, is not uncommon, and is administered by providers who are not pro-perly equipped or trained. All the babies in this study survived, since only mothers of live babies were interviewed. In three of these five cases, it was the mother-in-law, aunt or dai who had revived the baby, and in the remaining two cases, theRMP revived the infant. Provider interviews suggest that several common traditional methods are adopted to address birth asphyxia, such as sprin-kling water on the infant, chewing black pepper and blowing into the infant’s ears, mouth and nose, covering the infant with a bas-ket and making a loud noise near the ears, or stroking the cord towards the baby. Women reported that unlike RMPs, dais and elderly women are aware of how to loosen the umbilical cord if it is around the baby’s neck at birth.RMPs also sprinkle water on the baby, but deal with asphyxia more aggressively – they hold the baby upside down and slap its back, and in one case, had given the infant steroid injections.Prolonged LabourSeven of the nine women who experienced life-threatening con-ditions, and four whose problems were not life-threatening, re-ported prolonged labour, classified as contractions for more than one day and one night. Prolonged labour was usually accom-panied by other problems, such as heavy bleeding and loss of consciousness.According to jankar burhis and dais, the actions taken in the case of prolonged labour are similar to those taken during a nor-mal delivery. In addition, they also provide emotional support to the mother by way of advising the mother to be brave, allaying her fears and enabling her to relax; and calling for various ritu-als to pray for a safe birth. Some dais applied herbal medicines externally but none reported using medicines internally to speed up childbirth. They also conducted internal examinations and could generally diagnose obstructed labour. RMPs addressed prolonged labour by giving the mother oxytocin injections. Sometimes they gave additional, often un-necessary, injections (such as steroids and vitamin injections) along with intravenous fluids. Some RMPs performed episioto-mies, described by women as a “chota operation” that is necessary for a ‘chota bachedani’ (small uterus). TwoRMPs reported per-forming episiotomies when they found the vaginal tract too small. This practice of conducting episiotomies is perceived bydais as an example of the unethical practices of RMPs. “I use both hands to open the mouth of the vagina; I pour coconut oil and slowly stretch the skin. Then the skin does not tear. I don’t approve of the “doctor” [RMP] doing a small operation [episio-tomy]. It is a shameful thing. I feel that if the delivery is done carefully and slowly, the skin will not tear and there will be no need for stitches. If there is a small tear, it will heal on its own, with a hot compress. The “doctor” [RMP] will not do this, but will do the “operation” in order to make money” (BD, dai). Retained PlacentaThree of the nine women experiencing life-threatening compli-cations, who reported a retained placenta, said that the dai had removed the placenta manually. Most jankar burhis and dais reported that they first try to remove the placenta by pushing hair down the throat of the mother to make her gag, while at the same time placing her in a squatting position. Failing this, they remove the placenta manually. Usually, they neither use gloves nor wash their hands before undertaking the procedure.RMPs reported that they administer injections to expel the placenta. If this fails, they recommend that the dai removes the placenta manually. A few RMPs reported that they remove the placenta manually, wearing gloves that are not sterile, presum-ably to protect themselves rather than the mother. EclampsiaAlthough none of the women had experienced eclampsia or suf-fered from fits during childbirth, this complication is being dis-cussed because providers noted that this was one of the most serious problems that they had encountered. Dais and jankar burhis referred to this condition as “childbirth epilepsy”, and considered the condition so serious that none would treat these cases: “If this type of epilepsy is not treated beforehand then the woman may die. If she doesn’t go to hospital she may die” (PD, dai).Symptoms such as swelling of the body during pregnancy, however, were generally not taken seriously by the community, or even some dais and jankar burhis. Most attributed swelling to nutritional deficiencies and advised dietary changes, but re-ported that their advice was not heeded. Some RMPs however, appeared to be better informed and more likely to recognise the need for prompt treatment: “When she comes for an examination I check the blood pressure, else she might get eclampsia. This is a very dangerous illness” (“Dr” B, RMP).Post-partum Hunger and Breastfeeding Problems The practice of starving the mother after delivery (‘narak upas’) is considered essential for the health of both the woman and the infant in the study areas. Post-partum fasting and extreme hun-ger was more common among first-time than higher order moth-ers – all 14 first-time mothers who delivered at home reported post-partum fasting and extreme hunger as compared to nine third-time mothers who reported both post-partum fasting and
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly68hunger. The two women who delivered in the women’s health centre did not observe this custom. Even women who requested food and water were not given an-ything to eat or, at best, fed a small amount of warm water, bread or biscuits. “I remained hungry during the long labour; I had to put in a lot of effort on an empty stomach. I was given rice to eat only five days after the delivery” (KD, first-time mother).Informed women also adhered to such practices, as can be seen from the following quote: “The nurse [ANM] told me to eat eve-rything, but my mother [anganwadi worker] and aunt wouldn’t let me. They said I would have to follow the rules of the village. My stomach was empty and I was hungry, but what could I do? Next time I have a baby I won’t follow any rules” (SD, first-time mother).Providers’ narratives also suggest the persistence of the prac-tice of narak upas. In one extreme case, as the dai noted: “a woman had a delivery and she died of thirst, asking for wa-ter”. However, several providers noted that this practice may bechanging. “Earlier there were many rules, but now there are none. Earlier no food was given after delivery, but these days every kind of food is allowed” (SD, jankar burhi).RMPs recognised the importance of a healthy diet for newly-delivered women but did not make much effort to reverse tra-ditional community resistance to allowing women to eat, argu-ing instead that “[people] don’t listen to us, they will follow their own rules”. Thirteen of the 32 women reported the absence of breast milk for four or five days after birth, and both mothers and dais and jankar burhis recognised the link with post-partum fasting. “I was given rice to eat after four days. I was given only tea and bread for three days. I was told not to drink too much water or my baby would get a cough. I followed all the rules. When I started eating rice, I began to have milk in my breasts. For four days we fed the baby sweetened water” (JB, first-time mother).Some dais and jankar burhis acknowledged that rules about fasting were harmful but were engrained as a part of village tra-dition: “villagers won’t listen to me, they will follow their rules”. Other providers however, continued to maintain that fasting is needed to “dry” the mother’s body, so that she stops bleeding, a problem perceived as more harmful than lack of breast milk. Obstacles to Accessing Quality CareNarratives suggest a host of obstacles inhibiting safe deliveries and good practices among women in the study area, includ-ing lack of access to quality and affordable care, and delayed