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Traditional v. Biomedical Orientation in Maternal Health Care
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Traditional v. Biomedical Orientation in Maternal Health Care

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Dai or Doctor?

Dai or Doctor?
National Communication Association 2013, Washington, DC.
Health Communication Division
Competitively Selected Papers in Health Communication

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  • Urban migrant spaces face negative outcomes caused by the avoidable delay in seeking medical help While health care policy initiatives train the dai to advise institutional assistance in a timely manner, such measures also need to address the communicative framing among migrant women of the biomedical orientation as a dependency-inducing step only undertaken during an emergency when all else is failing
  • Training the TBAs to manage common antenatal, perinatal, and neonatal conditions has seen some success in reducing neonatal mortality in populations with limited access to health care (see Gill, Phiri-Mazala, Guerina, Kasimba, Mulenga, MacLeod, et al., 2011 for Zambia; Goudar, Dhaded, McClure, Derman, Patil, Mahantshetti, et al., 2012 for India). In large part, this reduction in neonatal mortality has been attributed to successful following of best practices such as using a clean delivery kit, a plastic sheet for delivery, a boiled blade to cut the cord, a boiled thread to tie the cord, and use of antiseptic to clean the umbilicus (Seward, Osrin, Li, Costello, Pulkki-Brännströmm, Houweling, et al., 2012). more than half the deliveries continue to be home-based, conducted in the squatting position, with the umbilical cord being cut using the edge of a broken cup
  • While useful in gaining a descriptive understanding of biomedical practices and TBA profiles, such findings do not enrich our understanding of traditional maternal health practices and their dialogic framing of the maternal body as life-generating and healthful, nurtured through holistic practices in symbolic commune with nature and ultimately undermine the contribution of traditional approaches in health maintenance and construction for the women. By undertaking this descriptive, interpretive examination of the locally situated, emergent meanings of maternal health and the maternal body, this study provides an insight into the socially constructed nature of maternal health and ultimately, how it shapes the choices made by women in the basti.
  • This theme addressed the framing of tensions between the biomedical and traditional maternal health orientation as being too goal-oriented versus holistic and empowering, e.g., the bio-medical system was described as inducing dependency (upon medicine) and being outcome-based whereas the traditional was described as maintaining the balance of energy in the woman’s body. By framing local knowledge as socially constructed such that it reflects local circumstances and realities, women’s care seeking behavior can be productively illuminated (Petterson, Christensson, Freitas, & Johansson, 2004).
  • Traditional privileges an intimately connected, organic view of the maternal body and nature-as-nourishment.Institutional care seen as ignoring the meanings of maternal health embodied in daily rituals leading to such symptoms of ill-health as flabby stomachs and a post-pregnancy body dependent on Western forms of medicine. Meaningful integration of the biomedical orientation requires embodying local customs and norms in practice, for example, for maternal practices this emphasizes (re)defining maternal care around the woman’s comfort with discussing issues of modesty (Saravanan et al., 2012), accepting that childbearing and childbirth are located within the sphere of women’s experiences.
  • Although it has been advocated that TBA training should involve different stakeholders including consumers and traditional caregivers to improve MMR outcomes, there is a need to remove the TBA from its present perception of being circumstance driven, marginal, and high-risk health care practice (Sharma, Johansson, Prakasamma, Mayalankar, & Christensson, 2012). In its present status, there is a large variation in the training, education, and competencies of the dai as well as an absence of national legislation recognizing midwifery as an autonomous profession in South Asian countries (Bogren, Wiseman, & Berg, 2012). In their critical ethnography Hilton et al. (2001) note that western medicine was seen as a more defined domain practiced primarily by trained physicians whereas traditional medicine included home remedies, dietary practice, healing practices, and the use of healers considered to be knowledgeable such as veds, homeopaths, babaji’s, and pundits and had a spiritual dimension.
