Abstract
Lok Swaasthya Paramparaas (Local Health Traditions) are widespread but by and large they have gone almost "unnoticed" by Planners of Health with few exceptions. In this respect the area of Mother and Child Health (MCH) is rather unique inasmuch as not only do we have the largest body of expert practitioners of Local Health Traditions in this area, - namely dais, but also this is the only area where the government has (however grudgingly) "taken note" of their existence.
A review of the existing literature on Dais, Dai Training and Studies and Surveys on Local Health Traditions in the area of MCH shows that-
1. All the studies and "evaluation" are performed solely from the view point of the modem Western System of Medicine.
2. Dai Training has not taken note of any of the strengths of the tradition or paid attention to encouraging them. It does however appear to have provided valuable inputs in terms of delivery under aseptic conditions and improved referral services.
3. Local communities and dais tend to be treated as a "clean slate" where no knowledge exists. In general the community knowledge is viewed with great suspicion and often pronounced as "Obscurantist/Superstitious" etc in great haste. Even the studies that have been made specifically to observe community practices are often in the nature of an exercise in "anthropology", namely, they appear to hold the view that "unless we comprehend these practices we cannot change them, control them or replace them with "our" package".
It is clear that the communities themselves and the dais will have to play a crucial role in MCH services. There is a widespread feeling that "Dai Training" has not met the expectations on many counts numbers quality of training etc. and a lot of reviews have been made of these failures. The following steps appear to be quite essential in our context if we are to make optimum use of dais and lok Swaasthya Paramparaas in our MCH programmes:
1. Practitioner of ISMs as well as Local Health Traditions need to be actively involved in' -
- "Evaluating" Local Health Traditions
- "Evaluating" the function of dais
- Developing material for dai Training
- The dai training programme and
- Design of future studies and surveys in this area.
2. There is a need to take stock of studies and trials on MCH that have been done by the researchers in ISMs and also have a clearer picture of the relation between ISMs and Local Health Traditions.
3. Practitioners of Modern Medicine and planners of Health Policy need to show a greater willingness to enter into a dialogue with practitioners of Lok Swaasthya Paramparaas and ISMs in a spirit of openness and mutual respect - this is essential if we are to evolve health policies that can build on the inherent strengths of these traditions.
List of Abbreviations
ANC -Ante-Natal Care
ANM -Auxiliary Nursing Midwife
ISM -Indigenous Systems of Medicine
LHV- Lady Health Visitor
LSPSS- Lok Swasthya Farampara Samvardhan Samithi
MCH MO -Mother and Child Health Medical Officer
NIHFW - National Institute of Health and Family Welfare
NIPCCD - National Institute 'of Public Co-operation and Child Development
PHC - Primary Health Center
PNC - Post-Natal Care
TBA - Traditional Birth Attendant
WHO - World Health Organisation
I -INTRODUCTION
In India as well as in most other non-Western Societies today, there exist two distinctly different systems of medicine - namely, the Traditional system, and the Modern Western System of Medicine introduced during the period of colonial rule. A uniform feature of all these societies is that the Western System serves less than 15% of the population, though it often takes up a lion's share of the health budget. In India, even today (as it was around the turn of the century and earlier) only a small minority of our population is served by Western Medicine. In the last ten years, there has been a lot of talk about "paying attention" to traditional systems of health care. In 1976, the World Health Assembly took note of the role that Traditional Medicine can play in the extension of health services, particularly to the remote rural areas. In 1977 the World Health Assembly passed a resolution (WHO 30.49) urging interested governments to give "adequate importance to the utilization of their traditional systems of medicine with appropriate regulations".
However, it is interesting that traditional systems of medicine exist in India not only in the form of the organized sector - that is Vaidyas, Hakims etc. who are trained in the colleges of Ayurveda, Unani and Siddha systems of medicine but also in the form of the widespread Lok Swaasthya Paramparaas - that is local health traditions. There is a great range, variety and multiplicity of these traditions. These may cover an entire spectrum of practitioners the housewife or grandmother who is at handling home remedies, the Dai or the traditional birth attendant, the folk or tribal local health practitioners (known by various names in different parts of India - Vaidu in Maharashtra, Vaidhyan in Tamil Nadu, Dhami in Sikkim etc.), some families which specialize in treating single diseases as well as certain practitioners who are adept in highly specialised areas such as bone setting, Visha Chikitsa (treatment of poison), etc. Besides such practices which come under the category of "treatment", there are also a variety of practices which are part and parcel of our daily existence which help in maintaining good health. These may include knowledge of properties of various foods - what to eat and what to avoid in some seasons and in some disease conditions etc., cultural practices such as periodic fasting, sports, games and exercises including the practice of Yoga for maintaining normal health, adopting of food and life style according to a seasonal regimen (rutacharya) - to name a few.
In diverse areas of Health there exist a vast amount of knowledge and practices which represent the wisdom of thousands of years of observation and experience. While in any given area (such as medicine) there may be a body of experts or learned professionals, knowledge also prevails in other forms more diffuse or scattered among the rest of the people. In Indian tradition, it seems to be a general principle running through all, types of learning that knowledge can and does prevail in various forms and also gets communicated in many ways, each, serving its own purpose.
This can perhaps be best illustrated in the case of medicine where classical medical texts themselves deal with this issue. A classical text such as Charaka Samhitha expounds general principles of drug action based on the six factors - Dravya, Guna, Rasa, Veerya, Vipaka and Prabhdava. It also discusses remedies for several diseases and lists specific drugs. These may get modified to suit local conditions. In any recipe for a drug, one can substitute a non-principal component (Aparadhaana Dravya) with an equivalent, which may be listed in the sastras or selected on the basis of the principle of Rasa, Veerya etc.