decision-making. For example: “When I examined her I found she was passing clots of blood and there was a lump of tissue in her birth passage. I told the family to take her to hospital but they called the “doctor”[RMP]. He also advised them to go to hospital. It took them two days to arrange the money – they sold one cow. Then they hired a vehicle and took her to a private nursing home in Chas. The doctor refused to admit her and said, “Take her to Purulia” [to the government hospital]. We reached Purulia at night. The doctor there said, “Take her to Bankura”; he didn’t want to admit her either. We pleaded with him; we said, “If she dies, then she dies, but please admit her”. So they admitted her. She was taken to the labour room, and they tried to find a vein to give her saline. Her body was swollen up by then. She was thirsty and asked me for water, then she died. If they had gone two days earlier, when I had told them, she would have lived” (PD, dai).Lack of Access to Appropriate and Quality Care Findings indicate the paucity of trained and accessible providers and appropriate facilities in the area. ANMs, for example, do not live in the village and the sub-centres remain closed most of the time. In contrast, dais and jankar burhis are easily available and provide a much-valued and timely service. Likewise, RMPs are easily available, more accessible, better equipped with medicines and other supplies, and more willing to accommodate traditional rituals and practices thanANMs and government doctors. However, the easy availability of jankar burhis, dais and RMPs could be an obstacle to timely intervention in obstetric emergen-cies. Typically, if the jankar burhi or dai encounters a problem, she calls the RMP, and recommends hospitalisation only if the RMP fails to address the problem. Dais described cases in which families called a secondRMP when the first one was unsuccessful, and then an ojha, in a last desperate attempt to avoid hospitali-sation. Availing the services of different care providers is time-consuming and could be potentially fatal. The reluctance ofRMPs, dais and jankar burhis to refer the woman to an institution is not entirely irrational. Facilities are located at a considerable distance, and transport and money need to be arranged, causing inordinate and dangerous delays. Moreover, neither basic nor emergency obstetric services, includ-ing for treatment of post-partum bleeding, are available in the study areas.Poor Perceived Facility-Level Quality of CareAlthough there is a growing acceptance of modern allopathic medicine, an obstacle to accessing institutional delivery is the poor perceived quality of care at facilities. Women reported that providers are not sensitive to their needs; that women in labour are abused, scolded and even slapped; and that dais or jankar burhis are not permitted to accompany them into the labour room. Women also feared unnecessary procedures in institu-tions, such as insistence on caesarean-section deliveries. “I went to the nursing home with my sister-in-law. She was taken inside a room, no one was allowed to go in with her. The nurses gave lots of abuse to women in labour” (JB, first-time mother).“City doctors will not wait a whole day for the delivery to take place. They will cut open the stomach and bring out the baby” (MD, third-time mother).Jankar burhis and dais also reported experiencing threaten-ing quality of care at facilities. In some cases, hospital staff also demanded money for handing over the baby. “In the hospital I have no rights. If I tell them I know something about delivery they tell me, “Then why have you brought her here? You should have done the delivery in the home!” (RD, jankar burhi)“I accompanied my niece to the [government] hospital, but I was not allowed inside the labour room. When the baby was born, the nurse came to ask for money, soap and cloth. We didn’t give
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly70delivery. While there is a growing acknowledgement – albeit thus far dangerously misplaced – of the role of modern allopathic medicine, this is equally offset by a resistance to seek an insti-tutional delivery, and a fear of the nature of modern practices adopted in these facilities and the quality of care received in hospital settings. At present what is disturbing is that the allo-pathic care women are “choosing” may actually be detrimental to their health and also result in potentially life-threatening delays in addressing pregnancy-related complications. Findings also clearly show that the environment offers poor rural communities few options in terms of quality, accessible and affordable emer-gency obstetric services. Study findings argue for a multi-pronged approach that will enable safe pregnancy-related practices for women in the exist-ing socio-cultural and health service scenario in rural Jharkhand. Skilled home-based services need to be provided to women ex-periencing normal deliveries and efforts made to train available attendants in sound modern practices while, at the same time, in-corporating useful and harmless traditional practices employed by communities during delivery – a “best practices” approach. Strategies need to take into account the multiple players at the time of delivery. Misperceptions and unsafe practices adopted by dais and jankar burhis as also harmful practices adopted by RMPs need to be addressed. The rampant misuse and overuse of potentially dangerous drugs during childbirth must be checked: greater vigilance in the sale and use of drugs must be ensured; and healthcare providers – RMPs in particular – women and com-munities must be apprised of the dangers of misuse of injections and drugs.Given that every delivery may result in complications, that skilled birth attendants do not reside in villages and that institutions are several hours away, community-based birth attendants can be taught to conduct normal deliveries, treat minor problems, provide obstetric first aid for complications, refer complicated cases, and make families aware of available transport that can be used in case of an emergency. In addition, community-based birth attendants need to be made aware of the steps to be taken ensure the mother arrives at the hospital alive. With training, effective community-based attendants can considerably reduce three of the delays that contribute to ma-ternal mortality: the recognition of a complication, the decision to access a higher level of care and the time spent in reaching the facility. At the same time, the RMP is clearly an acceptable link to modern medicine. The feasibility of drawing dais or RMPs into the maternal health programme and upgrading their skills needs to be explored,in particular trainingRMPs in the use of oxytocin/methergine and training dais in the use of misopros-tal for post-partum haemorrhage, a finding reinforced in studies in other resource-poor settings [Darney 2001; Gulmezoglu et al 2001, 2003].Likewise, the feasibility of establishing low-cost and client-friendly clinics/birthing centres, such as the women’s health centre, needs to be explored. These clinics are a step in the di-rection of providing modern allopathic care while at the same time remaining sensitive to women’s preference for a familiar attendant in the labour room, incorporating useful traditional practices, carefully eliminating the harmful ones and respecting the community’s customs. At the same time, however, more effort needs to be made to-wards providing a workable referral channel for emergency obstetric care and access to blood banks in the district. Finally, there is a need to review the quality of care in existing institu-tions and to build more respectful and client-centred interaction with women, their families and their attendants.Notes1 That is, with a Body Mass Index (BMI) (ratio of weight to height-squared) of less than 18.5 kg/m2.2 Oxytocin injections (trade name Pitocin or Synto-cinon), referred to in the community as “hot”, “deliv-ery”, “pain-increasing” or “strength-giving” injections, are recommended for post-partum haemorrhage. Oxytocin is administered intravenously to augment labour, but should be given in a facility equipped to perform caesarean section deliveries under close su-pervision. Administering oxytocin during labour can lead to foetal distress, birth asphyxia or neonatal death, or uterine rupture resulting in the death of the mother. 