12.7 Closing Thoughts

The ritual content of the perinatal journey in Bihar, and anywhere else, is vast and complicated. We used several in-depth methods to document and understand as much of this ritual fabric as we could. We found many particular fascinating beliefs, such as the worry that a jealous woman can steal an unborn child by pulling a string from the sari of a pregnant woman if she goes out in public. We learned about a special bird called jiloi that was frequently referred to as a source of risk for pregnant women. The jiloi bird clearly had the effect of restricting movement of pregnant women, especially at potentially dangerous times like the night or early morning. However, we could not definitively determine if the jiloi bird is a ‘real’ bird or mythological. In one FGD we were told with confidence that it is not a an owl or a bat. We learned of many precautionary measures to avoid evil eye and that the eclipse is an especially dangerous time during which pregnant women should not even handle scissors or sharp objects.

Most of these rituals and beliefs had biomedical implications that were neutral or seemingly quite minor in concern. They were all motivated by a desire to promote health or avoid risk, even ones that do seem problematic from a strictly global-health perspective. For example, the view that a pregnant woman should not over eat for fear of having a baby that is too large and hence causes a difficult labor was common. Biomedically, the recommendation is to substantially increase the diet during this time. However, some Mothers we talked to do not increase their diets during pregnancy and many even reduce the amount of food they eat. Which is especially concerning in an area where many women begin motherhood in a state of nutritional stress. As such, this is a belief for concern but it is nonetheless motivated by desires to promote health and avoid risk.

We also learned a great deal about the positioning of the ASHA. This increased understanding for the ASHA’s role as an interface, or this ‘insight hiding in plain sight’ (because it is contained in the very description of her role) has far reaching implications. Sometimes the ASHA cannot be in the home at times when her messages need to be. The Dai is sometimes in this space, but often has the directionally opposite influence on the behavior of interest. Ritual could be leveraged as a tool to help the ASHA reach more trusting relationships earlier on in the lives of Mothers, or could help establish a connection between a woman and her ‘new’ ASHA after she moves in with her husband’s family. In the previous section we gave two examples for what forms these rituals might take (Figure 12.9 and Figure 12.10). We also think that stronger relationships with the Dai could be facilitated with ritualistic approaches that tie themtogether as they serve a common purpose.

The ASHA is most clearly ‘in the middle’ when it comes to neutral and traditional behaviors. The Dai and families influence most such behaviors more than she does, but the ASHA is clearly closer to the families and households than any other actor affiliated with the formal medical system. This liminal nature of the ASHA was remarked upon or empirically supported in all aspects of the project. Exploring how this in-between state creates tensions that we can help relieve or opportunities that can be more effectively leveraged is an important area for further study.

Some of the behaviors that the ASHA is charged with influencing have increased dramatically in uptake. These include behaviors like institutional delivery and ANC registration. Behaviors that are ‘inside the home,’ and some that seem clustered around delivery, may be more difficult to change. These include treating the cord stump with a substance, bathing the newborn within 24 hours, or increasing the diet during pregnancy. For the ASHA to extend her reach she will need new tools or a shift in role perception where she shifts from service-extender to social-change agent.

We also realized the importance of drawing a distinction between ASHA-as-person and the ASHA program. For evaluations of ASHA efficacy, it is important to focus on factors that occur at the level of individual ASHAs from those that occur at the programmatic level. We recommended many ways that the program could find ways to remove barriers to service delivery that help extend the reach of the ASHA’s high efficacy. We also realized that the program assumes a ‘deficit model’ as the primary tool of persuasion that it encourages the ASHA to use. This inadvertently interferes with the potential of the ASHA to be a mobilizer and cultural facilitator.

Lastly, evaluations of the ASHA program often contain inherent contradictions. The ASHA receives very little medical training and her realized strengths are supposed to be tied to her intimate knowledge of local beliefs and rituals, not of medical knowledge. Yet, many evaluations will question the ASHA’s efficacy based on evaluations of medical knowledge without providing a context for interpreting the scores or considering factors closer to the ASHA’s immediate skill set. An ASHA 2.0 is possible and the time is right to re-imagine this aspect of a complex medical system. Doing so will require broad reform; reform that targets ASHA’s abilities as a cultural facilitator and shifts away from rote presentation of checklists and simple biomedical recommendations. Our work shows that the ASHAs of Bihar are highly effective, but their potential can be expanded with the proper support.