In tune with such an understanding, from time to time vaidyas produce texts and manuals which set out prescriptions for drugs in any given area based on what is available and suitable to the requirements of that area. For example the text Rajamriganka lists 129 recipes and in his foreword the editor Ayurvedacharya Nataraja Sastri states that it is a compilation that must have been made by a vaidya belonging to Tamil Nadu it contains recipes based on herbs readily available in Tamil Nadu. Such recipes are not only easier to formulate since the raw material is readily available but they are also most suited to the area, in accordance with Charaka's dictum "For a person who belongs to a particular country or a region, Aushad his from the same region are most wholesome".
The fact that it is the particularity of the context that is the overriding consideration and the shaastric principles are to be considered as precepts and guidelines and not applied in a mechanical or legalistic manner is driven home in many of our classical texts. As an instance we quote the following shloka
"A vaidya who com-" prehends the principles of Rasa etc. would discard treatment if not wholesome to the patient in a given situation; even if it is prescribed in the texts on the contrary he would adopt treatments that are helpful to the patient, even if they do not find a mention in the texts".
Thus the general picture that emerges seems to be that the "classical texts" in any area of learning may set out broad general principles as well as their application in a given context, say a particular region of the country. But in various different contexts or regions, knowledge does prevail and gets expressed based on the given situation, and the generalities get adapted, modified or even overridden sometimes based on the specificity.
"Folk" and "Classical"
What do our shaastras themselves say about the relation between ISMs and LSPs?
The Charaka- Samhitha states (Sutra sthaana, Chapter I, Shloka 120-121) that - Oushadihi naama roopaabhyaam, jananthe hyajapaa vane, avipaashchaiva gopaashcha ye cha anye vanavaasinaha - "the goat herds, shepherds, cowherds and other forest dwellers know the drugs by name and form...". Similarly Susrutha states (Sutra sthaana, Chapter 36, Shloka 10) that - "Gopaalaasihaapasaa vyaadhaa ye chaanye vana charinaha, moola jaathihi cha tebhyo Bheshaja vyakthi Ishyathe -" one can know about the drugs from the cowherds, thapasvis, hunters, those who live in the forest and those who live by eating roots and tubers".
As we had indicated earlier, in Indian tradition, the fact that knowledge can and does prevail and gets communicated in various forms, each serving its own purpose is widely seen and accepted. This can be illustrated not only in Science or Technology but in various areas. For example, songs and literary works are classified in five groups based on how they are formulated and how easy they are to comprehend, namely as, Narikelapaakam, Ikshupaakam, Kadaleepaakam, Drakshaapaakam and Ksheerapaakam. The form most difficult to comprehend is the Narikelapaakam - it is like a coconut; to be eaten, the shell must be broken, the fruit grated and-, then mixed with food. Next is Ikshupaakam, the sugarcane form, which has to be crushed to extract the juice. Next is the Kadalipaakam, the banana form which has to be just peeled to be eaten. Easier still is the Drakshapaakam - grape form which can be eaten without any processing, and the easiest of all is the Ksheerapaakam or the milk form which can not only be easily consumed, but also is a wholesome food for all ages and people in all conditions. In a similar vein in Sanskrit the literary composi-tions are classified into three groups: Prabhu Samhitha, Suhrut Samhitha and Kantha Samhitha. Prabhu Samhitha instructs like a Prabhu or Master who punishes when rules are transgressed (eg. instructions such as in the Vedas), Suhruta Samhitha instructs like a friend who advises on what to do and what not to do (eg. like the Puranas), and Kantha Samhitha which instructs like a Kantha or one's beloved who advises and cites examples, coaxes or pleads or persuades as the situation may require to achieve the same end, namely 'upadesa' (eg. as in Kavyam).
It is noteworthy that these different formulations or forms of communication are not understood as being part of a hierarchical system where one can replace or supersede another or is considered the generally superior form. Each one serves a specific need and may be the most appropriate for a particular context or for a given purpose.
Mother and Child Health
One important area wherein there is a widespread traditional knowledge in the community is the area of Mother and Child Health. This area is rather unique in the-sense that this is perhaps the area where the largest specialized body of traditional health practitioners exist, namely. Dais. This is also special inasmuch as this is the only area where the Government has (however grudgingly) taken note of the existence of local health practitioners, namely, Dais. Dai training is now an essential part of the maternal and child health programme of not only in India but over 50 other countries.
LSPSS had decided to hold a National Convention on the theme of Traditional Practices in the area of Mother and Child Health. It was felt that there is a need to obtain detailed information on various prevailing traditional practices relating to Mother and Child Health. It "was decided that the survey would be in the nature of an in-depth interview for which purpose a questionnaire in three parts was prepared, the 'questions pertaining to -
1. Ante-natal care
2. Practices of the Dai and
3. Post-natal care of the mother and child.
The survey was conducted by 26 different organizations spread over 12 different states of the country. In each location 100 women were interviewed - 25 responses were obtained from pregnant woman for part one of the questionnaire, 25 responses were obtained from dais for part 2 of the questionnaire and 50 responses were ''obtained for part 3 of the questionnaire; 25 from mothers who had a child less than one year of age and 25 from women who had experienced many pregnancies. Thus a total of 2,600 responses were obtained from across the country.
The tabulated results of each survey were made available to a group of Ayurvedic Acharyas for evaluation of the results from the view point of Ayurvedic theory and practice. Each Acharya commented upon the various practices observed as below :-
a. Sound and complete
b. Sound but incomplete
c. Harmful or
d. No basis for comment/needs further study
Later a workshop was held in February 1989, where the representative of field groups who had conducted the surveys and the Acharys who had evaluated the survey got together for a detailed discussion. Some of the conclusions were revised on the basis of this workshop and the survey results were tabulated in fresh formats. At present a consolidated All India report of these findings has been prepared.