3 Methergine (trade name ergometrine maleate or methylergonovine maleate) is prescribed for post-partum haemorrhage. Methergine is contraindi-cated in women with high blood pressure or heart disease. ReferencesBarnes, L (2003): Abortion Options for Rural Women: Case Studies from the Villages of Bokaro District, Jharkhand, CEHAT/Healthwatch, Mumbai. Barnes, L and N Datta (2004): ‘Quality of Women’s Repro-ductive Healt Services: A Case Study of the Bokaro District Jharkhand’ (unpublished). Darney, P D (2001): ‘Misoprostol: A Boon to Safe Mother-hood...or Not?’,Lancet, 358 (9283), pp 682.Ganapathy, S, J Ramakrishna and Z Mathews (2000): ‘Birth Rites and Rituals: Intrapartum Care and Care-seeking in Rural Karnataka’ in C Puri and P F A Van Look (eds),Sexual and Reproductive Health: Re-cent Advances, Future Directions, Vol 1, New Age Inter-national, NewDelhi, pp 309-25.Gulmezoglu, A M, J Villar, N N Ngoc et al (2001): ‘The WHO Multicentre Double-blind Randomised Con-trolled Trial to Evaluate the Use of Misoprostol in the Management of the Third Stage of Labour’,Lancet, 358(9283), pp 689-95. Gulmezoglu, A M, F Forna, J Villar et al (2003): ‘Prostag-landins for Prevention of Postpartum Haemorrhage (Cochrane Review)’ inThe Cochrane Library, Issue 4, John Wiley & Sons, Chichester. International Institute for Population Sciences (IIPS) and ORC Macro (2000):National Family Health Survey 2- India, IIPS, Mumbai. – (2001): National Family Health Survey (NFHS – 2), In-dia, 1998-99: Jharkhand, IIPS, Mumbai.Jan Chetna Manch (1997): ‘Report of the Status of Wom-en’s Health in Rural South Bihar’, Bokaro (unpub-lished). – (1998): ‘Women Helping Themselves to Health: The Experience of Jan Chetna Manch, Bokaro’ Bokaro (unpublished). – (2002): ‘Self-Help Groups and Women’s Health: Im-pact of Micro Credit Groups on Women’s Health in the Chas and Chandankiari Blocks of Bokaro District, Jharkhand’, Bokaro (unpublished).Jeffery, P, R Jeffery and A Lyon (1989): Labour Pains and Labour Power: Women and Childbearingin India, Zed Books, London.Ministry of Health and Family Welfare (MOHFW) (2005): ‘RCH Phase II: National Programme Implementation Plan’, Government of India, New Delhi.Murthy, N and A Barua (2002): ‘Dying Needlessly in Childbirth: Social Factors Contributing to Maternal Death in India’ (unpublished report), Foundation for Research in Health Systems.Patel, T (1994): Fertility Behaviour: Population and Soci-ety in a Rajasthan Village, Oxford University Press, Delhi.Pinto, S (2006): ‘Divisions of Labour: Rethinking the ‘Mid-wife’ in Rural Uttar Pradesh’ in JChawla (ed), Birth and Birthgivers: The Power behind the Shame, Har-Anand Publications, New Delhi, pp 203-38.Ram, K (1998): ‘Maternity and the Story of Enlightenment in the Colonies: Tamil Coastal Women, South India’ in K Ramand M Jolly (eds),Maternities and Moderni-ties: Colonial and Postcolonial Experiences in Asia and the Pacific, Cambridge University Press, Cambridge, pp 114-43.Ransom, E I and N V Yinger (2002): Making Motherhood Safer: Overcoming Obstacles on the Pathway to Care, Population Reference Bureau, Washington. Registrar General, India (RGI) (2000):Sample Registra-tion Bulletin, RGI, New Delhi. Sagar, A (2006): ‘Doctors’ Business or Women’s Business? Towards Making Childbirth Safer for Poor Women in India’ in J Chawla (ed), Birth and Birthgivers: The Power behind the Shame, Har-Anand Publications, pp 251-304. Sharan, M, D Strobino and S Ahmed (2005): ‘Intrapartum Oxytocin Use for Labour Aceleration in Rural India’, International Journal of Gynaecology and Obstetrics, 90, pp251-57.Thaddeus, S and D Maine (1994) ‘Too Far to Walk: Mater-nal Mortality in Context’, Social Science in Medicine, 38(8), pp 1091-1110. Van Hollen, C (2003): Birth on the Threshold: Childbirth and Modernity in South India, Zubaan, New Delhi.
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly62Women’s Experience of Childbirth in Rural JharkhandLindsay BarnesThis article seeks to enhance our understanding of childbirth-related practices among rural women in Jharkhand and the obstacles they face in seeking appropriate care. It documents women’s experience of childbirth from their own perspectives, and the perceptions of providers regarding birthing practices. It also describes women’s perceptions of complications experienced during childbirth and the actions taken to address these problems, and explores the obstacles women face in accessing appropriate and timely care. The findings are intended to bridge the gap between policy and programme makers (and implementers) on the one hand, and poor, rural women – for whom the services are provided – on the other.The government of India is committed to the Millennium Development Goal of reducing the maternal mortality ratio by three-quarters by 2015; specifically to less than 100 per 1,00,000 live births by 2010 (from 540 in 1998-99) [IIPS andORC Macro 2000]. A key strategy to achieve this goal would be to ensure that “all women have access to high-quality delivery care… namely, a skilled attendant at delivery, access to emergency obstetric care in case of a complication and a refer-ral system to ensure that women who experience complications can reach life-saving emergency obstetric care in time” [MOHFW 2005: 103]. The goals of India’s National Population Policy, 2000 are to achieve 80 per cent institutional deliveries and 100 per cent deliveries by trained birth attendants by 2010.However, these goals need to be contrasted with the reali-ties on the ground. Significant proportions of rural women in India continue to face enormous risks during pregnancy and childbirth due to obstacles experienced in obtaining timely and appropriate care. Evidence, for example, from Jharkhand though sparse, supports the finding that the majority of rural women in India do not receive quality care during pregnancy or childbirth. In 1998-99 only 7 per cent of rural deliveries in the state took place in institutions and 11 per cent of rural births were assisted by trained health professionals [IIPS andORC Macro 2001]. The situation is compounded by women’s poor health status; 73 per cent of rural women in the state are anaemic and 43 per cent are chronically energy deficient [IIPS andORC Macro 2001].1There is a need to better understand the factors influencing healthy pregnancy outcomes. While the clinical causes of ma-ternal mortality in India are well known [RGI 2000], it is clear that childbirth-related practices and beliefs, such as the use of oxytocin2 to augment labour, perceptions of heavy bleeding as normal, delayed initiation of lactation and starvation of the new mother, also have the potential of compromising healthy preg-nancy outcomes. The objective of this paper is to enhance our understanding of childbirth-related practices among rural women in Jharkhand. It documents women’s perceptions of complications experienced during childbirth and the actions taken, and explores the obsta-cles women face in accessing appropriate and timely care. It also explores the perceptions of providers regarding birthing practices. BackgroundTo understand the complexity of the obstacles that inhibit rural women from obtaining necessary and appropriate care for pro-blems during childbirth, the “delays” framework is useful: that is, I am grateful to Dinesh Agarwal, Pertti J Pelto and Leela Visaria for valuable comments. Lindsay Barnes (janchetnamanch@rediffmail.com) is project director, Jan Chetna Manch, Bokaro.
