3.6 Chapter take-aways

In this Chapter we report the results of focus group discussions (FGDs) and key informant interviews (KIIs). We describe an extensive and complex set of traditional and biomedical perinatal rituals. We describe the occurrences, objectives and explanations of health-related beliefs and behaviors during pregnancy and postpartum. We document perceived physical and supernatural threats and the constellation of beliefs and rituals used to mitigate them. The information from these discussions was used to shape the quantitative surveys and key themes were explored further in the following chapter.

The majority of perinatal rituals are motivated to promote health or reduce harm to the baby and mother. The majority do not have negative implications for health.

Community members frequently use a range of services from different sectors. For example, it is now common for women to give birth in medical clinics (bio-medical healthcare system) and call the Dai to confirm that their labor has begun prior to going to the hospital.

The goals of perinatal health practices in high-risk contexts such as Bihar are often protective or promotive: to avoid negative outcomes, such as miscarriage, difficult labor, or birth defects, or to achieve positive out- comes, such as infant and maternal wellbeing and health.

Many health-related behaviors and beliefs are interconnected. Biomedical and traditional views often co-exist and evidence of perceived tension or conflict is fairly rare.

There are multiple examples of replacement, conflict and complementarity of traditional and biomedical health practices:

Replacement:

  • mothers who reported no longer applying mustard oil to the infant’s umbilical cord stump following birth (traditional perinatal health practice), in favor of applying nothing after the wound has dried, which is consistent with the biomedical recommendation for umbilical cord care.

  • mothers who reported no longer waiting for the Hindu pandit or Muslim maulana to initiate immediate breastfeeding (traditional perinatal ritual), which is consistent with the biomedical recommendation for immediate and exclusive breastfeeding.

Conflict:

  • continuing to apply mustard oil on the infant’s umbilical cord stump following birth, which is inconsistent with the biomedical recommendation for umbilical cord care.

  • mothers who reported delaying breast- feeding until a Hindu pandit or Muslim maulana visits the mother and infant at home (traditional perinatal ritual), and instead feeding the newborn a mixture of cows’ milk and water, inconsistent with the biomedical recommendation for immediate and exclusive breastfeeding.

Complementarity:

  • applying mustard oil on the rest of the infant’s body, but avoiding the umbilical cord stump, which incorporates traditional perinatal ritual massage of the infant following birth, and is consistent with the biomedical recommendation for umbilical cord care.

  • mothers who reported calling a Hindu pandit or Muslim maulana on a mobile phone to receive blessings from the hospital immediately after birth, which incorporates traditional perinatal ritual religious blessings to initiate breast- feeding, and is consistent with biomedical recommendation for immediate and exclusive breastfeeding.

Perinatal rituals serve multiple functions within communities. Consider Chhathi, a perinatal ritual widely practiced throughout Bihar, India, on the 6th day after birth. It serves social functions; it marks critical transitions in the lifecourse (birth and parenthood), it marks the initiation of the infant into the family, it has symbolic meaning to ritual practitioners and it reinforces social cohesion within the community. It also has instrumental functions; it is believed to reduce the risk of negative outcomes for the new baby (e.g. ward off the threat of evil eye).

ASHAs and Mothers report very similar personal health practices (another theme echoed in later chapters).

Embeddedness and liminality

Part of the rationale for embedded health care workers is that they might be effective at facilitating social change, but reviews of ASHA program have wondered if the role of service extenders overshadows that of social-change agent.

Analysis of this qualitative dataset also raises a question about the degree to which ASHA’s see themselves as culture-change agents. It seems that being a persuasive agent of change is overshadowed by emphasis on incentivized health services. We also find evidence supporting the notion that even though a commonly viewed strength of CHW programs is that they are members of the communities they serve, ASHAs are nonetheless seen as ‘outside the home’ whereas more traditional influencers, Dais especially, are ‘inside the home.’

On the other hand, many of the potential strengths of having embedded health workers are supported in this dataset. For instance, ASHAs perceive that they are highly regarded by their community. Community members reaffirm their recognition for the AHSAs.

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. ASHAs are not the only providers of maternal and child health services. 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. During the co-design process, this viewpoint developed much further as we realized that the perinatal journey is rather like a stage for the Mothers, with different constellations of influencers coming on and off the stage at different times, like actors in a play.

There is a prevailing sense among ASHAs that some services are really under the Dai’s scope. The Dai has seen the number of perinatal duties she supports decline over time. For instance, Dais do not deliver as often as they did before because of an emphasis on raising the frequency of institutional deliveries. 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.