Birth on the Threshold. Cecilia Van Hollen
and the Victoria Fund—it is clear that the status of health of Indian women and children served as the “grounds” for a discourse on childbirth in colonial India. Many goals were sought and achieved through this discourse, including the establishment of a network of allopathic institutions for maternal and child health (including hospitals and medical colleges); securing employment for European and Anglo-Indian women; providing the rationale for colonial administrators to move into the private sphere of Indian domestic life; and legitimizing the “civilizing” rule of the British. This is not to imply that individuals involved in these projects were not sincerely dedicated to the improvement of women’s health; nor do I mean to deny that some Indian women benefited from the new forms of allopathic maternal health care available. But it is important to point out which other, unstated colonial interests were served through these projects.
These funds were structured by colonial interests and limitations as well as by local issues of caste and gender, which resulted in a very different scenario of the professionalization of obstetrics in India than in the United States and Europe. The first critical difference is that due to the intersection of imperialist and local interests, women dominated the profession of obstetrics in India from the beginning. Even in urban centers of India where childbirth has become heavily biomedicalized, it has not been accompanied by the domination of male doctors, as is the case historically in the West. Second, despite ongoing efforts to slander the dais, their central role in overseeing deliveries in India was viewed as inevitable in the short term by the colonial administration, and continues to be viewed this way today. Although ever since the Victoria Fund, many have decried the failures of the dai-training programs, these programs continue to be supported (to some degree) by national and state governments in India today. Unlike the situation in the United States and many parts of Europe, the biomedical establishment’s control over childbirth in India can by no means be viewed as hegemonic.
Due to the combination of these two factors—the predominance of female obstetricians and the continued widespread practice of local midwives—the critiques which women have about the status of childbirth in India today differ significantly from the antihegemonic feminist critiques of the condition of childbirth in the West. The fact that women have dominated the field of obstetrics in India does not preclude the possibility that their practices are as saturated by patriarchal values as those of their male counterparts, since such values are to some extent inherent in biomedical obstetric training throughout the world. But the absence of male dominance in obstetrics in India does have important repercussions on the nature of the critiques of the professionalization of obstetrics in India. There is no significant “natural,” “female-centered” home-birth movement in India today, even among the urban middle and upper classes. Rather, based on ethnographic material presented in the remaining chapters, I will argue that the contemporary criticisms waged by the lower-class women whom I met in Tamil Nadu are less concerned with issues of male domination in the hospitals and with the birthing woman’s individual experience of birth, and more concerned with collectively experienced forms of class, caste, and gender discrimination which often prevented these women from getting the allopathic care they wanted.
CHAPTER 2
Maternal and Child Health Services in the Postcolonial Era
Having described the colonial context in which the professionalization of obstetrics emerged in tandem with a resigned acceptance of midwifery, I now move quickly through time to the policies and programs of the twentieth century which have informed the structure of public MCH services throughout much of the postcolonial era. In this descriptive chapter I hope to provide a general sketch first of the official structures of health care in India and in Tamil Nadu and then of the actual landscape of MCH care in Kaanathur-Reddikuppam and Nochikuppam. This chapter is intended to provide a basic framework through which to understand the more ethnographically and theoretically engaged chapters which follow. (See Appendix II for an outline of the official structures of rural and urban MCH institutions and practitioners in Tamil Nadu for 1995 that are described in this chapter.)
THE OFFICIAL STRUCTURE: THE BHORE COMMITTEE REPORT
A four-volume report by the colonial government’s Health Survey and Development Committee was published in 1946, known as the “Bhore Committee Report” (Government of India 1946) after the chair of the committee, Sir Joseph Bhore. This committee drew heavily on the recommendations of the Indian National Congress’s National Planning Committee, which was established under Jawaharlal Nehru’s guidance. The Bhore Committee Report attempted to analyze the state of health care in India and to make recommendations for the improvement of health care services in India overall.1 Drawn up on the eve of India’s independence in 1947, the Bhore Committee Report became the template for the structure of health care services in India in the postcolonial era, as reflected in the postcolonial government of India’s Five-Year Plans. The actual implementation of the institutional structures recommended in the report were initiated ten years following its submission. Many of the basic elements of this structure remain in place today.
The Bhore Committee Report called for the establishment of a socialist system of health care, emphasizing public health services and preventative medicine for the rural poor. Madras Presidency had been the first presidency to pass a Public Health Act in 1939, which put the responsibility for the provision of public health services, including maternal and child health, in the hands of the state. With the Bhore Committee Report, public health became the responsibility of the national government, although the implementation remained in the hands of the individual states. The model envisioned in the Bhore Committee Report was a three-tiered referral system, with primary health care services emphasizing preventative care available in primary health centers (PHCs) at the village level,2 secondary curative services available at the district level, and tertiary services available in the urban centers, often attached to medical teaching and research institutions. Rural women seeking allopathic services during childbirth were encouraged and expected to use this three-tiered system according to their needs.
Following the Victoria Fund’s approach, the Bhore Committee Report also posited that the hereditary dais would inevitably remain central to the care of Indian women during childbirth, at least in the short term. The report, therefore, supported efforts to provide basic training to the hereditary dais rather than trying to replace them with a new cadre of midwives. Government support of such dai-training programs continued in independent India, and these programs were included in the government of India’s Five-Year Plans.
In addition to Madras Presidency’s early move to take responsibility for public health services in general, the Madras Presidency’s Department of Public Health also took an active role in overseeing the training and deployment of auxiliary health workers specializing in MCH care, known officially as “health visitors.” In 1938 the Department of Public Health took over these responsibilities from preexisting voluntary organizations such as the India Red Cross Society. Based on a model borrowed from Britain, health visitors were women who were to be trained in such subjects as elementary physiology, home nursing and first aid, household management and dietetics, maternity and child hygiene, and character training and mental hygiene.3 The Bhore Committee Report envisioned that, after completing their training, these health visitors would be appointed to medical institutions serving women and conduct outreach work in the communities surrounding these institutions to provide basic health services and educate others on the merits of these topics.
It was, however, an ongoing struggle to make the establishment of such a cadre of auxiliary health workers a basic structure of the postcolonial public health service sector. Ever since the implementation of the three-tiered primary-health-based structure, state governments have faced great difficulties in convincing urban-trained doctors to take up employment in rural hospitals. This made it politically difficult to establish a cadre of auxiliary medical staff attached to primary health centers who could serve as community health workers, since some felt that the presence of such auxiliary health workers would be an impediment to sincere efforts to staff the PHCs with more-qualified doctors. There were also concerns that these auxiliary workers would begin to work independently of the doctors’ supervision, and that the rural poor would thus be served by under-qualified “quacks.”4
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