New Delhi: Janakibai is from Khargone district in Madhya Pradesh. She is one of the 10 lakh dais who works as a traditional birth attendant (TBA) in the country’s rural areas and urban slums. She has over the last two decades delivered 3-4 babies every week and is compensated by being paid anything between Rs25-100, a sari, bag of rice or just a coconut, depending on how much the family can afford.
Of greater value to her is the trust and respect she has earned from the young and old alike. She has groomed herself to be a semi-health worker, providing services that go beyond childbirth. Diligently carrying out post natal visits, she informs families about polio vaccinations and booster doses, promotes family planning, counsels on HIV/AIDS and drives home the importance of health insurance. With an enhanced awareness, she can make appropriate referrals to healthcare facilities in complicated cases, saving precious lives.
Janaki, along with 100 midwives from 11 states and their civil society organizations were in the capital recently to make a representation to the government for having a more defined and concrete role in public health programmes, specifically the National Rural Health Mission (NRHM). After having been part of the public health system for generations, these TBA-dais find themselves on the periphery, marginalized and ignored as castaways. They are seen as being redundant and are blamed for the high numbers of maternal and infant mortality rates that continue to haunt rural India. The government’s emphasis on institutional delivery and on including ASHAs (female local health volunteers) within the NRHM, has been at the cost of diminishing their worth. They want the NRHM, which is three years into its seven-year lifespan, to re-examine their delegitmization and to bring them back into the mainstream public health domain.
Dr Manisha Malhotra, assistant commissioner, Ministry of Health and Family Welfare clarifies that, “The NRHM has not disowned dais. It is up to the state government to be innovative and to integrate them into the public health system. The NRHM is considering guidelines for providing them financial incentives.”
Gujarat has done this successfully. The Dai Association Gujarat was launched in 2005 at the behest of the dais and various Civil Society Organizations who enhanced their visibility and capacity by creating stronger linkages in public health programmes. Supported by the state’s department of health and family welfare, the Association today has over 8000 dais and 18 NGOs under its umbrella. Two successive dai sammelans have been organized and based on their feedback, a unique helpline, ‘Dial 108’ was launched six months ago. A person wanting to access medical help just has to call the toll free number from a mobile or land line and within ten minutes find an ambulance equipped with oxygen, glucose and doctor at the doorstep. The system has not only worked but also allowed space for the local dai to hop on and facilitate in the event of an en route delivery that could happen. Often, members of the Association get recognized by their uniform saris and are ushered into labour rooms to assist doctors or nurses with deliveries.
It is precisely this kind of recognition and involvement that the TBA-dais are seeking. Abhijit Das, director for Health and Social Justice points out that for the last three decades, dais have been put through training modules, funded by governments and international agencies, and now suddenly they have been declared redundant. No country has achieved 100% success in maternal mortality, without enlisting support of women organizations. If MMR was brought down in Nepal, it was not by going in for institutional delivery alone but by making the Matlab experiment work through social mobilization of women groups.
The NRHM service delivery paradigm has been promoting institutional delivery through the Janani Suraksha Yojana (JSY) incentivization process. Abhijit says, “The government claims that six million deliveries have taken place in hospitals ever since JSY came into being and yet if you go on the field and hear stories from NGOs working there, you will find that the sight of maternal deaths in states like UP has at best shifted from home to hospital or in between places, making me cautious of equating institutional delivery with safe delivery.”
The table on the left, tracks institutional births in eight selected Indian states and it shows that more than 60% deliveries in rural India continue to be at home. Its a clear indicator that women are not accessing institutional care, whether because of lack of faith in the medical system, primary health care centres not being in close proximity for them to access services, not finding doctors on duty, there being hidden costs/ medical charges or just cringing under the touch of unfamiliar hands.
Bijladai from Jharkhand recounts how had it not been for her intervention, a woman who had to go in for a last minute cesarean section was rushed from Jharkhand to neighbouring West Bengal, since PHCs in and around the village were ill-equipped to handle the case. She adds, “The poor are treated badly and made to wait for hours, which is why many women prefer the dignity of their homes and not the clinical and uncertain environs of a PHC.”
Then there is the issue of having facilities but they not been manned or equipped well enough. Government figures indicate that 100% PHCs in Madhya Pradesh are functional 24X7, yet ten in Janakibai’s area operate sporadically and three have been shut down. She asks, “Should the woman in labour wait for the doctor to come in a setting where he probably has not turned up for a week or should I as the local dai, be allowed to take charge?”
The concerted effort made by the government to replace the dai with the more educated (minimum Class VIII), younger and relevant ASHA has created some tension in the field. Since dais represent marginalized sections of society and are illiterate, their candidature is weak. Their argument is that if they cannot be recruited as ASHAs, they should still be retained in the system so that they can help the women who may otherwise be denied safe delivery and post partum care. By being brought into the labour room and hospitals to assist doctors they could share skills that are exclusive to them – knowledge of traditional herbs, birthing methods, massages, nutritional advice, personalized care and follow up.