3.5 Chapter Discussion

The majority of rituals and behaviors are done with the intention to avoid risk or promote health and most are neutral with respect to biomedical recommendations. For example, wearing a thread around a wrist or hanging a wooden object on the wall do not negatively impact maternal or child health. Such behaviors may be opportunity spaces to strengthen trusting relationships or to find connections to other behaviors that are more directly impactful to health concerns.

Some rituals prevent exposure to certain avoidable risks. For instance, there were many mentions that a pregnant woman should not roam around. The beliefs around the Jiloi bird might be seen as preventing the pregnant woman from being exposed to certain hazards that could be associated with night and darkness.

A few rituals and beliefs are counter-to biomedical recommendations and these are especially centered in the first few days post-partum where we see practices like avoiding cereal as part of Chhathi, not feeding colostrum, bathing the newborn within 24 hours, or treating the cordstump.

Rituals and practices intended to avoid risks are often linked to specific outcomes, such as miscarriage, which is a very common concern.

Many of the reasons given for avoiding or adding specific foods also related to miscarriage, but beauty concerns about fairness of the lips and skin were also often mentioned. Influencers reported adding foods for general health of the mother and baby whereas avoided foods had specific consequences if consumed.

ASHAs’ beliefs about rituals largely echo those of the community. Throughout the perinatal timeline, non-medical rituals are almost identical for ASHAs and the communities they serve. Hence, ASHAs need to be better equipped both in terms of their self-efficacy and counseling when such beliefs come into conflict with the advice they are supposed to give.

The rituals and beliefs of ASHAs and their beneficiaries are very similar. They practice the same kinds of rituals and express knowledge of and concern about the same set of super natural forces: Jiloi Bird, Evil Eye, Impurity, and Eclipses. Future studies could try to learn more about how ASHAs reason through conflicts between ritual beliefs and biomedical advice.

Some rituals are likely rooted in patriarchy. For instance, restrictions on movement are common but as blanket statements could be seen as preventing a woman from exercising control. Some beliefs would even limit the food consumed by mother when pregnant or lactating. It is common practice for a woman to serve food to her husband and not eat for herself until he has finished eating and consumed all he likes (an ethnographic observation of this is described in the next Chapter 4.

ASHAs’ perception of the recognition they get from the community is high and they seem to be confidant of their stature within their community. ASHAs beneficiaries also reaffirm their recognition for the AHSAs, however the recognition is specific to some select services they provide over the others.

Dais are more ‘inside the home’ than ASHAs, in terms of services and decisions. The ASHA is perceived as handling outside services and specific incentivized outcomes. This may make it difficult for ASHAs to be an agent of change for behaviors within the home.

A dimension of ASHA’s role as a connector is that sometime she is seen by the beneficiaries as someone who represents the health system, which can result in an over-estimation or miss-estimation of ASHA roles and responsibilities. For some services, the beneficiaries are also meant to receive an incentive. When there is a delay or issue with such payments back to the mothers, ASHAs may be blamed by the community due to them being the face of the health system. Yet ASHAs have no control over the payment scheme meant to incentive mothers.

ASHAs are not the only providers of maternal and child health services overall. Rather, she is the provider and facilitator of specific services. Other formal and informal health service providers (Dai, RMP, etc.) are still quite prevalent, and they interject and navigate prominently in the perinatal timeline.

There is a prevailing sense among ASHAs that several certain valued services are really under the Dai’s scope. For instance, giving a massage to the mother and child for the first six days after delivery, checking the position of the child in the womb during pregnancy and perhaps taking corrective measures if there is a misalignment. While such services are valued, overall the Dai has seen the number of perinatal duties she supports decline over time. For instance, Dais don’t oversee the delivery as often as they did before. Dais are becoming less active with certain services as regional perspectives on maternal and child health services change - in part due to the NRHM program that launched the ASHAs. In spite of this potential for conflict over services we did not find many overt references to any tensions or negative feelings between ASHAs and Dais. There are some subtle signs of it in the quantitative data that take the form of having opposing influences on some behaviors but not clear signs of conflict.

3.5.1 ASHA’s role prioritization and expectations from the system

ASHAs prioritize some of their services over others. Roles like accompanying mothers for ante-natal checkups (ANC), ensuring institutional delivery, and other incentivized services are acknowledged by ASHAs more often than their roles as counselors. It seems that the goal of being a behavior-change expert, a persuader, and creating an enabling environment to improve home-based care can get overshadowed by duties that are more target-based or mechanical in nature. This observation ended up being an important piece of evidence supporting the design driver of increasing the role of the ASHA as a cultural broker.

That the goal of being a persuasive behavior-change agent can be overshadowed by mechanical target-based duties, begs the questions:

• To what degree does ASHA see her role as a persuader?
• Do communities see ASHAs as persuasive entities of social and behavioral change?

ASHAs association with other CHWs (AWW, ANMs) is limited to certain services and CHWs do not have thorough knowledge of each other’s responsibilities. There may be an opportunity to improve the overall behavior change strategy via increased awareness of one’s own role in relation to other CHWs.

ASHAs and AWWs are certainly more health-aware, in terms of biomedical knowledge and best-practices, than are RMPs and Dais (a finding that is extremely evident in the quantitative analysis).