Special issue with the Sunday Magazine
From the publishers of THE HINDU

Indian health traditions: October 08, 2000

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Skilled dais

Dr. Samatha Pottu

Perhaps all of us are aware that poor, rural women go through pregnancy and childbirth in a fashion different from that of their urban counterparts. And we are taught to believe that sooner than later, all women should be able to afford the "luxury" of hospital deliveries. It is time that we examined the assumption that a hospital delivery is superior to the way in which our rural women give birth to children. By closely observing the obstetric tradition of our rural women, we can have a realistic picture of the prevailing situation.

Mother and child with attendants, c. 8th century, Pala dynasty.

Obstetrics is practised by the traditional midwives (Dais) all over rural India. Even today, more than 50 per cent of deliveries are conducted by these rural professionals, who are highly skilled.

All through pregnancy the mother is attended to, advised and guided by the dai. Pregnancy is confirmed early by the dai by the unmistakeable symptoms that appear soon after conception. Some dais also detect pregnancy by observing the pulse (naadi) of the mother. The pregnant mother is administered herbal preparations made from locally available herbs. For example, vasambu with milk is given for the retention of urine. For swelling (oedema) in the legs, water boiled with dhaniya, dry ginger and palm sugar is administered. Sometimes an external application of a paste of Neermulli is recommended for this problem. All the health problems of women during pregnancy, such as constipation, urinary ailments and false labour pains and sometimes even premature abortion are managed efficiently by the dais. In the case of premature death of the foetus inside the womb, the dai is able to clearly understand the signs and symptoms and conduct a safe delivery. Since the dai belongs to the same village or a nearby village, she is often familiar with the social and family background of the mother. This enables her to provide tremendous psychological support to the mother.

Pregnant women are often brought to the dais with false labour pains. By administering simple preparations such as the juice of drumstick leaves with salt, or a decoction of jeerakam and dhaniya, or dry ginger and clove, they are able to detect whether labour has set in.

Dais follow an interesting practice to detect the approach of childbirth. According to dais in Bihar and Tamil Nadu, oil is poured on the navel of the mother and its flow is observed. If the oil flows down without staying in place, it means that childbirth is fast approaching.

The delivery position followed by dais is radically different from the "lithotomy" position (lying down with the feet up in stirrups) preferred by modern obstetric practice. The preferred posture is the kneeling position, which makes it easy for the mother to strain and bear down. The dais say that lithotomy brings the foetus up into the chest region of the mother and makes it difficult for the mother to bear down when the contractions begin. (In fact the lithotomy posture is designed more for the convenience of the attending doctor than that of the mother.) When the mother is exhausted, the lying position with the knees drawn up is used. In this posture when the contractions begin, the mother is made to hold her thighs while her head and back are lifted and supported. Again the main consideration is to make the straining and bearing down easy and efficient. The mother is always surrounded and physically supported by people of her own family and village. This provides a tremendous boost to the exhausted mother.

There seems to be no tearing of the perineum when dais perform a delivery. This is because

(a) the traditional birthing postures make it possible for the mother to bear down properly.

(b) The dai waits patiently till contractions begin and full dilatation takes place eventually. Dais often say that they can wait a few days after the initial labour pains begin.

(c) The dai helps the dilatation to reach the maximum during the labour. Large quantities of ghee or castor oil are used on the abdomen and hip regions as well as the mouth of the birth canal. This helps is in stretching the birth canal without causing any tears in the passage.

(d) The mother is told not to strain when there is no pain or contraction.

As opposed to this, in hospitals chemicals are injected to increase the contractions without a corresponding dilatation. The lithotomy posture does not allow the mother to bear down properly and efficiently. When the straining is done without appropriate dilatation, there is every possibility of the perineum tearing, often in a zigzag manner. This has resulted in episiotomy (cutting of the perineum) becoming a standard modern obstetric practice.

Dais are able to handle any presentation of the foetus with confidence. These obstetric skills seem to have completely disappeared from modern hospitals.

One other area where the traditional practice of the dais is radically different from that of hospitals is in the cutting of the umbilical cord and delivery of the placenta. The current practice is to cut the umbilical cord as soon as the child is delivered. The dai does not severe the connection between the child and the placenta. The umbilical cord is retained until the baby cries or starts breathing. In cases where the child fails to cry, resuscitation is achieved by pumping the placenta in warm water with salt. At times, this procedure may last up to an hour before the child is revived. The other reason for retaining the umbilical cord is that this helps in the easy delivery of the placenta.

The dai also becomes the paediatrician to the child and takes care of the newborn. The loose abdomen of the mother is tied with a cloth. The mother is given regular oil baths, and her diet regulated carefully. Medicines are administered where required. This is important since ill health of a nursing mother affects the child directly through the mother's milk. In cases where breast milk is insufficient, the mother is given numerous herbal preparations which increase lactation.

Thus the traditional midwife, is highly skilled in obstetric practices. Prenatal care, conducting normal and safe deliveries without the pitfall of episiotomy, manipulations of abnormal presentations of the foetus to bring about a normal delivery, resuscitation of the newborn where necessary, postnatal care - all these fall within the domain of the dai's practice.

Scores of studies have highlighted the invaluable service rendered by the dais to our society. However, in the official circles there is a total lack of understanding of their skills. They are considered a necessary evil, only to be tolerated as some stop-gap arrangement until modern hospital care can reach all rural India. It is time the dais are given their rightful place in society and the recognition they richly deserve.