There are a number of studies and surveys which are already available at present which have gathered data regarding local health traditions in the area of Mother and Child Health. Most of these studies have been done by practitioners of modern systems of medicine - trained fields like Nutrition, Obstetrics, Gynecology, Paediatrics, community health etc. Almost all these studies suffer from the limitation that the "Evaluation" of the local health traditions is done invariably only, from the point of view of the modern systems of medicine. Studies that have evaluated the practices from the perspective of indigenous systems of medicine are quite rare. One such example is the study of traditional child rearing practices of Nepal (Prad-han, H.B., 1981). Our purpose in this review is to make a review of these studies and the type of data gathered by them. There is a need to examine the data gathered also from the point of view of the Indigenous Systems of Medicine (ISM) - namely Ayurveda,- Siddha and Unani systems.
For the purpose of this review we have taken up a survey of the material available regarding Dais and their training and we have looked at some of the data available regarding traditional practices in the area of Mother and Child Health. We have tried to illustrate the need for an input from ISMs by pointing out the basic principles of some of these practices which have their roots in ISMs.
II. ON DAIS AND THEIR TRAINING
How many Dais?
It is estimated that there are over 600,000 dais in India who attend to a majority of child births and use traditional orthodox methods but in certain parts of South India deliveries are more often performed by family members or neighbors’. According to official sources "Even today dais continues to deliver 50-60% of births in rural India. Only lQ-15%1 deliveries are accountable to PHCs and SCs". (NIHFW,1983).
Though the official figures of the percentage of deliveries attended to by TBAs is usually placed in the area of 50-60%, a number of studies seem to indicate that in reality the TBAs may be attending to a much larger number of deliveries. Figures as high as 90% has been observed in the Udaipur area of Rajasthan (Mathur, H N et. al. 1979). Similarly a detailed study of TBAs in 23 villages that was made in Punjab in 1971, has the author observing that "nearly 100% of the deliveries are conducted by them" (Kakar, D.N. 1972).
Attitudes to Dais
Though there is often a (grudging) admission of the importance of the dai, the attitude towards them remains1 by and large one which may range anywhere from contempt to amused tolerance. Various official documents tend to underplay her technical skills or prowess. A recent report charaterises them thus - "Our Indian villages abound in such dais. These traditional dais are usually elderly ladies whose work reflects the customs and beliefs of the community. The rural mass by tradition being ignorant of modern health protection measures still relies more on the dai who generally attends the delivery because of cultural consideration, social proximity, easy availability, readiness to provide services and even personal help on human consideration or on such payments which a family would easily afford" (NIHFW, 1983).
Sometimes the dais' function is ridiculed as in the following account - "In India sometimes a child birth closely resembles a criminal scene. The mother is forced to assume awkward postures and all kinds of dramatic motions are performed on her abdomen. Ventilation in .the place of delivery is strictly prohibited lest God of Death should enter the room. The room is made smoky to avoid evil spirits. When the labor begins the vaginal canal is lubricated with clarified butter or the common mustard oil. This is repeated with manual stretching of the birth canal. Usually warm milk with butter is given to mother" (NIHFW, 1983).
Yet another attitude which is very common is to. view the dai as being of some consequence lonely for their potential to impart "messages" that can be passed on from the modern medical sector, be it that of modern nutrition or Family Planning. The most prominent such "message" that a Dai is expected to impart is in the area of Family Planning (See for example, Kakar, D.N., 1972). Various other attempts have been made. For example in Saharanpur District of Uttar Pradesh Dais were used to impart Nutrition Education (Sharma, Urmil, 1987). Similarly they have been used to record birth weight range (Kumar, Vijay, 1986). From this view point it follows that the dais' own knowledge is important not as an entity in itself but only in terms of how it will, relate to new knowledge of which she will be the carrier. Thus it is said that "Those who want to train, and encourage TBAs to. participate in modem MCH and family planning programmes need to know what these midwifes are doing in their own communities in order to determine whether new responsibilities would be appropriate or feasible (emphasis ours). Programmes that are designed without taking sufficient account of prevailing customs may not succeed, as was the case in India and Pakistan in 1960s" (N1FW, 1983).
A Necessary Evil?
Right since the inception of the official "notice" of dais, the attitude has been that they are only a stop-gap arrangement to be used till the modern system of medicine can reach all people. The Bhore committee (Bhore, J 1946) as well as the Mudaliar committee (Mudaliar,A L, 1961) had both recommended "the training of all TBAs as an "interim measure" to improve the mid-wifery services in India". Similar is the outlook of WHO, which seems to view them at best as "necessary evil". For example the Report of a recent WHO Consultation on TBAs states that -"Traditional Health Practitioners including Traditional Birth Attendants have looked after the health of their communities for generations and will undoubtedly continue to do so for many years to come, given the scarcity of modern health care personnel .... (emphasis-ours) (WHO, 1985). In fact it appears that the public health authorities were forced to come to terms with TBAs inspire of their efforts to ignore/eliminate them. For example the WHO Expert Committee Report on TBAs says that there is a need to - "....increase the skills of traditional birth attendants in view of their influence on the family on the one hand, and of the repeated failure of legislation to prevent them from practicing on the other hand ( emphasis ours ) even in many advanced countries of the World !" (WHO,1966)
Thus a lot of statements are made very loosely in a patronizing tone with very little detailed examination. A typical example is as follows - " Many of their practices are harmless and provide psychological and emotional support to the mother and the family. However, there are certain practices which are harmful to the mother and child and need to be eradicated. They generally do a good job in case of normal delivery but are not able to do anything when complication arises" (NIHFW, 1983).
