Midwifery in colonial India
From the archive (this feature originally appeared in Wellcome History issue 28 [PDF], spring 2005) – by Dr Supriya Guha
In 1902, the first Midwives Act was passed in England to restrict practice by unlicensed midwives. In 1903 the creation of the Victoria Memorial Scholarships Fund in British India sought to restrict the practice of untrained birth attendants in India and create a category of trained midwives.
From the beginning, the numbers of women trained were very small and the results were not encouraging, with the doctors who undertook to implement the scheme reporting gloomily on the unresponsiveness of their pupils.
The Fund had an extremely limited catchment area, since it deliberately restricted itself to the training of women who were already practising as Dais or traditional birth attendants and offered stipends as inducements for training. The scheme, which deliberately excluded women not from traditional midwife castes, bore the imprint of H H Risley, a member of the committee established to make recommendations for the Fund. Risley, as a Bengal Civilian, had written a comprehensive ethnography of the tribes and castes of greater Bengal, which included detailed accounts of customs of childbirth. As with many scholars, his knowledge was to provide certain idées fixes, chiefly relating to the immutability of caste-related practices. There was also political sensitivity to the question of domestic or ritual customs.
The sensitivity arose partly from an adherence to the spirit of the Proclamation of 1858, which had promised the Government would not interfere in religious matters. What constituted religious practice was a vexed question but there certainly was a close connection between caste and childbirth. Only women of the lowest castes worked as midwives, although their function was more limited than the term suggests. Their role was more a ritual one, as they performed the highly polluting act of cutting the navel-cord and carrying away the placenta. A household where a Dai had not attended remained polluted, so that if the woman arrived after the actual birth, she was still paid a token fee.
Schemes to train traditional midwives seemed to assume a homogenous class, whereas there was a clear division of skills and status within their ranks. In more prosperous households, there might be two kinds of attendant: the more ‘skilled’ women who attempted to speed up or facilitate the actual labour and the cord- cutters to perform the polluting tasks that the former would refuse to do.
In rural areas, there was, in addition, a system of reciprocity where friends and relations gathered to help each other in their labour. Extremely poor women had little recourse to any aid at all. Most doctors remarked on how much easier a time of it peasant women seemed to have than the ‘listless inmates of the zenanas’ (referring here to both Hindu and Muslim women of the upper classes), whose inactive and secluded lives made them peculiarly vulnerable to obstructed labour. The attention of the medical establishment and of most official bodies was thus resolutely turned on the upper- and middle- class women who observed ‘purdah’ or seclusion, suggesting that mortality rates were higher among this section. Actually, puerperal sepsis was the single largest killer of women and infants, and poorer women were equally, if not more vulnerable.
If the level of skills of the Dais was indeed as low as the doctors’ reports suggest, poor women were fortunate to go without their assistance. The better-paid Dais played a more active and, probably, more dangerous role in childbirth, while the ‘cord-cutters’ may have done little in terms of manipulation and intervention during labour. Dais frequently massaged the perineum and pressed points on the abdomen to speed labour. This was said to be the cause of the high incidence of uterine prolapse found among Indian women, especially those who had had several children.
A doctor reported to the Victoria Memorial Scholarships Fund that normal cases were comparatively safe from the intervention of the Dai as they were often over before her arrival. In cases of delayed labour, interference could result in fetal arms pulled off, rupture of the uterus, lacerated cervix and perineum and applications that resulted in partial or complete atresia of the vagina. The third stage of labour was speeded by the Dais massaging the patient’s abdomen, sometimes after making her stand up against the wall, till the placenta came away. Dais were also said to frequently attempt to remove the placenta manually.
Under the influence of ideas of the Enlightenment, the notion of Nature being allowed to take its course had dominated European obstetrics since the 18th century. Consequently, with the development of technology to alleviate complications of labour, there was a simultaneous move towards less intervention in deliveries. Thus, the bulk of the criticism levelled at the Dais’ practices dwelt not so much on their inability to assist in a crisis of labour as on their ‘meddlesome’ and violent methods. From this point of view, it was most important to train the very women who were ‘skilled’ or interventionist and whose clientele included the women seen as peculiarly vulnerable.
The training of Dais, as with the establishment of Purdah Hospitals (another peculiar occurrence in colonial medicine in South Asia), was concentrated in northern and eastern India. In South India, the relative readiness of Indian women to train as nurses and midwives as well as the rarer observance of seclusion made the issue less pressing. Training schemes for Dais had been attempted by missionaries for many years, especially in the Punjab, Sind and Utter Pradesh, before they received official recognition. Some of them had been remarkably successful, with the work of Miss Hewlett in the Punjab in the 1870s being frequently cited.
It had proved difficult to replicate the success of the missionary schemes. The medical establishment in Bengal was, for instance, consistently pessimistic about any experiments in Dai training. The doctors who wrote the history of women’s medical work in India attributed the failure of any such work in this province to the pervasive spirit of scepticism among the medical men who were in overall charge. Apart from the mutual distrust between doctors and Dais, there was a paucity of clinical material because of the small number of women confined in hospitals. Both patients and Dais objected to maternity cases being handled by male doctors.
Despite the failure of most previous schemes, however, the Victoria Memorial Scholarships Fund hoped it would succeed by drawing on the growing pool of medical women who worked in India after the establishment of the Dufferin Fund in 1885. The early reports of the VMSF were not encouraging but by the 1920s, some success was cited in parts of India, notably in the receptive territories of Punjab and Sind.
In her paper, ‘Is the Indigenous Dai worth training?’, Dr K M Bose from the Punjab emphasised the importance of the Dai as a part of the traditional village community. It was this, she argued, that made it important to win her cooperation. Why, in fact, was this cooperation so difficult to procure? Most of the doctors reported the unwillingness of Dais to attend any training classes and their even fiercer resistance to any attempts at supervision. The famed recalcitrance of the traditional Dai sprang, as the doctors reported, from her invariable illiteracy and inability to comprehend alien ideas such as asepsis. It is also possible that it was that very location in the community that proved inimical.
Dr James Wise, the Civil Surgeon of Dacca, described in his reports to the Medical Department a peculiar institution called the Mohalla system. Every Dai claimed to have a monopoly of confinements in her particular neighbourhood. Some even produced old documents (from precolonial authorities) to bolster their claims, which were generally accepted by other Dais and by the families who patronised them. Any interlopers were deeply resented and attempts to introduce trained midwives could be seen as encroachment. In villages, it was not unusual for prosperous households to make land grants to a Dai’s family, which would then confer the monopoly of midwifery to the latter. This was related to the ritual role of the Dais and could also be by way of a reward for the delivery, for instance, of a male heir. This meant that there was very little incentive to join training classes, although some medical women attempted to train the young daughters of Dais in recognition of the hereditary nature of the trade.
By the 1920s, midwifery became a matter of contention within nationalist politics. Poor conditions of childbirth had been used to depict Indian society as backward- looking, most famously in Mother India by Katherine Mayo. Nationalist politicians took up the cause in the various local bodies established under the reforms of 1919. Although the Victoria Memorial Scholarships Fund survives to this day (under a new name), the role of Dais continued to be more ritual than ‘medical’ and served to fill the gap left by the inadequacy of medical services. Indeed, replacing the Dai altogether has proved an elusive goal to this day.