blind: none had any previous education or had ever exercised their mental faculties: they were very prejudiced and jealous of their reputation and in addition honestly convinced that no one could teach them anything as regards normal labour. They believed that doctors were required in abnormal cases, but they also believed that they themselves were the proper judges as to when a doctor should be called in. This was and is the general opinion of their patients and it is the attitude of the people of India at the present day. They are only very slowly beginning to realise that the great mass of the abnormal cases are due to neglect and ignorance in the treatment of normal labour.64
In the end, this report reflects extreme ambivalence about the value of working with hereditary dais through the Victoria Fund. Nevertheless, throughout the report there is a sense that despite the innumerable obstacles faced in training hereditary dais and in reforming “the Indian woman,” the continuation of the work of the Victoria Fund remained essential to the stated goals of reducing infant and maternal mortality in India. The dai-training programs were viewed as necessary stopgap measures, while the long-term goals lay in the development of a cadre of professionally trained women doctors, nurses, and even midwives who would oversee deliveries in hospitals.
The director of public health for the Madras Presidency in 1923, quoted above, was less willing to concede that short-term government support of hereditary dais should be continued. He sought to prevent dais from practicing in the presidency and proposed to do so through the passage of a government act modeled after the Midwives Act of 1902 in England, which required all midwives to be licensed and penalized all midwives practicing without licenses. Through such an act, he felt that all dais would be replaced by certified midwives who would not be drawn from the pool of hereditary dais.65
In 1926 the government of Madras Presidency passed the Madras Nurses and Midwives Act requiring certification and registration of all nurses, midwives, health visitors, auxiliary nurse midwives, and dais.66 Under this act, anyone working without a certificate of registration could be fined, as could anyone issuing false certificates or anyone falsely using such titles as “registered nurse” or “registered dai.” Applicants who wished to be put on the register had to pass standardized exams and had to provide testimonials of both their professional competency from medical personnel and their “good moral character” from persons of “good social standing.” The council deciding who could and could not be on the register included representatives from all the above categories of practitioners except dais. Obviously, the administrative difficulty of officially training all dais and penalizing all those dais practicing without certification was insurmountable. Additionally, it would be interesting to know, although impossible to ascertain, how councils voted on the “moral” qualifications of dais given the construction of dais as inherently immoral. Clearly this legislation was more symbolic than pragmatic. Many dais then, just as today, of course continued to practice without any government training or licensing. Nevertheless, this act did represent the government’s ongoing efforts to publicly condemn the traditional practices of the dais while simultaneously demonstrating a commitment to officially recognize and sanction the work of those dais who went through dai-training programs.
Throughout the Victoria Fund report, and in the numerous other government reports on maternal and child health at the time, the high rates of infant and maternal mortality are attributed to the general ignorance of the Indian population and specifically to the evils of the untrained dai in her (mis)management of birth. The report does not consider how maternal health during pregnancy results in high rates of infant and maternal mortality as well as miscarriages and stillbirths. A 1928 study of maternal mortality in India reported that 31 percent of “abnormal” obstetric cases and 54 percent of maternal deaths were caused by “diseases of pregnancy,” whereas in Britain only 7 percent of “abnormal” obstetric cases and 35 percent of maternal deaths were caused by “diseases of pregnancy.”67 Poor maternal health during pregnancy is, of course, directly related to poverty and thus to broader structures of political economy.
The Victoria Fund report does not, however, consider how the political-economic structures under colonialism might have negatively impacted women’s health. For example, colonial systems of labor and wage structures rendered women increasingly economically dependent on men, thereby diminishing their ability to take advantage of whatever medical services might be available.68 Furthermore, colonialism was directly implicated in the spread of deadly epidemics of smallpox, cholera, and the plague, and was responsible for famines which devastated communities throughout the subcontinent. In the face of these man-made disasters, it was the health of women and children which suffered the most.
In sum, when we consider these two funds together—the Dufferin Fund 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