Dai Training
During the pre-independence era dai training programmes were organized as an integral part of maternity and child welfare by the Chelmsford League, Countess of Dufferin Fund and later on by the Indian Red Cross Society. During the early post independence period the MCH programme was under the control of the State Government and subsequently dai training programme came under their purview. The Government of India initiated a scheme of training of dais during the Second Five Year Plan under MCH programme as a centrally sponsored scheme. UNICEF assisted project of training of dais began in 1957, to train them expeditiously so that- "they could conduct deliveries effectively at home and also get involved in family planning motivational work" (NIHFW, 1983). In the experiments carried out in Narangwal, dais were encouraged to conduct normal deliveries, but were advised to refer women for antenatal (ANC) and post-natal (PNC) care to specially trained family health' workers. They were paid Rs.l/- for reporting each ANC or PNC mother to the clinic. They were also advised to seek the help of trained workers in case of complicated or prolonged labour. However, these programmes of training dais have had limited success due to a variety of reasons.
During the Second Five year Plan the Government of India started Dai Training. The training was initially spread over a period of six months which included both class room as well as supervised practical field training. The training was to be conducted in PHCs or SCs in rural areas and in MCH centers in urban areas. The key person for planning and conducting the training programme was ANM under the supervision of the Lady Health Visitor (LHV) of the PHCs in rural areas and the LHV/ANMs under supervision of Medical Officer (MO) in charge of MCH Centre in the urban areas. A nominal amount of Rs.3/- per session was also allowed as stipend to the trainee dais. Despite the central support many States did not give high priority to the programme and implementation of the Scheme differed widely. As" a result against a target of 35,000 dais, only 15,000 (42.9%) could be trained during this period (i.e. during 1957-1962).
The scheme was continued during the successive Five Year Plans and during the, Fourth Plan period it was transferred to the Family Planning Department. By and large the scheme of dais training showed a slow progress till the end of the 4th plan with only 40-42% achievement of the set target.
Dai and Family Planning
In 1967 the Central Govt, tried to stimulate it through a programme assisted by USAID. Accordingly training was conducted at the PHCs with a stipend, provision of special midwifery kit, monthly retainer and later replenishment of kit supplies. The training had further added focus on motivation for family planning. India’ was probably the first country to utilize TBAs in a national family planning programme in early 1960s. In 1971 to boost the scheme, the Government of India considered to train about 75,000 dais. Since then many local health institutions and PHCs in some States continued to train the dais to improve the care of deliveries and to spur the acceptance of family planning but the scheme did not catch up. According to an official report (NIHFW, 1983), some of the possible reasons for this shortfall were diagnosed as -
(i) The prolonged duration of training of six months and lack of motivation among the health functionaries to guide them.
(ii) Delay in distribution of maternity kit and stipend money.
(iii) Lack of community education regarding the value of trained dais in maternity care
(iv) Considering dai with a kit as a government health functionary and refusing to pay for her services.
The Government of India appointed a sub-committee in 1973 to examine the functioning of the dai training scheme. After reviewing the dai training scheme, it recommended creation of such facilities which motivate dais to undergo training and cater for improvement in their knowledge and skills related to -
(a) Human reproductive system and care of mother during antenatal, natal and post-natal period;
(b) Aseptic practices and
(c) Contraception education
As a consequence to the above during 5th plan period, the initially fixed targets were raised in 1977 to train 90,000 dais and major changes were incorporated in the training strategy. The duration was reduced from six months to one month during which dais were to attend at the PHC/SC twice a week for instructions and demonstrations and the rest of the four days of the week in the field under active supervision of the ANMs/LHVs of the area. The stipend was also revised to Rsl300/- per month instead of Rs.3/- per day. Further at the end of training each trained dai was provided with a maternity kit free of charge. In addition she was entitled to a payment of Rs.2/- for registration of each antenatal case at PHC/SC prior to delivery and if it was after delivery her entitlement was Rs.l/- per case.
Its emphasis from April 1978, when UNFPA provided financial assistance to the scheme has been to promote acceptability of small family norm, reduction in the rate of infant mortality and to improve community participation in rural health services delivery. At present, the tasks expected of the dais are to -
(a) Get registered every pregnant women contacted by her at the SC or PHC.
(b) Provide antenatal, natal and post natal care to mothers
(c) Educate mothers to attend nearby SC/PHC for regular check up, taking tetanus toxoid immunization and nutrition education.
(d) Ensure aseptic arrangements for home confinement.
(e) Refer pregnant mothers to PHC/SC in case of complications or case being beyond her competence.
(f) Educate and motivate mothers to adopt small family norm and advise them about the availability of family planning services in the SC and PHC.
(g) Educate mothers about breast feeding, weaning, immunization and spacing between pregnancies.1
(h) Report vital events related to mother and child to the concerned health centre
(i) Educate all pregnant women to take Iron and Folic acid tablets as prescribed
(j) Inform mothers about the availability of MTP services at PHC.
(k) Coordinate her work with activities of ANMs at SC for early registration, regular investigations, check up of mothers and children, postnatal visits, family planning services and motivation.
(1) Seek for the replenishment of dai kit.
III. LOCAL HEALTH TRADITIONS OF MOTHER AND CHILD HEALTH
Aside from the role played by Dais, the two other important areas wherein observations are available are the areas of ante-natal care and post-natal care. In the following section we have summarized some of the important observations in these two areas and have tried to illustrate the need for the use of ISMs to comprehend these practices.