REPRODUCTIVE HEALTHEconomic & Political Weekly december 1, 200763the delays in recognising life-threatening complications, making the decision to seek care, reaching a health facility and receiving quality care at the facility [Ransom and Yinger 2002; Thaddeus and Maine 1994]. Several studies in India have highlighted one or more of these delays as affecting safe pregnancy outcomes. A study in Andhra Pradesh, Madhya Pradesh and Orissa, for example, concluded that the delay in recognition of complications and the failure to obtain timely treatment were major factors underlying mater-nal mortality [Murthy and Barua 2002]. Studies in Tamil Nadu showed that rural women expressed fears about delivering in hos-pital, including being alone without family, being scolded for ex-pressing pain, having to accept family planning measures against their will, and being questioned about their post-partum beliefs; women also reported apprehensions about hospital procedures and forced surgery [Ram 1998; Van Hollen 2003]. In contrast, a home birth was perceived to be associated with comfort and lack of fear; and studies have noted that traditional birth attendants provided much-valued support to women in labour [Patel 1994; Pinto 2006; Sagar 2006]. The adoption of “modern” dangerous practices in home deliv-eries, in particular the use of oxytocin injections, has been noted in numerous studies [Jeffery, Jeffery and Lyon 1989; Sharan, Strobino and Ahmed 2005; Van Hollen 2003]. Evidence suggests that rural women with the financial means often resorted to prac-tices such as oxytocin injections because they wished to deliver at home rather than in a hospital or health centre, while taking advantage of what they perceived were the benefits of modern medicine [Sharan, Strobino and Ahmed 2005; Van Hollen 2003].Studies show that facility-level practices are not always safe. For example, a study of delivery practices in rural Karnataka concluded that although most deliveries occurred at facilities be-cause of complications, no more than 30 per cent of the women were delivered by a physician; moreover, the majority of wom-en in labour were administered oxytocin to hasten the process and were discharged a few hours after delivery with little or no advice [Ganapathy, Ramakrishna and Mathews 2000]. Maternal Health in JharkhandSince the creation of the state of Jharkhand in 2001, the state government has made efforts to improve maternal healthcare services. Doctors have been employed on a contract basis and posted in rural health centres, labour rooms have been built and the health budget has been substantially enhanced. Several national and state level programmes have maternal health components and aim to increase institutional deliveries as a fast track towards reducing maternal mortality. These programmes, however, do not take into account the ground realities in such poorly developed states as Jharkhand and are not always sensitive to the realities facing women in the state, such as the paucity of institutions to cater to maternal health needs, the lack of affordable services and the perception of poor perceived quality of care in facilities. Moreover, programmes pay little attention to diet and nutrition, traditional pregnancy-related practices (both harmful and beneficial), or the fact that women themselves have little say in decisions concerning their own lives. In addition, few programmes build awareness at the community level of the possible dangers associated with preg-nancy and delivery. Study SettingThe study was located in Bokaro district, Jharkhand, where the facilitating community-based organisation, Jan Chetna Manch, Bokaro has been working for over a decade. Jan Chetna Manch’s activities include helping women set up self-help (savings and credit) groups, now numbering more than 350 in 75 villages. The federation of these women’s groups runs a women’s health centre where antenatal care and other health services are provided. The centre also houses a birth centre where trained village women health workers conduct normal deliveries.The study was conducted in Chas and Chandankiari, two poorly developed blocks in Bokaro district. Although located close to large urban, industrialised centres, most villages in these blocks do not have electricity, tarred roads or a regular supply of drinking water. Compared to many districts in Jharkhand, there are fewer scheduled tribe households in this area. Villages are largely populated by scheduled caste and backward caste Hindus, and Muslims. Most people work as marginal farmers, casual manual labourers or in small family businesses. Women are predominantly poor, marginal farmers.While little is known about maternal health in this setting, a few studies have been conducted by Jan Chetna Manch. Findings suggest that rural women are reluctant to access institutional care during childbirth. Some women had accessed delivery care from the women’s health centre, but the vast majority preferred to call the village “doctor” (rural medical practitioner or RMP) and deliver at home even during emergencies [Barnes 2003; Barnes and Datta 2004; Jan Chetna Manch 1997, 1998, 2002]. In-formalassessments show that while more women are accessing antenatal care in villages where women’s self-help groups exist, their health remains poor. A random sample of 100 women who had accessed care at the women’s health centre from the fifth to the ninth month of pregnancy showed that 83 weighed less than 45kg during the fifth month of pregnancy (42 were less than 40 kg) and 47 weighed less than 45 kg during the ninth month of pregnancy (14 were less than 40 kg). Similarly, another random sample showed that 66 out of 75 women who registered during the first trimester of pregnancy at the women’s health centre had a BMI of less than 18.5 kg/m2, signifying severe chronic energy deficiency [Barnes 2003; Barnes and Datta 2004; Jan Chetna Manch 1997, 1998, 2002].Women’s compromised health is compounded by the limited and poor quality public sector facilities available in the study areas. Although both blocks have primary health centres (PHCs), few deliveries are conducted in these facilities. The referral hos-pital in Chas does not have facilities for emergency obstetric care. Private healthcare, available in the neighbouring cities, is expen-sive and used only in emergencies. Accessing referral hospitals is difficult as most villages are connected only by mud roads and some are completely isolated. Public transport facilities are limited and while private transport is available, it tends to be expensive, especially in emergencies.
