12.1 A Ritual Lens: Most rituals are intended to promote health or avoid risk

Many of the benefits of a ritual lens come as consequences of trying to document what rituals do and how they work. The previous Chapter (Chapter 11) focused on perinatal ritual content, experience, and associated beliefs and behaviors through an expansive narrative. Here we focus on the many extended ways that studying ritual provides added perspective for building valuable insights relevant for understanding performance and motivation.

The majority of perinatal rituals are motivated to promote health or avoid risk. In Table 3.3, we document 1399 mentions of various rituals and practices across the FGDs and KIIs summarized in Chapter 3. Of these, 99% were intended to either promote health or avoid risk (32 % were intended to promote the health of the mother or baby and 67% were intended to avoid risks). The few behaviors that were not coded as risk avoiding or health promoting had intentions that were unclear or unspecified. This motivational alignment between perinatal and biomedical rituals is essential to keep in mind for ASHA messaging and training. It can also be a source of tension if well-intended and typically harmless traditional practices are labelled as ‘bad’ by outsiders who are either evaluating ASHA efficacy or attempting to promote a new initiative.

In addition to being motivated to promote health or avoid risk, the majority of rituals were either neutral or consistent with biomedical recommendations. Across all rituals identified in the FGDs, 86% were consistent with biomedical recommendations or neutral, and only 13% seemed to counter biomedical recommendations in some way. Of the rituals that seemed to counter biomedical recommendations, the majority (91%) occurred postpartum and consisted of behaviors like bathing the newborn immediately after birth, feeding water to the newborn after birth, or discarding the colostrum, none of which occurred in large percentages. We note, however, that this early postnatal period is a time when ASHAs lack access to mothers and that many of the interviewed mothers did not receive a home visit from the ASHA in the first week postpartum.

12.1.1 Different belief systems often coexist, and may even complement each other

Chapter 3 also identifies relationships that can occur when novel biomedical and traditional community rituals come into contact. These include replacement, conflict, and complementarity. Of these, complementarity is likely the most desirable outcome and the one that could be positively encouraged by ASHAs. An example of complementarity is allowing a new mother to receive blessings from a maulana or pandit via mobile phone immediately after birth, which facilitates timely initiation of breastfeeding because in some cases a mother might wait until after the next scheduled prayer to begin feeding. Another example is rubbing mustard oil on the body of the infant but not the chord stump (as opposed to specifically rubbing it onto the cord stump). Solutions to cases of apparent conflict in ritual or belief that involve adjustments to achieve such complementarity could be part of the ASHAs role as she shifts from service extender to cultural facilitator.

12.1.2 Rituals and behavior change

An overview of the first wave of qualitative data collection (Chapter 3) provided some clear implications for understanding ASHA dynamics and for designing interventions aimed at improving motivation and ability. First, behavior change strategies should not try to change behaviors that aren’t harmful or in some way impeding a key health-outcome. Likewise, evaluations of ASHA performance should avoid criticizing or penalizing ASHAs for sharing beliefs with the communities they serve. Because a major strength of ASHAs (and most other CHWs) is that they are familiar with local customs and norms, because they likely engage in many of the same behaviors as the mothers they serve, labeling community beliefs as problematic may interfere with efficiently leveraging ASHA strengths. In approaching behavior change efforts, one should minimize the amount of friction between systems of belief. The view that holding some of the same traditional views as the mothers they serve suggests a lack of ASHA efficacy could undermine the rationale of programs and could negatively impact efforts to improve ASHA performance.

As evidenced by instances of complementarity between traditional and biomedical rituals, traditional practices that do interfere with biomedical goals can be altered in a way that preserves the original intention of the ritual and achieve alignment with the biomedical goal. In general, designers of interventions may want to avoid points of conflict between systems of belief, particularly if the conflict itself is not limiting the ability to improve a health behavior. In many cases, traditional or normative beliefs will have little or no conflict with the target of an intervention. In other cases, there may be a subset of behaviors that are traditional and normative, or particularly tightly held, that conflict with biomedical advice. The messaging requirements and the nature of the challenges to the intervention design will be different in each case.

Engineering a new ritual as part of an intervention could be challenging, but there are many ways that ritual tools can help diagnose where key friction points might present barriers or suggest where behaviors need to be affected indirectly or as part of a constellation of behaviors. For example, some behaviors are more rooted in norms than others and these may also have more elaborate or deep connections to tightly held beliefs.