ANTE-NATAL CARE
General
In general it appears that the extent of ante-natal care provided by dais is very low in most communities. The extent of antenatal care varies from almost nothing in much of India, Pakistan and Bangladesh to close and continued personal contact in parts of South East Asia and Latin America. A detailed study regarding antenatal care provided by Dais in Pondicherry ( Ghosh ,B N, 1968) shows that there is virtually no ante-natal care. One reason for this situation could be that this is provided informally at home and does not call for much interaction with the dais. It is likely that women did not feel the need to approach a dai during the antenatal period unless there were complications. In a study on the scope and nature of maternity health services rendered by dais in Meerut District of Uttar Pradesh the authors reported that - "Help of dai during the ante-natal period was sought by an insignificant number of wives and that too for suspected mal-position and correction by her" (Gandhi, H.S. et. al. 1980). In areas where ante-natal care is given by the dai, massage is prominent. It has been reported in general that dais perform massage during this period (See for example Barns, T. 1980)
However, several practices observed as part of ante-natal care have been recorded. It has been observed in Bangladesh (Bhatia, S, 1981) that sexual intercourse is discouraged in the last few months of pregnancy in the belief that it may harm the fetus. Sometimes it is reported that sexual intercourse in late pregnancy is prohibited as "it would amount to incest since the body of the child is already formed" (Kakar,D N, 1972). The Bangladesh study (Bhatia,S, 1981) also says that the woman works throughout pregnancy and hard physical work is avoided only during the later stages.
Food
This is an area where the local communities abound in various do's and don’ts which often appear to be not comprehensible to the modern investigator. Among the general advice given to the pregnant woman on food, prominent seems to be the advice that food should be eaten only moderately so as to avoid a large fetus and difficult delivery. This has been observed in Bangladesh (Bhatia, S, 1981) as well as during our survey (LSPSS, 1988). Besides such general advice, there is also an elaborate classification of foods based on criteria such as hot or cold, according to taste and other properties. A detailed report on classification of such foods in South India has been made (Katona,Apte,J 1977) and such observations have also been made based on a field study in Naokhali in Bangladesh (Rea, M A, 1981).
A detailed study in Andhra Pradesh of 144 Dais and 640 rural women has recorded a number of do's and don’ts in the matter of food during pregnancy (Krishna, T.P. et. al, 1984). I Among the foods to be avoided were pumpkin, banana, brinjal, gongura, guava and papaya. In general foods considered 'hot' were avoided during pregnancy. Yet another study in Andhra Pradesh lists that eggs, jiggery (and papaya which are considered to be hot foods are forbidden for fear of abortion (Rau, Parvathi K, 1968). The same study also states that citrus fruits, butter Ayurvedic milk and curds are forbidden for fear of cold.
Ayurvedic approach to the care of pregnant women
Ayurveda provides a comprehensive theoretical frame work and various practical suggestions regarding the care of the pregnant woman. In connection with some specific practices reported in the above surveys the following observations made by Ayurvedic Acharyas are very pertinent (LSPSS, 1989). The importance of Massage during pregnancy has been stressed in Ayurveda. It is said that among the activities that can help in a health normal delivery are - "Massaging the body with Kaphahara drugs in the upward direction". Sexual intercourse during pregnancy is also prohibited as is any activity that involves sudden pressure on the abdomen.
As regards food, generally Ayurveda advises the intake of foods having Mad-hurarasa and taking more fluids. Dry, hot, spicy, heavy food items are to be avoided. Many foods that are avoided by the local community are indeed soundly justified on Ayurvedic terms. For example, raw Papaya which is avoided by many communities is considered Ushna and Tikshna and can cause abortion. The craving for certain foods and the fluctuating likes and dislikes are very well understood by Ayurveda and specific help is suggested. For example, if a woman has a strong craving for charcoal or ash it is recommended that she can be given the charred ash of Triphala which can do her good and if she has a craving- for clay/mud/brick she can be given Gairika (Red Ochre) fried in ghee. The understanding regarding strong likes and dislikes and conflicting feelings about some foods is that a pregnant woman possesses two hearts (one of her own and another of the fetus) - in fact she is called as Douhridini-which literally means -"she who has two hearts". Hence it is said that she may have conflicting or fluctuating feelings as per the dictates of her desires as well as that of the foetous.
Certain other food items mentioned are controversial. For example, while some prefer the use of eggs other hold that it can be given if the digestive power of the pregnant woman is good as per the dictum "Garbham Amagarbhend" which means that the foetus can be nourished by other substances having the same quality.
Ideas… among 'these' people
Inability to appreciate the nutritional concepts which are outside the frame work of modern nutrition is particularly striking in some areas such as the understanding of forbidden food combinations. Referring to these beliefs a researcher in Andhra Pradesh observes that "The idea that some combinations are harmful while others are wholesome also exists among these people. Perhaps inadequate methods of preservation and psychological factors are responsible for such beliefs, we do not know. A few examples of the combinations believed to be harmful are cooking together fish and milk or eggs and green leafy vegetables. Some of the more beneficial ones are said to be that of drinking milk after eating mangoes, to remove its "heat" and eating jiggery after eating peanuts to remove "pittham" or biliousness. Such beliefs are found all over India and are so strongly entrenched in the minds of these communities so that it would appear impossible to change them in any dietary programme geared to improve them" (Rau, Parvathi, K. 1968).
