Birth on the Threshold. Cecilia Van Hollen
reported this information to the MPHW in the mini-health-center. In addition, lay firstaiders could provide basic first aid care to people at home. Each mini-health-center was staffed by a male and female MPHW. The training for MPHWs was one year for male MPHWs and eighteen months for female MPHWs. The extra six months for female MPHWs was to provide training in MCH care. The VHS doctors working in the rural areas generally worked for VHS only on a part-time basis, making occasional visits to the various mini-health-centers to check up on the centers’ status.
The mini-health-center in Kaanathur-Redikuppam consisted of a small cement-block room with a desk which was cluttered with vials of different sorts of medicines and packets of pills. And there were two metal fold-up chairs—one for the MPHW and one for the patient. Attached to the room was a tiny waiting area which was open to the outside road, though partially protected by a fence made of rough sticks and thatch. There was also a rubbish pile, haphazardly dumped to the side of this waiting area, which contained, among other things, medicine wrappers and bottles and used syringes that attracted a swarm of flies. I found myself spending quite a bit of time in this dingy waiting room since the open hours for this mini-health-center were fairly inconsistent. But the male or female MPHW in charge did usually show up, and many people from the area did come to seek his or her advice and get treatment for all sorts of ailments.
In Kaanathur-Reddikuppam, Muttamma’s own son was the male MPHW during the time of my research. The female MPHW who was attached to this center when I began my research left VHS halfway through the year and established her own private practice seeing deliveries in her own home in a town about forty-five minutes away by bus from Kaanathur-Redikuppam. She was replaced by another female MPHW who also had to travel by bus to come to the center, which meant that she was not available for emergency care during off hours. The female MPHWs were trained to conduct deliveries in homes if it became absolutely necessary that they do so. But their mandate, while working for VHS, was to educate women about prenatal care, deliveries, and postnatal care, and refer them to a hospital for deliveries. The headquarters of VHS only opened up its own obstetrics ward in 1994; the MPHWs were just beginning to refer women to that hospital for deliveries. Although the VHS female MPHW was an important source of information regarding MCH care in the vicinity, and she provided some pre- and postnatal care, she rarely in fact conducted deliveries herself.
Like the female MPHW who left to start her own practice conducting deliveries in another town, Shahida had been trained as a MPHW at VHS. After working for VHS and other voluntary health organizations in other regions of Tamil Nadu, she and her husband had come to Kaanathur-Reddikuppam in 1994 to establish their own clinic, and she was privately conducting home deliveries in the area. She and her husband were living in a room attached to the home of Murugesan (the panchayat president described in the Introduction), which was on the southern end of the main street of Kaanathur-Reddikuppam. They had set up their clinic in that house. Although Shahida would see prenatal and postpartum patients in the clinic if they came to visit her, she conducted all her deliveries in the homes of the laboring women.
Shahida’s arrival had created a certain amount of resentment on the part of Chellamma, a fifty-five-year-old maruttuvacci who had been conducting home deliveries in the area for over twenty-five years. Chellamma’s home was on a small path just off the main road near the mini-health-center. Like most hereditary maruttuvaccis, Chellamma had learned how to conduct deliveries through observation and apprenticeship at home rather than through any formal dai-training program. Karpagam, who lived in a thatched house off the open road leading from Kaanathur to Reddikuppam, had undergone a dai-training course at the Kelambakkam PHC in 1990 and also conducted home deliveries on occasion. This was not a hereditary profession for her. She was, however, quite critical of the training she had received since it was very time consuming and did not adequately compensate her for loss of pay due to missed work. She was also bitter that her clients did not pay her adequately and so she found herself seeing fewer and fewer home deliveries over the years. I have met some hereditary midwives in Tamil Nadu who complained that after they had gone through the dai-training programs their clients were more hesitant to pay them than they had been prior to the training, since these clients believed that the midwives were now receiving regular payment from the government.
For both Chellamma and Karpagam, the delivery work was very much part-time. Chellamma had worked most of her life as an agricultural laborer, and Karpagam was working as a laborer on construction sites.8 Neither of these women provided prenatal care. They came only at the time of the delivery. Chellamma would also come for postpartum visits to bathe the baby and prepare postpartum medicines, but Karpagam did not provide these services.
There was one pharmacy in Kaanathur-Reddikuppam, which was located on the main road in the middle of all the shops. This pharmacy was run by a man whom most people referred to as a “doctor.” He had MPHW training and had also taken a three-year course in Siddha medicine. When people asked this pharmacist what he recommended in terms of prenatal and postpartum care for mothers, he tried to encourage them to take Siddha medicines.9 But he complained that people no longer had the patience required for Siddha medicines to really take effect, and they were increasingly demanding allopathic medicines, especially injections, for immediate results. It was because of this attitude, he said, that he was increasingly being summoned to accompany Chellamma to deliveries to give vitamin B12 injections to speed up labor. The pharmacist also occasionally gave mothers and newborns immunization shots. The pharmacist’s shop was a private enterprise, so patients paid a fee for the medicines and services he provided.
In addition to the care provided by the VHS workers, Shahida, Chellama, Karpagam, and the pharmacist, women in the area could also get some government-provided prenatal and postpartum care at the local balwadis (day-care centers), which were run by the government’s Integrated Child Development Services (ICDS). ICDS had become a national program throughout India, but it was modeled on a scheme initiated in Tamil Nadu during M. G. Ramachandran’s term as chief minister in the 1980s. In Tamil Nadu, this program was often called by its original name, the Chief Minister’s Noon Meals Scheme. This program had helped to establish balwadis in low-income communities throughout the state. The balwadis served as free day-care centers for children ages two to five and provided them with free lunches that were supposed to include rice, dal, soya flour, vegetables, and occasionally eggs. In addition, at these balwadis, packets of dried nutritious food (in Tamil referred to as cattu u
In addition to the above-mentioned MCH services for women within Kaanathur-Reddikuppam itself, services were also provided by various hospitals outside of Kaanathur-Reddikuppam. The PHC which serviced Kaanathur-Reddikuppam was located in the town of Kelambakkam. Very few women from this area chose to go to the Kelambakkam PHC just for their deliveries. This was partly due to the distance. As the crow flies, Kelambakkam was quite close. But the route there from Kaanathur-Reddikuppam was indirect and arduous. People would first take a bus going south to Kovalam and then get an auto-rickshaw or van to take them on a long dirt road riddled with potholes through the paddy fields back up to Kelambakkam, which lay on the east side of the canal. The trip by this route took about forty-five minutes. Most felt that travel to Madras was much more convenient even though it took a bit longer. Furthermore, they felt that the quality of care in the larger “government hospitals” in Madras was superior to that of the PHC. The “government hospitals” had emergency care for such things as cesareans, whereas the PHC did not. Those who did go to Kelambakkam for their deliveries only did so if they were planning to undergo sterilization following their delivery. Because the PHC in Kelambakkam was the central