5.4 Chapter take-aways

The biomedical and traditional practices, behaviors, and rituals presented in the chapter have been pieced together based on the insights and observations of trained PCI investigators with extensive experience interviewing women about maternal health and related practices in Bihar. These insights are not mere assumptions or anecdotes but an iteration of everything we learned through a yearlong period of research. Moreover, these female investigators have brought their experience beyond the project through their decade-long contribution in hundreds of studies in Reproductive, maternal, newborn, and child health (RMNCH).

This chapter presents Roshni’s journey chronologically in tabular format, which starts even before the actual pregnancy begins. And this interview provided us with a unique opportunity to explore the precursors of pregnancy and how these expectations, practices, and rituals manifest and associate with behaviors (both biomedical and traditional) and rituals prevalent during the perinatal timeline. We divided the journey into five timeframes: pre-pregnancy, first trimester, second trimester, third trimester, and few initial weeks after birth.

These insights provide an experiential view of pregnancy in rural Bihar, where biomedical, traditional, religious, and cultural practices coexist and sometimes co-influence and co-regulate each other. For this very same reason, we did not segregate these behaviors in subcategories to emphasize the interconnectedness, embeddedness, and continuity of this journey. Moreover, We illustrate the roles of various health and non-health influencers during the perinatal timeline and when and why they become relevant through this journey. The chapter reaffirms the project hypothesis of a complex ecology of health behaviors through a rich and holistic representation of perinatal experience in rural Bihar.

Next, we describe the most salient empirical findings from this data stream based on the core themes of Project RISE:

Lived Experience

The narrative documents the relevance of religious and cultural beliefs in influencing behaviors during the perinatal journey and the interaction between these beliefs and biomedical behaviors. One interesting example is the belief in witchcraft known as ‘Godi Sun Karna,’ where a woman trying to conceive and perhaps struggling to get pregnant steals the thread from the cloth worn by a pregnant woman. Many miscarriages are attributed to this curse, and it causes Roshni to head advice about avoiding markets and not roaming around. This avoidance can impact access to services and checkups. Another example is the belief in traditional health practitioners, pundits, and maulanas to treat ailments with their knowledge of traditional medication and divine powers. Sometimes, pundits provide special ‘kheer’ to grant male children or prescribe special herbs and medicines for women trying to conceive. In some Muslim families, when the labor starts, ‘Maulvi’ (Muslim priest) provides consecrated oil and water for the pregnant woman. She drinks the water and applies the oil on her hair to ease the pain and quicker delivery. These are a few of several examples where these non-health influencers play an active role in the perinatal journey and influence health behaviors.

Connectedness

From the point of view of the mother and her family, pregnancy is not an aggregate of isolated events like registration, ANC checkups, delivery, etc.; instead, it is a busy and active timeline with multiple behaviors, traditions, and beliefs linked and overlapped with one another.

There are multiple examples of replacement, conflict, and complementarity of traditional and biomedical health practices. During the initial 3-4 months, Roshni and her family hide the pregnancy from everyone, including the ASHA. There are multiple reasons for it, including fear of evil eye, embarrassment (especially for young mothers), and misfortune. In some cases, women do not want to take any modern medicine or vaccine too early in the pregnancy because they perceive modern medicine and vaccines as harsh, which can create complications when the fetus is in the early stage of development. The combination of these beliefs leads to a delay in revealing the pregnancy to ASHA, which delays the registration and subsequent ANC checkups. One example of complementarity is the ritual called ‘God Bharai’ and its older version ‘Sadhoar.’ These rituals are celebrated in 6-7 months of pregnancy to celebrate the child’s expected birth, and one of the key activities is to offer at least five varieties of fruits, sweets (sonth ladoo), Yogurt to the pregnant woman. The practice is based on the belief that if a pregnant woman craves anything but doesn’t eat what she is craving for, the child may have similar issues mentioned above after birth. This ritual aligns very well with promoting diversity in a pregnant woman’s diet, and it can be extended to diet diversity during lactation.

Embeddedness

The narrative provides another opportunity to illustrate the dynamic and complex landscape of biomedical and traditional beliefs prevailing in the community and multiple influencers, which bring certain constraints and opportunities for ASHA’s services. One such example of a constraint is the mid-pregnancy move of women from their in-laws’ home to their parents. This practice has its benefits and challenges. While staying at their parents’ place may help young women manage the anxiety and stress of their pregnancies due to familiarity, openness, and reduced responsibilities. However, this move abruptly interrupts the building relationship with the ASHA, which can affect her influence on health behaviors. Moreover, when the woman goes to her parents’ home, it becomes difficult to develop to establish a good rapport in such a short time, which again can limit the influence. Another example is the varied perspectives for public and private health care in the community. While ASHAs are well respected in the community, these perspectives guide certain behaviors. Another example is of ANC checkup, where pregnant women go for TT injection and essential checkups during the VHND sessions when invited by the ASHA. However, due to limited services at the VHND and lack of trust in public hospitals for costly and high-end tests, they go to private clinics for ultrasound checkups. The influence and cordial relationship of ASHA may not work if the community lacks confidence in the quality of the service itself.