The fact is that this has a very sound basis in Ayurvedic theory. According to Ayurvedic Vaidyas certain combinations of food stuffs are known to produce harmful effects - a phenomenon that is termed as "Viruddhahaara". In fact, more than a dozen types of Viruddhas, i.e. incompatibility, have been listed. Unfortunately, the education in Nutrition received by most of our researchers does not touch upon Ayurvedic knowledge systems. The result is that even the most sympathetic scientist tends to view these customs as quaint beliefs ".... among these people..." much like an anthropologist investigating peculiarities of people in a distant land or culture.
Delivery
It has been often suggested "Labour takes place in a darkened room where lights and shiny objects are taken away because of the belief that Tetanus is caused by reflected light" (Barns, T. 1980). However, we find that the dai has sound reasons to back her practice of having a room with very limited lighting. In a conversa-tion with Dais in Thirupporur (PPST, 1988), it was observed by them that since the new born infant has not been exposed to any light it would be injurious and something in the nature of a shock to the baby to be exposed to very bright light. Hence it was felt that moderate lighting which would enable the dai and a helper to work conveniently was quite adequate. Many dais also specifically think that they found the modern practice of having bright lights in the delivery room (or operation theater) quite objectionable since it may adversely affect the baby.
Delivery Position
Several variations in delivery positions have been observed. It is generally observed that during delivery the woman is in a reclining position or semi reclining position. However, several variations including the squatting position have also been observed There has been a fresh spurt of interest in recent years to try and examine the logic of various delivery positions. A study of various delivery positions (so called 'primitive' delivery positions) has tried to understand their utility for various specific needs (Russel, ) G B, 1982). Randomized trials have also been undertaken to study the effect' of ambulation (Stewart, P, Calder., A.A,, 2984) but they have not been conclusive.' A similar study on the use of the birth chair to compare the effect of the sitting or squatting position1 for delivery with the normal position does not show any change in the length of labour or the incidence of the operative delivery (Stewart, P. et. al., 1983). Many communities have retained the great skills possessed by experienced midwifes to handle abnormal deliveries (LSPSS, 1989). It has been observed, for example, in Bangladesh (Bhatia, S., 1981) that a mid-wife would turn the child if the head is not pressing (in the normal position).
Induction of Labour
Several methods are in vogue to induce labour. The study of Dais in Pondicherry (Ghosh, B N,|l968) shows that prolonged labour is treated by either administering milk boiled with garlic to the j women or by inducing her to vomit. Just as there are methods for inducing labour several methods are also observed for treating delay in the delivery of placenta. Among the methods reported are: inducing the woman to vomit, reported in Bangladesh (Bhatia, S 1981), or giving certain hot foods such as raisins, ginger and sugar in Tea (Gideon, 1962).
POST NATAL CARE
A cross cultural study of over 200 societies indicates that "most societies limited maternal work load in the post partum period and few societies stopped the normal duties for prolonged periods of time. In about half the societies, women were expected to return to normal activity within two weeks after the child birth". (Jimenez, M H, and Newton. N, 1979).
Colostrum
It appears that by and large in traditional societies the milk produced by the mother during the first one to three days (that is, the colostrums) is not fed to the baby. This has been reported widely. In Bangladesh it is said that breast milk is discarded for the two to three days post partum as it is "widely thought to be poisonous" (Barns T, 1979). A different study in Bangladesh where a group of health workers described, child bearing practices which they observed during their work concludes that, breast feeding starts four days after birth until which time the infant is fed on honey mixed with water (Bhatia, S 1981). The Pondicherry study shows that breast feeding starts on the first, third or fifth day post partum and before being breast-fed, the infants are fed with sugary water (Ghosh, B.N., 1968). A study of 100 mothers and their new born from 12 villages in the Chevalla Taluk in Andhra Pradesh observed that colostrum is discarded and over half the mothers believe that it causes indigestion. Before breast feeding, the baby is fed with honey or water (Karan S. et.al. 1983). A more detailed study from Bangladesh wherein over 100 villages were surveyed observed that colostrum was discarded by 71% of the mothers (Khan, A.R. et. al 1981). A similar observation regarding the practices in Naokhali in Bangladesh has also been made (Ria, M.A, 1981).
A cross-cultural study covering 53 societies observing the cultural characteristics of breast feeding notes that - "initiation of breast feeding is sometimes delayed by two to three days in which case colostrum is thought to be harmful. Substitutes are then given, such as sweetened water using a variety of products for example sugar and honey" (Miehoff A and Meister, N 1972). However, there are also some exceptions to this trend which have been observed in India. In a study of 170 mothers in a tribal community in Orissa it has been observed - "Breast feeding starts within 12 hours after delivery in 83% of the cases and feeding of colostrum is accepted by all women" (Mohapatra, S S, and Baag, R K, 1982).
However, it seems clear that the predominant practice is still the practice of the avoidance of colostrum for the first one to three days. This is amply borne out by a comprehensive study of infant feeding practices that was carried out recently. This study on Infant-feeding Practices was carried out by the Nutrition Foundation of India in the State of Maharashtra, West Bengal and Tamil Nadu with the collaboration and active participation of the heads and staff of three institutions in the country – the Tata Institute of Social Sciences, Bombay; the Child-in-Need Institute, Calcutta and the M.A.C. Institute of Community Health, Madras.