  • Although it has been advocated that TBA training should involve different stakeholders including consumers and traditional caregivers to improve MMR outcomes, there is a need to remove the TBA from its present perception of being circumstance driven, marginal, and high-risk health care practice (Sharma, Johansson, Prakasamma, Mayalankar, & Christensson, 2012). In its present status, there is a large variation in the training, education, and competencies of the dai as well as an absence of national legislation recognizing midwifery as an autonomous profession in South Asian countries (Bogren, Wiseman, & Berg, 2012). In their critical ethnography Hilton et al. (2001) note that western medicine was seen as a more defined domain practiced primarily by trained physicians whereas traditional medicine included home remedies, dietary practice, healing practices, and the use of healers considered to be knowledgeable such as veds, homeopaths, babaji’s, and pundits and had a spiritual dimension.
  • Health-seeking behavioral outcomes have been assessed through biomedically-driven criteria (e.g., hemoglobin levels or compliance with iron supplements) In traditional orientation the maternal-child life-body balance and life-vitality are seen as health outcomes TBA-based family planning services reflect a biomedical bias in their focus (recruiting, escorting women to health centers, and supplying maternity kits) “If you are illiterate you think differently from those who are literate, those who are illiterate try to draw on their own traditional knowledge, and are very superstitious, they feel we will go to the hospital, we don’t know what they will do to us there, they will do an operation, they will kill us, many people will say that they will swap your baby for a dead one and sell your child, many illiterate people think like this” (# 13)Need to address the local perceptions of the women About four women in the sample of 25 women interviewed for this study felt differently. Increase skilled TBAs to manage maternal complicationsIntegrate traditional and biomedical in women’s lives
  • Dai is one of our own A basti mother or an elder A repository of traditional knowledge Recent interest in holistic health practices alludes to the blending of faith, the body, and healthfulness as one seamless concept, whereby the individual is treated along with their condition. Articulating shared understandings of maternal health How traditional approaches are discursively legitimized in the face of urban transition and migrationBelief that traditional practices maintain the delicate, dynamic balance between the maternal body and the food it consumes Traditional maternal health orientation as holistic and empowering, life-giving, nurturing, and protective Fear that such a frame encouraged dependency on medicineBiomedical frame ignorant of the nurturing properties of food and its intimate relationship with the maternal body
  • Framing of the biomedical profession as favoring Cesarean and intrusive Tensions of navigating the maternal body as an unnatural condition. Sensitivity in recognizing women’s feelings of modestyA quarter of the women interviewed women perceived the bias against the biomedical tradition as a product of illiteracyBias against TBAs The women started with communicating a deep regard for the biomedical tradition and the medical practitioner. Yet, they would move on to describing why that point of view was not appropriate for them. If the pregnancy went wrong, and the dai recommended seeking emergency assistance, they would approach a healthcare institution.
  • By undertaking this descriptive, interpretive examination of the locally situated, emergent meanings of maternal health and the maternal body,

Traditional v. Biomedical Orientation in Maternal Health Care Traditional v. Biomedical Orientation in Maternal Health Care Presentation Transcript

  • DAI OR DOCTOR? • THIS RESEARCH WAS FUNDED BY THE SALISBURY UNIVERSITY FACULTY RESEARCH SUPPORT GRANT (2011). • IT FOCUSES ON PART OF THE INTERVIEW DATA. • THE RESEARCHER IS GRATEFUL TO THE WOMEN AND CHILDREN OF THE BASTI FOR THEIR GENEROUS PARTICIPATION.
