Birth on the Threshold. Cecilia Van Hollen

      INTRODUCTION

      Childbirth and Modernity in Tamil Nadu

       Modern Birth and the Transformation of Gender

      Whereas earlier anthropological approaches to reproduction tended to focus on how reproductive practices and beliefs reflected social and cultural systems,¹ scholars now argue that anthropology can benefit from viewing reproduction itself as a key site for understanding the ways in which people re-conceptualize and re-organize the world in which they live.² This book also takes this processual view of culture-in-the-making.

      What then is reconceptualized and reconfigured in the process of the modernization of birth for poor women in Tamil Nadu? This book does not make one, overarching point about the transformation of ideas and practices relating to childbirth in Tamil Nadu at the end of the millennium. It does not provide the reader with some neatly packaged before-and-after scenario of modernity as the grand makeover. Instead, like the intricate patterns of kōlams which adorn the thresholds of houses in Tamil Nadu, this book loops and swirls around several key points of reference, each of which is given equal valence. Each point in the kōlam maintains its independence, suspended in space in the interstices of the looping lines which pull the individual points together into one web of interlocking boomerangs flying in different directions. Unlike the elaborate kōlams drawn for the festivals of Pongal or Dipavali, with hundreds of individual points, mine is a very humble kōlam. I do not begin to touch on all the ways in which childbirth and reproduction are being transformed. I have tried to highlight those aspects of change which seemed to be of greatest concern to the women whom I met and which had the greatest impact on their decisions about where to go for prenatal, delivery, and postnatal care. Also, out of my interest in underlining unique aspects of modernized birth in Tamil Nadu, I have highlighted those transformations which are different from those noted in similar studies of the biomedicalization of birth in Europe and the United States.

      My kōlam twists around five primary processes of change, five aspects of the modernizing process which impact childbirth in Tamil Nadu: 1) the professionalization and institutionalization of obstetrics, 2) transformations in the relationship between consumption patterns and reproductive rituals, 3) the emergence of new technologies for managing the pain of birth, 4) the international mandate to reduce population in India, and, 5) development agencies’ agenda to spread biomedical conceptions of reproductive health for mothers and children. These processes, taken together, have transformed cultural constructions of reproduction and social relations of reproduction in myriad ways.

      In the process, constructions of gender are reconfigured. First, women’s reproductive bodies have become irrevocably linked to colonial and postcolonial state interests as well as to the interests of transnational development projects. This is particularly evident in the context of international fears of India’s “population explosion.” Women in India have thus come to be viewed as the bearers of bodies to be counted. The state of Tamil Nadu prides itself on being a “success” in the area of modern population control. For women in Tamil Nadu, being sterilized or having an IUD is a sign of being “modern.” But women have mixed feelings about this embodied modernity.

      Second, new forms of ritual and patterns of consumption and exchange, along with new drugs for pain, have radically altered the cultural construction of women’s power, or sakti, such that in some respects women are said to have more sakti than in the past, while in other respects they are said to have less. But to culturally ascribe women with more or less sakti can have unexpected effects on women’s social power.

      And, finally, new concepts of nutrition and disease are transforming understandings of the mother’s body, the baby’s body, and the relationship between the two. Some of these new concepts have the potential to save lives. But when this transformation is occurring in the context of a developmentalist discourse, which reinforces social differences by equating poverty and non-biomedical practices with “underdevelopment,” new concepts of the body are unevenly conveyed and may be resisted because of the condescending way in which they are imparted. Whereas non-biomedical understandings in Tamil Nadu tend to view the mother-child body as one, this entity is coming to be viewed as two distinct bodies, in the context of not only biomedical praxis but also policy, where the emphasis has shifted from maternal-child health care to a focus on the child as a separate entity. In Tamil Nadu, where female infanticide is reported to be on the rise in some poor communities, poor mothers in general are increasingly viewed as potential criminals, and non-biomedical practices are sometimes associated with this criminality. Clearly, then, new constructions of gender, and particularly of motherhood, are class-specific. That is, they are reconstructions of lower-class mothers.

      My kōlam then turns around a sixth point. I try to assess how the five processes of modernity mentioned above, in relation to other factors, influence the “choices” poor women and their families make about the kind of care to seek for childbirth-related needs. “Choice” here is in quotation marks simply to remind us that the decision-making process is never a matter of the free will of rational, value-maximizing individuals, but, rather, it is always enacted in political-economic contexts and shaped by socio-cultural factors such as gender, class, caste, and age. As Linda Garro points out, however, an awareness of the contextualized nature of “choice” does not negate the relevance of applying a decision-making perspective.³

      In her work on decisions regarding obstetrical care among the Bariba of Benin, Carolyn Sargent suggests that we anthropologists should differentiate between aspects of the decision-making process in which an individual “believes herself/himself to be engaged,” on the one hand, and the macro-social forces which may be more evident to an external analyst, on the other hand. Thus, she argues, women have a definite sense of making rational choices.⁴ In my own research in Tamil Nadu, I found women to be not only aware of but extremely articulate about what we might call the “macro” factors impinging on their reproductive decisions. In fact, I do not feel that it is useful to make a distinction between the “macro” and the “local” in discussions of decision making. As the reflexive turn in anthropology reminds us, even the “macro” of the analyst is always locally constructed.⁵

      Like most complex societies within which medical anthropologists work today, India contains a plurality of medical systems of knowledge and practice, including multiple forms of biomedicine; “indigenous” systems of medicine such as Ayurveda, Unani, and Siddha; homeopathy; and a wide variety of medical knowledge tied to religious practice and astrology.⁶ These all become part of the decision-making process for women during childbirth.

      In India biomedicine is most commonly referred to as “allopathy.” The other term most frequently used by informants is “English medicine.” In the medical anthropological literature terms such as “Western medicine,” “modern medicine,” and “cosmopolitan medicine” are often used interchangeably with “biomedicine.” In this book, when referring specifically to the Indian context I use the term “allopathy” or “allopathic medicine,” since my aim is to stay within the specific ethnographic field of my research and to underscore my point that biomedicine always takes on a unique form at the local level. When referring to the global context, I use the term “biomedicine.”

      There has been very little anthropological or sociological attention given to the use of allopathic services for childbirth in the context of India’s medical pluralism in the postcolonial period; although Kalpana Ram’s work on the management of birth among the Mukkuvar fishing community in southern Tamil Nadu is an important exception.⁷ Most of the studies dealing with these questions were carried out by colonial historians (as I discuss in Chapter