At the Bombay Centre, it was observed that breast-feeding was initiated only after 48 hours after' birth in an over-whelming majority (79%) of infants. Seventeen percent infants received their first breast-feed between 24 to 48 hours after birth, and only 3% within the first 24 hours. On the other hand, at the Calcutta Centre, it was seen that as many as 48% of infants were put to breast within 24 hours after birth, another 18% between 24 to 48% hours and only the remaining one-third of infants had to wait till the third day to start obtaining breast-feed. The Madras Centre seemed to occupy an intermediate position. Twenty four percent of infants received their first breast-feed within 24 hours after birth, 16% between 24 to 48 hours and the remaining one-third had to wait for longer than 48 hours. There were differences between Study Groups within each Centre. Notwithstanding these differences, in all Study Groups an overwhelming majority of infants were put to breast for the first time, only after 48 hours after birth (emphasis ours). In all Centers, the percentage of children receiving their first breast-feed more than 48 hours after birth, was higher in the rural areas than in the cities. Similarly the current annual report -of the Director General of ICMR states that - " A study was carried out in six States on the knowledge and breast feeding practices in tribal areas. 44.5% reported not feeding colostrum to the babies. Mothers who did not feed colostrum to their babies Were of the view that it was "impure" milk and not good for the babies' stomach" (p.56 of ICMR, 1988)
As for the use of colostrum there has recently been a discussion and debate within the Ayurvedic community. In general the Ayurvedic view supports the prevalent practices in the community of not feeding colostrum to the new born child. It is felt that the colostrum cannot jbe assimilated by the system of the new born child and that it does not meet the requirements laid down while testing quality of mother's milk for this suitability to the baby. A detailed discussion on the various aspects of cotustrum from the) view point of Ayurveda is given in a special issue on Peeyush (Colostrum) published recently (Nanal, Ramesh, 1989).
Massage to the Mother and Baby
Post-Parum Massage to the mother has been widely reported in various communities. In general ghee or oil abdominal massage is given to the mother (Barns, T, 1980). A j detailed study of about 300 dais in 132 villages of Mahabubnagar Taluk observed that almost all of them gave post partum massage to the mother in order to relieve muscle pain and to restore the shape of the abdomen (Jesudason, V, 1977). A similar study of 52 dais in Haryana states that every day - "Her (i.e.the mother's)" abdomen is massaged with ghee or oil" (Lai S, Adarsh, 1980). A detailed examination of various aspects of maternity in Central India has also shown that the mother and infant are massaged with oil and turmeric (Thomson, C.S, 1983). Similarly, it is widely reported that the baby is massaged daily or even twice a day (Bhatia, S, 1981 Mohapatra, S.S. and Baag,R.K., 1982 Pradan H.B., 1981 Thompson, C.S., 1983 etc.)
Food
In some cases there has been a detailed record of what is given to the mother after child birth. For example the following is given in Pondicherry area, on the day of birth (Ghosh, B N, et. al., 1968)
(i) 3 balls made to the size of lemon with the mixture of asafoetida and palm jaggery
(ii) 3 balls made to the size of lemon made of turmeric with jaggery.
(iii) 3 balls made to the size of lemon, made of black-jeera, roasted and powdered with palm jaggery.
A detailed study in Andhra Pradesh lists the following foods to be avoided during lactation - ,brinjal, pumpkin and gongura. In general 'cold' foods are avoided (Krishna, T.P, et. al. 1984). The authors are however charitable enough to conclude that - "They (Dais and mothers) have their traditional beliefs that determine their food behavior during pregnancy and lactation, some of which may be rational and some not so rational". Post partum massage to the mother and baby is widely supported by Ayurveda. As for the food restrictions observed during the period of lactation many of the practices reported in surveys - such as the survey in Andhra Pradesh are found to be quite sound from the Ayurvedic view point. Practices such as the administration of medicinal mixtures with components such as black jeera, turmeric, asafetida etc., as reported in Pondicherry, are held to be quite sound from the Ayurvedic view point.
LSPSS Survey
The survey taken up by LSPSS shows that there is widespread knowledge in the community regarding many areas of Mother and Child Health. Some of the areas where the community was observed to have traditional practices which are shown to be sound from the Ayurvedic perspective are; diagnosis of pregnancy, the care of the pregnant woman, attending to her special desires, management of common ailments during pregnancy, regulation of her food and behavior, management of normal deliveries, practices of breast feeding, handling of post partum bleeding or fainting, care J of the new born baby - massage, treatment for common ailments, teething disorders etc. More details can be obtained from the Report on the Survey with the Evaluation of Ayurvedic Acharyas which is now available (LSPSS, 1989).
IV. DISCUSSION AND CONCLUSION
The need for the involvement of Dais continues to be felt and emphasized increasingly. A recent ICMR evaluation admits quite candidly that "for a long time to come, intranasal care will have to be provided on a non-institutional basis" (ICMR, 1989)., The general world trend is in a similar direction and an increasing number of countries are taking to the training of TBAs. In a worldwide survey conducted by the World1-Health Organization, 24 out of 64 countries surveyed were reported to have training programmes for TBA in 1972 (Verderse, M and Turnbull, C M, 1975). Ten years later 52 countries have training programmes for TBAs (WHO, 1982). The Government of India's prospective plan for the development of Health Manpower seeks to "...ensure one TBA for every 1,000 population" (India, 1981)
Achievements of the Dai Training Programme
According to a recent report of the ICMR (ICMR, 1989) the current maternal mortality rate is 4-7 per 1000 live births, the infant mortality rate is 90 per 1000 live births and the incidence of low birth weight infants is 35-45 per cent.
Is dai training having any significant input on this scene? Two broad areas where it is generally felt that the programme has had an impact is in the decreasing of infant mortality due to neonatal tatanus and in improving the referral system. In terms of the contribution that the training or TBAs can make to decreasing the rate of infant mortality we need to have some realistic assessments. A detailed study of six years duration in Punjab concluded that "Causes of death in the neonatal period were strongly related to differences in child care; those of the later post neo-natal period to the unfavourable environment......Tetanus neonatorum accounted for about a :fourth of neonatal deaths" (Gordon, John E, 1965). However, a detailed survey of the available evidence by Ross, indicates that ".... evidence that by itself the training of traditional birth attendants does lead to a reduction in neonatal tetanus incidence in practice is by no means conclusive. None of the relatively few studies which have been published on this topic to date stands up to detailed methodological scrutiny, though the vast majority are encouraging rather than discouraging" (Ross, David.A., 1986).