  • TRADITIONAL V. BIOMEDICAL IN BIOMEDICAL ORIENTATION IN URBAN RESETTLEMENT NEIGHBORHOOD IN INDIA Vinita Agarwal, Ph.D. Assistant Professor, Salisbury University
  • TRAINING THE TBAS • 3.7 mill neonatal deaths and 3.3 mill stillbirths globally • 88% in developing countries • More than 80% of deliveries by untrained TBAs • Unclean delivery sheet • Broken edge of cup to cut umbilical cord • India’s MMR declined from 254 in 2004—2006 to 212 in 2007— 2009 but high in urban centers (Delhi MMR: 300) • Efforts to improve access to institutional delivery through cash incentives, training of TBAs faces challenges • Gender specific complexity of rural—urban migration • Gendered access, exclusion, marginalization • Cost, threat to female modesty View slide
  • RESEARCH GOAL • Interrogate transitory migrant spaces in urban areas • Fertile sites for communicative (re)tellings of traditional knowledge • Ongoing sense-making in maternal health discourses. • Communicatively-grounded description • Traditional and biomedical maternal health beliefs of migrant women participants in one temporary urban resettlement community (basti) in India • To inform reproductive health policy in gendered migration. View slide
  • TRADITIONAL MEDICINE • “The sum total of knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve, or treat physical and mental illnesses” (WHO, 2008) • Integrative balance between nature and human body (GeistMartin, et al., 2008) • Achieving discursive legitimacy for traditional medicine (Dutta & Zoller, 2008) • Challenges in assimilating these in maternity health practices • Practitioner disapproval • Goal discrepancies • Misaligned expectations
  • DAI AND MATERNAL HEALTH IN THE BASTI • Traditional as parallel authoritative knowledge form • Go beyond descriptive, outcome-based evaluations • Interrogate implicit “authority” of the biomedical over traditional • Role of everyday processes in maternal health knowledge • Dai in the women’s lives and meanings of maternal health in the basti RQ • What are the discursive strategies employed by urban migrant women in a temporary neighborhood basti to legitimize the traditional maternal health knowledge practices of the dai?
  • METHODS
  • METHODS • IRB approval 2011, 14 days in basti daily trips, New Delhi, India • Video-recorded semi-structured interviews N = 25 • 3—7 pages each, Hindi, transcribed professional agency • Observer-as-participant: (Lindlof & Taylor, 2002) • Lived day-to-day understandings, from multiple viewpoints • Foregrounding participants’ contextual experiences framing the maternal body in the traditional and biomedical perspectives • Talking, helping, observing, playing with the children as time allowed within the daily routines
  • ENTERING THE SCENE • Familiar stranger • Approval of the basti dai, also informal head of basti • Informant as teacher (Gubrium & Holstein, 2001) • Privacy concerns DATA GATHERING • Moderately phrased schedule, elicitation interview • Probing and structured questions • Domain-specific questions combined with probes for meaningful comparisons • Complimentary reciprocity experiences (Gubrium & Holstein, 2002)
  • DATA ANALYTIC STRATEGIES • Draw on researcher standpoint • Sensitizing concepts first pass (Charmaz, 2001) • Sensitive to local frames and meanings • Line-by-line data gathering analysis • Member validation of emerging categories • Meanings from significant issues (Ellingson & Buzzanell, 1999) • Implied and explicit meanings • Codes for comparison of emerging categories across participants • Codes synthesized into categories representing recurrent themes
  • RESULTS
  • TRADITIONAL WAYS KEEP THE BALANCE • “if we go to the doctor, we will have to eat rice, sometimes they will put you on a glucose drip, so in our customs, we don’t have glucose at this time. . . So if they give you so much of all this, so our balance in the body gets spoilt.” • Faith, tradition, spirituality • Herbs, diet, massage with empathetic understanding of gender sensitivity • Day-to-day practices • “we don’t let her have shower with cold water. . .” • “we give her a potion to drink . . . So our stomachs do not expand”
  • TRADITIONAL WAYS KEEP THE BALANCE • Balance between maternal body and fetus • “Over there medicines do all the work . . .” • Traditional work of achieving maternal health is based on knowledge of the natural order of preparation and ingestion, the properties of herbs, even the material of the cooking vessel. • “When we take traditional herbs and medicine. . . it cleans out our stomachs, brings life to our bodies. . . So now when you have a kid, in that matter you should eat the traditional nutrition about two months, then it will benefit you in the sense that your body will be healthful and vital and your child will be full of life, when he/she drinks her mother’s milk, then the child also gets life” (# 7)
  • DOCTOR MEANS WELL, BUT GOOD FOR EMERGENCY • “What we do, how do they know? They don’t live here, how will they know what we think?” (# 20)
  • DOCTOR MEANS WELL, BUT GOOD FOR EMERGENCY “In my village, women do not go to the hospital to give birth, they call the dai and give birth at home. . . only when there is a big emergency, then we take the woman to the hospital, if the baby is born at home, then we don’t go to the hospital.” (# 18)
  • DOCTORS TRY TO DO CESAREAN, ARE INTRUSIVE • Fundamental, ontological distrust of biomedical community • Training dais to offer referrals to hospitals • Offer tetanus toxoid vaccinations helpful • “They (the medical community) only ask us to go to the hospital so we can give birth early, they will give us medicines and injections for that. . . this is in God’s hands, not in our hands, is it?. . . the medical community will advise everyone to go to the hospital, but what is our practice, is our practice, everyone has their own beliefs.”
