1. Sara Price, MA
Applied Medical Anthropologist

2. The purpose of this research was to use the lens of Critical
Medical Anthropology (CMA) to examine the
effectiveness of Evidence-Based delivery practices,
marketed by NGOs for use in CHCs in rural, southern
Rajasthan, India.

3. Maternal Mortality: To improve MMR globally:
India’s national maternal mortality The World Health Organization has
rate (MMR): produced a set of Evidence-based
~212 deaths per 100,000. (Office of Register General of India, 07/2011) Delivery practices (EBDs)
These practices are organized into
Rajasthan’s MMR is higher than
the national average:
three stages of labor and include:
1) Skills for conducting abdominal and pelvic
~318 deaths per 100,000 live births (Office of
examination
Register General of India, 07/2011)
2) Managing all stages of labor, intra-partum
care, newborn resuscitation
3) Management of post-natal complications
(Ministry of Health and Family Welfare 2010).

5. Research Location:
In-depth Interviews and Participant
Observation:
Interview Participants:
 11 skilled-birth attendants working in
community health centers (CHCs) in
Udaipur, Banswara and Praptaghar
 6 expert staff with local NGO staff training
and evaluating SBA’s use of EBDs
Participant observation of:
 SBA trainings
 Evaluations of SBA performance post-
training.
17 interviews were conducted between
August 2011 and November 2011

6. 1) These practices were developed through a
number of international non-governmental
research initiatives, mostly conducted in
sub-Saharan Africa. These practices were
not field tested for an Indian context, nor
were they made specific to the context and
conditions of local factors impacting MMR
and IMR.
2) While practices such as cessation of
excessive fundal pressure and
administration of IM oxytocin during 2nd
stage delivery have been shown to
reduce MMR/IMR, many of the practices
are not possible or practiced consistently
by SBA staff because of infrastructural
issues (such as time, patient case loads,
etc.) or requests from family members to
use certain practices to hasten delivery.

7.  Ex: One SBA from Banswara
commented: “We can use these
practices in the labor room whenever
we want. But sometimes the families
don’t want the patients to get the
practices…and all we can do is try to
refuse their request and try to explain
the process” (Interview 09/19/2011).
 These quotes illustrate some of the
tensions between how SBAs practice
and interpret EBDs, and what the
community expects from institutional
delivery rooms.

8. 4) Finally, and most importantly, despite the
fact that these practices were immediately
implemented into the CHC system from state
and NGO initiatives, there is little to no
evidence that EBDs in their current
application has done anything to improve the
maternal and infant health outcomes
reported in southern Rajasthan.
3) The primary thrust of these
practices is to encourage natural
delivery, however, most patients
assessing CHCs in our sample had
already labored for some time at
home, and were seeking care
because they felt some kind of
assistance or augmentation was
necessary.

9. ▪ The findings of this study conclude that while there is
some medical potential in using EBDs for health,
normal deliveries they should be monitored and
evaluated to asses they’re relevance within the local
context of rural CHCs. It may be the case that these
practices need to be tailored to incorporate practices
that trained staff could follow depending on the context
of the labor presenting. The common causes of MMR
and IMR should also be taken into account, and
incorporated into these practices.

10.  EBDs represent a unique product marketed from a globalized perspective. Yet the lack of
empirical evidence that links their application to improved maternal and neo-natal health
outcomes reveals them as primarily symbolic and in need of revision.
 There is no evidence that EBDs have reduced maternal or infant mortality in southern
Rajasthan.
 The promotion of EBDs as scientifically legitimate becomes questionable then,
particularly when little data supporting their effectiveness in an Indian context is
available.
 Furthermore, EBDs are imported from a view of the labor process articulated through a
combination of humanitarian initiatives and research supported by the global north, and
fuelled into the global south. In the case of EBDs, most of the data supporting the
utilization of these practices was carried out through western public health initiatives
conducted almost exclusively in Africa. However, NGOs often receive directives from
both state and/or IGO forces in the form of financial support and programmatic
implementation support if they incorporate practices, like EBDs into their programs. This
begs the question: Who benefits from these programs?

11.  Determine locally/regionally specific causes of
MMR/IMR; make EBDs relevant to reducing
those specific conditions/circumstances
 Evaluate EBDs within a local context
 Monitor their effectiveness in reducing
IMR/MMR; Re-design if necessary
 Utilize SBA perspective in program/policy
development

12. The results of this study point to a significant juxtaposition between the
imagined benefits of EBDs and the real barriers associated with the
usefulness of these practices. Evidence-based delivery practices in their
current state have not been shown to significantly reduce MMR and/or
IMR in southern Rajasthan. Evaluating, monitoring and re-designing
these practices so they conform to the context and community need
during delivery, provides an opportunity for re-imagining a labor room
environment that incorporates strategies for making birth safer in a
way that becomes meaningful within the context of delivery in rural
southern Rajasthan.