The Need for a Dialogue
There are several pointers from many directions which seem to indicate that there is a need for a serious dialogue, with an attitude of openness and mutual respect between the modern medical practitioners on the one hand and Dais as well as the other practioners of Local Health Traditions and practitioners of Indigenous System of Medicine (such as Ayurveda, Siddha and Unani) on the other hand.
Often a feeling is voiced by the "trainers" that they are faced with a strongly rooted local tradition against which the current efforts are futile. For example a study of the programme for training TBAs in rural Tamil Nadu, says that "...Practices and routines which are deeply rooted in the local culture cannot be changed by a few weeks of lectures and demonstrations..." (Lartson, L.T., et. al, 1987). Despite this the TBAs continue to be 'trained' by personnel with modern medical back-ground usually ANMS or Health workers with no Knowledge or understanding of the practices of TBAs (World Health Organization, 1984). Several studies also bemoan the continued failure of many TBA training schemes and many reviews have been made (WHO, 1984).
This situation calls for an open minded dialogue between the practitioners of modern medicine and practitioners of ISM/LoJt Swaasthya Varamparaas. Merely dubbing the Local Health Traditions "Un-sound/Superstition" etc. is not going to be very productive. For example a recent national seminar on traditional practices in Mother and child care has listed several traditional practices with the general advice that these are harmful (National Institute of Public Cooperation and Child Development, 1989). The summary report of the above seminar has listed a lot of practices as follows : "Following practices are harmful for mother and/or for the child and need to be phased out by the community....- nutritious food termed as hot or cold". It goes on to say that - "Dietary intake should be adequate after delivery without restrictions on any nutritious food". Such statements indicate that there is no realization of the fact that the local health traditions may be rooted in a scientific tradition whose theories, terms etc. are quite different from the modern medical tradition. Hence we need to understand their varied terms and approaches before we can comment upon them.
One other valuable contribution which the ISM practitioners have made is to offer concrete effective alternatives for certain harmful practices which need to be replaced. For example it is often observed that pregnant woman may have a strong craving for certain things such as soil or ash. This is termed as being unhealthy by both modern and ISM practitioners. Modem practitioners have merely condemned the practice, but Ayurvedic Acharyas have offered certain substances which can serve as substitutes For example it has been suggested that instead of Ash, the pregnant woman can be offered charred powder of Triphala which can be beneficial to her. Similarly instead of soil fried garika (red ochre) can be offered. (LSPSS Report, 1989).
Dai Training
A new orientation is needed in the dai training programme. It appears that the dai training commenced since the public health authorities were forced by the ground reality to come to terms with them in spite of efforts to ignore/eliminate them. The World Heath Organization expert committee report on TBAs said as early as 1966 that, there is a need to - "...increase the skills of TBAs in view of their influence on the family on the one hand and of the repeated failure of legislation to prevent them from practicing on the other hand (emphasis ours) even in many advanced countries of the World " (WHO, 1966). There is now a need to consciously adopt a more positive attitude and recognize and appreciate their strength rather than merely 'tolerate' them as - 'necessary evil'. Their training has to be in a manner and idiom' that they can relate to comfortably and there can be a valuable input in this area from the ISM Community.
Studies by ISM Practitioners
There also exist a large number of studies on various aspects of Mother and Child Health from J the view point of ISMs. For example, there is large number of studies dealing with the following topics from an Ayurvedic view point.
a. Treatment of specific diseases and conditions such as - Sterility, Leucorrhea, Oligospermia, Azospermia, Pregnancy Anemia, Oedema, Urogenital Prolapse, etc
b. Effect of Administration of Specific Ayurvedic drugs for particular conditions such as the use-of Mandoor Bhasma in pregnancy; drugs for influencing the course of labour etc.
c. Studies on the efficacy of cerain Ayurvedic procedures advocated in relation to Mother and Child Care such as basti, use of picchus etc.
There is a need to take up a-comprehensive review of such studies and trials both as an aid to understanding various Lok Swaasthya Paramparaas which have their roots in Ayurveda and to assess the efficacy of some of the classical prescription procedures in actual use. A representative list of some such studies in the area of Prasuti-Tantra is provided in the Appendix.
Conclusion
We put forth the following suggestions towards an approach to Lok Swaasthya Paramparaas :
1. Understanding and evaluation of Local Health Traditions has to be done with the active input of the perspective of ISMs
2. ISM practitioners need to be involved actively not only in the evaluation but also in the design of various such surveys and studies.
3. There is a need for a fresh outlook towards Dais - the enormous strength of the Dai tradition need to be understood and encouraged.
4. The programme of training dais needs to be restructured so that major inputs are received from ISMs.
5. Experienced Dais and ISM practitioners should also be involved in developing course material and in teaching Dais.
6. A detailed exercise needs to be undertaken for taking stock of various studies and trials in the area of MCH that have been made from the perspective of ISMs.
7. Above all, the various practitioners of modern medicine and planners of public policy on health need to show a greater willingness to enter into a dialogue with practitioners of Lok Swaasthya Paramparaas and ISMs in a spirit of openness and mutual respect. This is essential if we are to evolve a Health Policy that can make the best use of the inherent strengths of these traditions.
Acknowledgement
This review was originally presented at the National Convention of LSPSS in 1989. The author would like to acknowledge the help received from LSPSS.
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Author:A.V. Balasubramaniam
