Vithika Pande: Lessons from dais—can we learn from traditional systems?

Vithika PandeMany attempts have been made recently to better understand the social determinants of health (World Health Organization report “Commission on Social Determinants of Health). However, understanding health from a cultural lens is equally important and it is essential to consider this while designing health policies and programs.

In India there has been a rich and diverse set of healing traditions based on classical knowledge as well as regional folk practices, however, their popularity subsided when modern medicine (popularly known in India as allopathy) rapidly progressed with state patronage. Today we see that, under the name of medical pluralism, different systems of medicine and healing are hierarchically organized, with biomedicine at the top followed by other professional systems of medicine. Although medicalization has benefitted our society, it is also important to consider the cultural aspects that affect patients’ health.

More recently, with the launch of the National Health Policy on AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy) in 2002, there has been an upsurge of policy interest in re-examining the role of local health traditions and how they might be utilized to ensure access to safe and affordable healthcare. However, it’s worth noting that policy efforts are skewed towards the codified and professional systems of medicine (such as AYUSH). Although there is definite intent here to mainstream traditional systems of medicine, it’s not clear yet how the state’s efforts will contribute to revitalizing local health traditions, including dai, bone setting, Visha Vaidya, Marma Chikitsa, etc.

Indigenous traditional midwives, who are popularly known as dais in India, are some of the oldest health practitioners in India, having served Indian society through many ages. However, the tradition lost the esteem it was once viewed with during the mid-20th century after childbirth became “medicalized” for upper and middle class women. It has also been argued that feminist discourses in the women’s health movement showed more concern for female gynecologists’ experiences in healthcare systems than indigenous midwives.

The indigenous traditions of midwifery started to become marginalized by global and national actors, as increasingly the focus was on establishing incentive programs and policies that would increase the number of institutional births (this being part of a global strategy to reduce maternal and newborn mortality in order to achieve Millennium Development Goal 5). However, the government’s attempt to improve maternal health by incentivizing women to have institutional births (by implementing policies such as Janani Suraksha Yojana) has its failings too. Encouraging institutional deliveries without addressing the perceptions of potential users is a seriously flawed approach to reducing maternal mortality.

According to the National Family Health Survey 3 (NFHS 3) conducted in 2005–06, only 44% of births among poor urban mothers in Delhi were institutional ones, as compared with the urban average of 67.5%. A more recent study shows that in the year 2012, out of the 824 women who gave birth in urban poor settlements in Delhi, India, 53% had given birth at home. Fear of hospitals (36%), the comfort of home (20.7%), and a lack of social support for childcare (12.2%) emerged as the primary reasons for having home births.

It is quite evident that families in India are still reliant on dais, despite stringent government policies discouraging home births. For example, preliminary conclusions from the Jeeva study, which looked at the experiences of women in four Indian states, show that for many women the first choice even today is care by dais because of their sense of responsibility, affordability, and continuity of care, among other reasons. The study covers a total population of around 40 000 and looks at the actual role of dais from a dual public health and indigenous knowledge perspective. In order to move towards better maternal and child health, the study calls for the recognition of traditional midwives’ contribution to mothers’ wellbeing.

I believe it’s crucial to look at reproductive health issues not from a single lens, but in accordance with cultural and economic realities. A mutual learning mechanism among the professionally skilled birth attendants and traditional healers has to be developed for the growth and accessibility of caring public health systems. Achieving this will require an unprecedented joint effort on the part of government and civil societies.

Vithika Pande is a student on an e-learning in public health management (ePHM) course at the Institute of Public Health, Bangalore. She is currently a project officer, women and child health, at the Biocon Foundation in Bangalore.

Competing interests: None declared.