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly64Table 1: Socio-Demographic Profile of Respondents NumberTotal respondents 32Caste/community Scheduled caste 10 Other backward castes 9 Scheduledtribe 4Other Hindu castes 2 Muslim 7Main economic activity of household head Cultivator 6 Marginal cultivator/agricultural labourer 12 Artisan (potter, carpenter, basket-maker) 3 Others* 11Landownership status Owns enough land to produce sufficient foodgrain for the year 6 Own enough land to produce sufficient foodgrain for part of the year 18 Landless 8Education status of respondent Non-literate 22 Literate, informal education 2 Class 1-4 4 Class 5-9 4 Class 10 (matriculation) and above 0Education status of respondent’s husband Non-literate 11 Literate, informal education 0 Class1-4 2 Class5-9 13 Class 10 (matriculation) and above 6*Includes non-agricultural wage work (e g, drivers) or work in a small business/shop, the steel plant, mines and the government. The study was entirely qualitative and comprised focus group discussions, key informant interviews and in-depth interviews. The sample was obtained from villages with self-help groups. A total of 10 villages were selected. Study DesignFive focus group discussions were conducted with women from selected villages to identify potential key informants, learn about local birthing practices and inform the community about the project. In-sights from these discussions helped to shape the content of key informant and in-depth interviews. Fifteen key informant interviews were held with ‘jankar burhis’, ‘dais’ and RMPs (also known as ‘gaon ka daktar’ or ‘jhola chap daktar’) (five each), using a semi-structured guide. As trained nurses, midwives or quali-fied doctors (with anMBBS degree) were not present during most deliver-ies, they were not interviewed.Finally, in-depth interviews were held with randomly selected pregnant and newly-delivered women from the 10 villages, irrespective of whether or not they were members of self-help groups. Care was taken to ensure that women of all major castes and communities from the study villages wererepresented. In all, 32 currently pregnant women and 32 women who hadrecently delivered a live birth (less than six months earlier) were interviewed. In addition, 12mothers-in-law and 12 husbands (not of the women inter-viewed)were interviewed. Interviews were conducted from ApriltoSeptember 2005. Each woman was interviewed twice within a month.This paper is based on 32 interviews with women who had de-livered a live birth during the last six months; 16 of whom had delivered for the first time (referred to as first-time mothers) and 16 who had experienced three or more deliveries (referred to as third-time mothers). These accounts are supplemented with information provided in key informant interviews. The names of all the respondents have been changed. Study FindingsRespondents were largely from poor, scheduled caste or other backward caste families, and were generally engaged in agricul-tural activities (Table 1). Pregnancy-related Practices: The Last DeliveryPlace of Delivery: As can be seen from Table 2 (p 65), none of the respondents had delivered in a hospital during the last pregnancy. Among first-time mothers, eight delivered in their maritalhome, five in their natal home, two in the women’s healthcentre and one at an aunt’s home. In contrast, almost all third-time mothers (14/16) delivered in their marital home. When asked about their preferred place of delivery, the dis-cussion usually revolved around the natal home versus the marital home rather than home versus hospital delivery. Many women said they would have felt more comfortable in their par-ents’ home, but did not want to burden their families with the responsibility and expense of childbirth: “A woman who is preg-nant forthe first time is not allowed to go to her parents’ house during her pregnancy. If anything happens to the baby there, her parents will be needlessly blamed; moreover, they [the girl’s parents] will have to man-age everything themselves. It would be like carrying someone else’s bur-den” (SD, first-time mother).Beliefs and practical considera-tions also determined the location of delivery. For example, if the baby had died in the natal or marital home after a previous childbirth, the death would be attributed to evil spirits re-siding there, and the woman would try to avoid delivering there in the next pregnancy. Practical consid-erations included distance from a healthcare provider or to the nearest town, issues about who would bear the cost of delivery and the availability of family members to take care of other children. “I asked my husband what we would do if something happened to me at my in-laws during delivery. He said, “I will send you to your mother’s”. My mother had told him to take me there as doctors are available even at night. There are also more vehicles for transportation. Here [in-laws’ house] there are private hospi-tals but the treatment is not good. And there aren’t many doctors” (GB, first-time mother).Delivery at a hospital or nursing home was rarely a preferred option. Women feared that it would lead to unacceptable costs: “My mother-in-law and sister-in-law said that taking me to hos-pital would be expensive. Where would we arrange the money?” (KD, first-time mother).Moreover, an institutional delivery was perceived as threat-ening, particularly among those who had prior experience of pregnancy-related hospitalisation: “Everyone is scared in hospi-tal about whether they will cut open the belly or not” (AD, third-time mother). “I had problems when the [earlier] delivery took place in a hospital. They tied my legs to iron rods. When there was pain I would shake, and all the nurses would abuse me. In hospital nofamily members are allowed in the room” (KB, third-time mother).Even a woman who had been admitted to a nursing home following sepsis during her earlier delivery because of the unhygienic manual removal of the placenta by a jankar burhi 
REPRODUCTIVE HEALTHEconomic & Political Weekly december 1, 200765preferred a home birth with the same woman rather than return-ing to hospital.Attendance at DeliveryDeliveries were conducted by traditional attendants (jankar burhis and dais) and “modern” providers (RMPs). As Table 2 shows, almost all women who delivered at home were attended by an elderly woman, a relative or a jankar burhi, especially if a dai was unavailable. The dai was also called for almost every de-livery; in 14 cases she was called prior to the delivery and in 17 cases after the delivery. Third-time mothers were more likely to call the dai prior to birth (10/16) than first-time mothers (4/16).The division of work between the jankar burhi and the dai is often hazy. Typically, while both provide the mother support and encouragement by giving her oil massages and monitoring labour,includingassess-ing the dilatation of the cervix, the jankar burhi also provides other assistance such as calling the dai or RMP when required. Both the jankar burhi and dai remain with the woman throughout labour and delivery, palpating the abdomen to assess the posi-tion of the foetus, pouring oil on the navel to monitor the direc-tion of its flow, encouraging the mother-to-be to move around, squat and bear down, ensuring that she keeps drinking hot, sweet drinks or eating hot rice-gruel, helping the mother expel the placenta, cleaning the baby with oil, and bathing and wrap-ping the baby up. However, it is the dai who actually cuts the cord (with a blade) and ritually buries the placenta where delivery has taken place, gives the mother ‘mathvasi’ (presses her head into the mother’s belly whilst the mother is standing, to expel blood clots post-delivery) and ties the mother’s abdomen after delivery. While the jankar burhi may visit the mother for several days and accompany her to the hospital if necessary, the dai attends to her for six days following delivery, massaging her, giving her a hot compress with castor leaves and fomenting the baby’s cord with heat from a wick lamp. On the sixth day she helps the mother bathe in the pond and perform the ghat puja (prayers). A total of 20 women were provided services by the RMP dur-ing labour; 12 first-time and eight third-time mothers. An addi-tional six women (and their babies) were given only post-delivery tetanus-toxoid injections by the RMP. The RMP mainly adminis-ters oxytocin injections to speed up delivery or/and gives teta-nus-toxoid injections to the mother and baby after the birth; he also provides a saline drip if the jankar burhi, the dai or fam-ily members so prescribe. Some RMPs are present at the time of the birth, but typically they remain outside and do not assist the woman during the actual delivery. In most cases, the RMP is not expected to examine, attend or assist the mother-to-be. Although sometimes the RMP is permitted to conduct internal examina-tions, narratives highlight women’s resistance to this practice: “My husband wanted me to go to “doctor” S [RMP], but I do not like him. He was called for some deliveries, and the first thing he did was to stick his fingers into the woman’s private parts. He has no shame. Every time I see him I feel angry, so I did not consult him. After a whole night of pain, the dai told my husband to call “doctor” R [anotherRMP], he doesn’t examine women. He gave me four injections and waited outside” (AB, third-time mother).The ‘ojha’ also plays a role during childbirth, but his impor-tance is waning due to the growing popularity of allopathic medicines. He does not usually visit the mother during labour, but water or oil is taken to him to perform rituals, which is then given to the woman to drink or to apply. The ojha is generally the last resort, and consult-ed when the dai and RMP are ready to give up on the delivery. In only four cases was the delivery at-tended by a trained attendant: two women were attended by the government auxiliary nurse-midwife(ANM) who provides services on a private basis; and two women were at-tended by trained personnel at the women’s health centre. Planning for ChildbirthPlanning for childbirth was rare. Women re-ported that they did not feel the need to plan ahead, that their families would somehow arrange things, that they put their trust in God or considered it inauspicious to plan in advance. “My husband and I didn’t plan where I would deliver. We thought we would see to that when the time came” (LD, first-time mother).A few women reported that they had arranged for money, from either their parents or husbands, in case of an emergency. Theamount was never more than Rs 500, not even enough for anormal delivery in a city hospital or to hire a vehicle to get there. None of the women had considered arranging a vehicle in advance. Indeed, all the mothers in this study had “planned” a home birth. Typically, mothers do not participate in delivery-related decision-making: “If the need arises to go out for the delivery, my brother-in-law and husband will decide where to go. They are the main people in this family. As long as they are there, they decide” (SD, third-time mother).Family SupportThere was a clear demarcation between the kinds of support pro-vided by senior women and men of the family. Women largely provided support within the home. For example, mothers-in-law called the jankar burhi, dai or even the RMP, and attended the delivery along with them or assisted them. They also assist-ed the woman following delivery, cooking for her or caring for her children. Indeed, as many mothers observed, the support of women in the family helped them cope with the pain of labour. “The delivery took place at night. My mother-in-law and sister-in-law were with me. When I was in pain they gave me a lot of support” (MD, third-time mother).By and large the “outside” tasks, including calling the RMP, arranging for a vehicle to transport serious cases to hospital, Table 2: Characteristics of the Last Delivery (N = 32) NumberPlace of last delivery Home 30 Women’s health centre 2Attendance at last delivery* Jankar burhi or elderly relative 29 Dai 31 RMP 36 Health worker in women’s health centre 2 Auxiliarynurse-midwife 2When dai was called for delivery Prior to delivery 14 Afterdelivery 17 Not called 1When RMP was called for delivery Prior to delivery (for oxytocin injections) 20 After delivery (for tetanus-toxoid injections) 6 Not called 6* More than one attendant reported. 