  • DOCTORS TRY TO DO CESAREAN, ARE INTRUSIVE • “In the hospital, they touch your stomach here and there, and prod you this way and that, with the dai, you can give birth in the comfort of your home. . . In the hospital, it is not that advisable to go there, because in the hospital the doctors may cut you up (Cesarean), they do different intrusive procedures.”
  • IT’S A MATTER OF LITERACY • “The doctor is also like a kind of god, but the dai also has her place, she is also right, but nothing compared to the doctor. The doctor can even revive the dead. The dai cannot do that.” (# 24) • “Now if we are smart enough and intelligent, then we can also learn how to do the dai’s work, and if we are able to go out and we go to the hospital, then we can see what is it that the doctor is doing?” ( # 7)
  • DISCUSSION
  • DISCUSSION • Traditional orientation embodied the organic relationship • Myths and rites • Materiality of traditional practices • Enactment through maternal health traditions • Maternal body as life-giving, sustained and protected • The biomedical tradition • • • • Pregnancy as a physical “condition” that needed treatment Violating belief of maternal body and nature connection Maternal body was an unnatural condition Assisted through medicines to fulfill its birth-giving goal
  • DISCUSSION • Center maternal body—nature connection • Incorporate the dai as the influential opinion leader • Trust in biomedical approach— • Situate the maternal body in community traditions • A support-system that respects traditional home-based care • Gendered dimensions of urban migrant sites • Fertile spaces of health knowledge (re)constitution • (Re)articulations of social roles, stories, frames of references, metaphors, and community-defining strategies.
  • RECOMMENDATIONS • To meaningfully assimilate the traditional and the biomedical approaches, maternal health campaigns: (a) take steps to incorporate individual food choices and address issues of modesty with women, (a) respect decisions made by the dai as legitimate forms of maternal care (e.g., taking showers), (a) take steps to nurture trust among the women, particularly through reassuring care given to protect the newborn (not be stolen), (b) keep family members center-stage as key publics in decisionmaking for perceived invasive procedures (e.g., Cesarean).
  • LIMITATIONS • As a mother and researcher seeking to understand maternal practices • Allowed full access to the women’s lives and stories along with my child, who played with the children in the basti. • The transcripts reflect challenges of staying with a similar set of question—order • Unique colloquial manner of responding to questions • Implicit assumption that I understand and am a part of the same cultural sense-making landscape • Many things would not be spelled out unless I explicitly asked.
  • SIGNIFICANCE • Socially constructed nature of maternal health • Women’s sense-making practices as they articulate traditional maternal practices in gendered urban spaces • Dai as a trusted guide • The maternal body within the family, basti, and local traditions • Legitimizing and delegitimizing practices <--> changing relationships, resources, social norms of urban migrant spaces.
  • VINITA AGARWAL, PH.D. ASST. PROFESSOR SALISBURY UNIVERSITY NCA, NOV. 21, 2013, DC