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly66purchasing medicines, informing relatives about the birth or ar-ranging finances, were performed by the men in the family. Some tasks, such as buying blades, calling the dai and accompanying the woman to hospital, were performed by both men and women. In a few cases, mothers-in-law/mothers also arranged money, if needed, especially if they were members of women’s self-help groups. While husbands did not provide much support at the time of childbirth, especially in extended households where otherfemale members were present and willing to help, some husbands had accompanied their wives for antenatal check-ups, or helped in the housework, looked after the children, or brought special foods for the mother post-delivery. “For 25 days after de-livery he [husband] did everything. He even washed the blood-stained cloths. He bathed the children, fed them and washed their clothes. My mother-in-law and sister-in-law live separately” (MD, third-time mother).Problems during ChildbirthGiven this scenario, and combined with the poor nutritional sta-tus of women and conditions of general poverty, many women had experienced pregnancy-related complications. Following from the general perception that pregnancy and childbirth are normal events, women’s own assessment of complications expe-rienced tended, by and large, to underestimate their seriousness, although the likelihood that a few may have exaggerated their symptoms cannot be discounted. Rather than depending on women’s own assessments, resear-chers chose to classify, on the basis of a study of women’s narra-tives, the level of seriousness of the complication suffered during delivery. Based on this classification, a number of respondents – 22 of 32 – were reported to have experienced the following pregnancy-related complications:(a) Nine women experienced serious complications, of whom the majority experienced two or more potentially life-threatening complications, such as heavy bleeding and retained placenta, pro-longed labour and heavy bleeding, or prolonged labour and birth asphyxia. Not a single woman experienced eclampsia or fistulae.(b) Thirteen women experienced somewhat problematic but not life-threatening complications, such as heavy bleeding unaccompanied by other problems.(c) Ten women experienced unproblematic deliveries.Although a number of women reported serious complications, it would not be appropriate, with this small sample, to draw conclusions about the magnitude of women experiencing com-plications. We reiterate here that this study is not an attempt to measure the extent of childbirth complications, but rather to understand women’s perceptions of complications experienced and actions taken, which are discussed in the following section. Heavy BleedingHeavy bleeding was the most common problem experienced. Seven of the nine women experiencing life-threatening con-ditions reported that they had bled heavily. Threeofthefour first-time mothers reported that they had also lost conscious-ness. Six of the 13 women who experienced some problems also reported heavy bleeding. All 22 women reported that following childbirth they had experienced weakness, and at the time of in-terview many showed symptoms of severe anaemia and vitamin deficiency. While most women who experienced heavy bleed-ing were given mathvasi by the dai, two women, who had lost consciousness, reported that mathvasi was not done. Although women did express concern about heavy bleeding to their birth attendants, irrespective of whether the attendant was a dai, a jankar burhi or anRMP, heavy bleeding was considered necessary and not a danger signal. “After the delivery I lost a lot of blood. When I told the doctor [RMP], he said that it was dirty blood, and it was better if it came out of the body. He said if he gave medicines to stop the flow, I would face problems later” (RB, third-time mother).Despite probing, providers could only vaguely indicate when they perceived heavy bleeding to be a danger signal. Indeed, some providers believed that the quantity of blood expelled depends on a woman’s physique. “If the blood flows far away, then I understand that too much blood is being lost. If there is heavy bleeding and two clots of blood come out, this is good. If these clots stay in the uterus they will cause stomach ache” (CD, jankar burhi). “There is no harm in more bleeding because it will dry the wounds faster” (BD, dai).Jankar burhis and dais, on probing, admitted that too much blood loss can be fatal; however, few took prompt or appropri-ate action. Most indicated that they would refer a woman with excessive bleeding to anRMP; only one dai reported that she would refer the mother to a hospital. “Yes it [excessive bleeding] is harmful. The woman becomes weak, her body may swell up and she may have little blood left in the body” (SD, jankar burhi).“If the bleeding does not stop, then I know she is having exces-sive bleeding. I place a ball of cloth at the mouth of the uterus and make her sit on a gunny bag. If the bleeding does not stop even then, I tell the family members to take her to a reputed doctor” (PD, dai). “If excessive blood flows out from the body, then a woman caneven die. That’s why I tell them to call the “doctor” [RMP] (KD, dai).RMPs were only slightly better informed about excessive bleed-ing. Several reported the need to cleanse the uterus of dirty blood. They often relied on the assessment of the dai or the woman giving birth. If haemorrhage was suspected, all RMPs re-ported giving methergine3 injections, often along with other in-jections and medicines; however, they did little else to stop the bleeding: “Sometimes the mother has stomach pain after deliv-ery. I give a methergine injection for that. All the dirty blood in the uterus comes out after this injection” (“Dr” S, RMP). “If I see blood is dripping under the bed, I know too much bleeding is tak-ing place. Then I give a methergine injection, a saline bottle, a vitamin injection” (“Dr” D,RMP). RMPs also referred cases that they could not manage. Two RMPs reported that a woman they had treated had died from excessive bleeding, and one noted that he had learned the importance of prompt referral: “A woman was having intense labour pains but was not able to deliver. I did an internal examination and found that the mouth of the uterus had opened only a little. I gave her seven injections, and then the delivery took place. But she started having continuous profuse bleeding. I asked the family to take 
REPRODUCTIVE HEALTHEconomic & Political Weekly december 1, 200767her to Jharia. Unfortunately she died on the way. Now I check excessive bleeding. If a bowl of blood is lost then I give injections. If it doesn’t reduce even then, I refer the case” (“Dr” B, RMP).Birth AsphyxiaFive women reported that their babies were born with severe birth asphyxia – i e, they were born with a bluish colour, did not breathe immediately and did not cry for at least 10 min-utes. In addition one woman reported symptoms of mild birth asphyxia in her infant. Of the 20 births that were preceded by an injection of oxytocin by the RMP, four infants experienced severe birth asphyxia and one experienced mild birth asphyxia. In contrast, of the 12 cases in which oxytocin was not adminis-tered, only one infant was reported to have experienced birth asphyxia (severe).Although these figures may not be statistically significant, they do suggest that birth asphyxia, a known risk of oxytocin, is not uncommon, and is administered by providers who are not pro-perly equipped or trained. All the babies in this study survived, since only mothers of live babies were interviewed. In three of these five cases, it was the mother-in-law, aunt or dai who had revived the baby, and in the remaining two cases, theRMP revived the infant. Provider interviews suggest that several common traditional methods are adopted to address birth asphyxia, such as sprin-kling water on the infant, chewing black pepper and blowing into the infant’s ears, mouth and nose, covering the infant with a bas-ket and making a loud noise near the ears, or stroking the cord towards the baby. Women reported that unlike RMPs, dais and elderly women are aware of how to loosen the umbilical cord if it is around the baby’s neck at birth.RMPs also sprinkle water on the baby, but deal with asphyxia more aggressively – they hold the baby upside down and slap its back, and in one case, had given the infant steroid injections.Prolonged LabourSeven of the nine women who experienced life-threatening con-ditions, and four whose problems were not life-threatening, re-ported prolonged labour, classified as contractions for more than one day and one night. Prolonged labour was usually accom-panied by other problems, such as heavy bleeding and loss of consciousness.According to jankar burhis and dais, the actions taken in the case of prolonged labour are similar to those taken during a nor-mal delivery. In addition, they also provide emotional support to the mother by way of advising the mother to be brave, allaying her fears and enabling her to relax; and calling for various ritu-als to pray for a safe birth. Some dais applied herbal medicines externally but none reported using medicines internally to speed up childbirth. They also conducted internal examinations and could generally diagnose obstructed labour. RMPs addressed prolonged labour by giving the mother oxytocin injections. Sometimes they gave additional, often un-necessary, injections (such as steroids and vitamin injections) along with intravenous fluids. Some RMPs performed episioto-mies, described by women as a “chota operation” that is necessary for a ‘chota bachedani’ (small uterus). TwoRMPs reported per-forming episiotomies when they found the vaginal tract too small. This practice of conducting episiotomies is perceived bydais as an example of the unethical practices of RMPs. “I use both hands to open the mouth of the vagina; I pour coconut oil and slowly stretch the skin. Then the skin does not tear. I don’t approve of the “doctor” [RMP] doing a small operation [episio-tomy]. It is a shameful thing. I feel that if the delivery is done carefully and slowly, the skin will not tear and there will be no need for stitches. If there is a small tear, it will heal on its own, with a hot compress. The “doctor” [RMP] will not do this, but will do the “operation” in order to make money” (BD, dai). Retained PlacentaThree of the nine women experiencing life-threatening compli-cations, who reported a retained placenta, said that the dai had removed the placenta manually. Most jankar burhis and dais reported that they first try to remove the placenta by pushing hair down the throat of the mother to make her gag, while at the same time placing her in a squatting position. Failing this, they remove the placenta manually. Usually, they neither use gloves nor wash their hands before undertaking the procedure.RMPs reported that they administer injections to expel the placenta. If this fails, they recommend that the dai removes the placenta manually. A few RMPs reported that they remove the placenta manually, wearing gloves that are not sterile, presum-ably to protect themselves rather than the mother. EclampsiaAlthough none of the women had experienced eclampsia or suf-fered from fits during childbirth, this complication is being dis-cussed because providers noted that this was one of the most serious problems that they had encountered. Dais and jankar burhis referred to this condition as “childbirth epilepsy”, and considered the condition so serious that none would treat these cases: “If this type of epilepsy is not treated beforehand then the woman may die. If she doesn’t go to hospital she may die” (PD, dai).Symptoms such as swelling of the body during pregnancy, however, were generally not taken seriously by the community, or even some dais and jankar burhis. Most attributed swelling to nutritional deficiencies and advised dietary changes, but re-ported that their advice was not heeded. Some RMPs however, appeared to be better informed and more likely to recognise the need for prompt treatment: “When she comes for an examination I check the blood pressure, else she might get eclampsia. This is a very dangerous illness” (“Dr” B, RMP).Post-partum Hunger and Breastfeeding Problems The practice of starving the mother after delivery (‘narak upas’) is considered essential for the health of both the woman and the infant in the study areas. Post-partum fasting and extreme hun-ger was more common among first-time than higher order moth-ers – all 14 first-time mothers who delivered at home reported post-partum fasting and extreme hunger as compared to nine third-time mothers who reported both post-partum fasting and 
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly68hunger. The two women who delivered in the women’s health centre did not observe this custom. Even women who requested food and water were not given an-ything to eat or, at best, fed a small amount of warm water, bread or biscuits. “I remained hungry during the long labour; I had to put in a lot of effort on an empty stomach. I was given rice to eat only five days after the delivery” (KD, first-time mother).Informed women also adhered to such practices, as can be seen from the following quote: “The nurse [ANM] told me to eat eve-rything, but my mother [anganwadi worker] and aunt wouldn’t let me. They said I would have to follow the rules of the village. My stomach was empty and I was hungry, but what could I do? Next time I have a baby I won’t follow any rules” (SD, first-time mother).Providers’ narratives also suggest the persistence of the prac-tice of narak upas. In one extreme case, as the dai noted: “a woman had a delivery and she died of thirst, asking for wa-ter”. However, several providers noted that this practice may bechanging. “Earlier there were many rules, but now there are none. Earlier no food was given after delivery, but these days every kind of food is allowed” (SD, jankar burhi).RMPs recognised the importance of a healthy diet for newly-delivered women but did not make much effort to reverse tra-ditional community resistance to allowing women to eat, argu-ing instead that “[people] don’t listen to us, they will follow their own rules”. Thirteen of the 32 women reported the absence of breast milk for four or five days after birth, and both mothers and dais and jankar burhis recognised the link with post-partum fasting. “I was given rice to eat after four days. I was given only tea and bread for three days. I was told not to drink too much water or my baby would get a cough. I followed all the rules. When I started eating rice, I began to have milk in my breasts. For four days we fed the baby sweetened water” (JB, first-time mother).Some dais and jankar burhis acknowledged that rules about fasting were harmful but were engrained as a part of village tra-dition: “villagers won’t listen to me, they will follow their rules”. Other providers however, continued to maintain that fasting is needed to “dry” the mother’s body, so that she stops bleeding, a problem perceived as more harmful than lack of breast milk. Obstacles to Accessing Quality CareNarratives suggest a host of obstacles inhibiting safe deliveries and good practices among women in the study area, includ-ing lack of access to quality and affordable care, and delayed decision-making. For example: “When I examined her I found she was passing clots of blood and there was a lump of tissue in her birth passage. I told the family to take her to hospital but they called the “doctor”[RMP]. He also advised them to go to hospital. It took them two days to arrange the money – they sold one cow. Then they hired a vehicle and took her to a private nursing home in Chas. The doctor refused to admit her and said, “Take her to Purulia” [to the government hospital]. We reached Purulia at night. The doctor there said, “Take her to Bankura”; he didn’t want to admit her either. We pleaded with him; we said, “If she dies, then she dies, but please admit her”. So they admitted her. She was taken to the labour room, and they tried to find a vein to give her saline. Her body was swollen up by then. She was thirsty and asked me for water, then she died. If they had gone two days earlier, when I had told them, she would have lived” (PD, dai).Lack of Access to Appropriate and Quality Care Findings indicate the paucity of trained and accessible providers and appropriate facilities in the area. ANMs, for example, do not live in the village and the sub-centres remain closed most of the time. In contrast, dais and jankar burhis are easily available and provide a much-valued and timely service. Likewise, RMPs are easily available, more accessible, better equipped with medicines and other supplies, and more willing to accommodate traditional rituals and practices thanANMs and government doctors. However, the easy availability of jankar burhis, dais and RMPs could be an obstacle to timely intervention in obstetric emergen-cies. Typically, if the jankar burhi or dai encounters a problem, she calls the RMP, and recommends hospitalisation only if the RMP fails to address the problem. Dais described cases in which families called a secondRMP when the first one was unsuccessful, and then an ojha, in a last desperate attempt to avoid hospitali-sation. Availing the services of different care providers is time-consuming and could be potentially fatal. The reluctance ofRMPs, dais and jankar burhis to refer the woman to an institution is not entirely irrational. Facilities are located at a considerable distance, and transport and money need to be arranged, causing inordinate and dangerous delays. Moreover, neither basic nor emergency obstetric services, includ-ing for treatment of post-partum bleeding, are available in the study areas.Poor Perceived Facility-Level Quality of CareAlthough there is a growing acceptance of modern allopathic medicine, an obstacle to accessing institutional delivery is the poor perceived quality of care at facilities. Women reported that providers are not sensitive to their needs; that women in labour are abused, scolded and even slapped; and that dais or jankar burhis are not permitted to accompany them into the labour room. Women also feared unnecessary procedures in institu-tions, such as insistence on caesarean-section deliveries. “I went to the nursing home with my sister-in-law. She was taken inside a room, no one was allowed to go in with her. The nurses gave lots of abuse to women in labour” (JB, first-time mother).“City doctors will not wait a whole day for the delivery to take place. They will cut open the stomach and bring out the baby” (MD, third-time mother).Jankar burhis and dais also reported experiencing threaten-ing quality of care at facilities. In some cases, hospital staff also demanded money for handing over the baby. “In the hospital I have no rights. If I tell them I know something about delivery they tell me, “Then why have you brought her here? You should have done the delivery in the home!” (RD, jankar burhi)“I accompanied my niece to the [government] hospital, but I was not allowed inside the labour room. When the baby was born, the nurse came to ask for money, soap and cloth. We didn’t give 
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly70delivery. While there is a growing acknowledgement – albeit thus far dangerously misplaced – of the role of modern allopathic medicine, this is equally offset by a resistance to seek an insti-tutional delivery, and a fear of the nature of modern practices adopted in these facilities and the quality of care received in hospital settings. At present what is disturbing is that the allo-pathic care women are “choosing” may actually be detrimental to their health and also result in potentially life-threatening delays in addressing pregnancy-related complications. Findings also clearly show that the environment offers poor rural communities few options in terms of quality, accessible and affordable emer-gency obstetric services. Study findings argue for a multi-pronged approach that will enable safe pregnancy-related practices for women in the exist-ing socio-cultural and health service scenario in rural Jharkhand. Skilled home-based services need to be provided to women ex-periencing normal deliveries and efforts made to train available attendants in sound modern practices while, at the same time, in-corporating useful and harmless traditional practices employed by communities during delivery – a “best practices” approach. Strategies need to take into account the multiple players at the time of delivery. Misperceptions and unsafe practices adopted by dais and jankar burhis as also harmful practices adopted by RMPs need to be addressed. The rampant misuse and overuse of potentially dangerous drugs during childbirth must be checked: greater vigilance in the sale and use of drugs must be ensured; and healthcare providers – RMPs in particular – women and com-munities must be apprised of the dangers of misuse of injections and drugs.Given that every delivery may result in complications, that skilled birth attendants do not reside in villages and that institutions are several hours away, community-based birth attendants can be taught to conduct normal deliveries, treat minor problems, provide obstetric first aid for complications, refer complicated cases, and make families aware of available transport that can be used in case of an emergency. In addition, community-based birth attendants need to be made aware of the steps to be taken ensure the mother arrives at the hospital alive. With training, effective community-based attendants can considerably reduce three of the delays that contribute to ma-ternal mortality: the recognition of a complication, the decision to access a higher level of care and the time spent in reaching the facility. At the same time, the RMP is clearly an acceptable link to modern medicine. The feasibility of drawing dais or RMPs into the maternal health programme and upgrading their skills needs to be explored,in particular trainingRMPs in the use of oxytocin/methergine and training dais in the use of misopros-tal for post-partum haemorrhage, a finding reinforced in studies in other resource-poor settings [Darney 2001; Gulmezoglu et al 2001, 2003].Likewise, the feasibility of establishing low-cost and client-friendly clinics/birthing centres, such as the women’s health centre, needs to be explored. These clinics are a step in the di-rection of providing modern allopathic care while at the same time remaining sensitive to women’s preference for a familiar attendant in the labour room, incorporating useful traditional practices, carefully eliminating the harmful ones and respecting the community’s customs. At the same time, however, more effort needs to be made to-wards providing a workable referral channel for emergency obstetric care and access to blood banks in the district. Finally, there is a need to review the quality of care in existing institu-tions and to build more respectful and client-centred interaction with women, their families and their attendants.Notes1 That is, with a Body Mass Index (BMI) (ratio of weight to height-squared) of less than 18.5 kg/m2.2 Oxytocin injections (trade name Pitocin or Synto-cinon), referred to in the community as “hot”, “deliv-ery”, “pain-increasing” or “strength-giving” injections, are recommended for post-partum haemorrhage. 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