Field Notes in Maternal Health

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Here is my newest piece for the Lancet Student. Enjoy!

Field Notes in Maternal Health: Discovering the Role of a Daimaa

I visited India earlier this year to study maternal and adolescent anemia and childbirth practices in rural Rajasthan. In Rajasthan and much of India, maternal mortality continues to be a leading cause of death amongst young women, such that India and Nigeria alone contribute to one third of all maternal deaths worldwide. (1) Between interviews and hospital visits, I spent much of my time with Dhuli Bhai and three other Traditional Birth Attendants or Daimaas, village level women who have been respected in their communities for centuries for their understanding of rudimentary medicine and birthing skills.

As India has progressed, their role and, in many ways, their stature in the eyes of the Indian government has diminished. (2) Many Daimaas have been marginalized and have been viewed as lacking adequate medical training and formal education. Additionally, India has pushed for the modernization of childbirth, has encouraged institutional deliveries, and even has implemented programs, such as the Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram, which incentivize women to visit local institutions for their delivery, rather than conduct deliveries at home under the attendance of a Daimaa.

Yet in the villages of rural Rajasthan, the role of the Daimaas remains fixed and powerful. Dhuli and other Dai’s are revered in their communities and villagers visit them to receive remedies for anything, from a common cold to postpartum complications.

One morning at 3:15 am, I woke up to the sound of Dhuli Bhai’s* voice. “Wake up, Priya. Woh thayaar hain,” she said, nudging me from sleep. This meant that “she,” one of the neighborhood women, was ready for her delivery and we needed to go with her to the hospital. I rubbed my eyes groggily, quickly changed my clothes, and off we went.

That morning, I watched Dhuli serve as a guide for maternal health – bringing a young woman to the local hospital for her delivery and later providing her with postpartum care. I walked with Dhuli through a rock-studded path in the mountains. She carried a large bag with her which contained emergency birthing equipment.

It was still dark outside, with the hush of the night interrupted only by the rustling of the corn fields and it took us forty minutes to reach Meera, a twenty-year old woman who was about to deliver for the first time. As we walked, I spoke to Dhuli about the process of childbirth in her community and what it was like to be a Daimaa. Did she enjoy taking women to the hospital? How did she decide whether to go to the hospital or to conduct the delivery at home?

Dhuli bhai peered back towards me with a wise and forgiving smile, and replied, “I always encourage women to deliver at the hospital, as this is what the government suggests. But Priya, remember that having a hospital doesn’t necessarily mean much. Hospitals are far away and not always great, and women sometimes deliver on the way there.” She paused momentarily to catch her breath. “If the delivery takes place at night, people fear that they will be beaten or murdered on the path to the hospital by “gundas” (thugs).” As she said these last words, I looked up at a dark, starry sky and a sliver of fear encircled me.

When we finally arrived at Meera’s house, we were greeted by her mother, father, siblings and her husband. Everyone had a cup of chai in their hands and anxiously paced around the front of the house anticipating the arrival of Meera’s child. Meera lay on a cot outside resting.

As we waited, I sat down next to her holding a maternal health textbook in one hand which Dhuli Bhai curiously peered towards. She noticed a picture of the birth canal and confidently went on to describe the process of implantation and embryogenesis as she had seen in the field. Her words were a reminder to me that a woman who had had less medical training than I had, still knew so much.

In the next hour, we waited for five or six more family members to arrive and all eleven of us made our way in a tempo to a government hospital in the neighboring state, Gujarat. When we finally arrived several hours later, the hospital was packed with throngs of women waiting for a delivery bed, a few nurses in white coats weaving between rooms, and a small child cleaning the floors. Dhuli Bhai noticed quickly that Meera was ready for her delivery and rushed to inform one of the nurses.

We were allowed to skip a long line and Meera was then brought to a bed where she was given half a tablet of misoprostol to promote forceful and faster contractions. Her delivery was then conducted hastily by a nurse-in-training without the use of anesthetic, and Meera was told not to cry.

All the while, I watched as Dhuli held Meera’s hand, rubbed her forehead, and later rejoiced when the baby was finally born. However, unlike many deliveries I had witnessed in the United States, there was no mother to fetus interaction or bonding and the little boy was whisked away to another room surrounded by family members who dressed and played with him.

Meera, Dhuli, and I remained in her delivery room where the mood was somber. Meera remained in pain. I looked at her and tried to smile, but she did not smile back. “Can I have some water?” she asked. I quickly poured a cup for her, she gulped it down, and then closed her eyes.

Meera and her new baby boy would meet a few hours later to begin breastfeeding and for a “check-up” by the attending doctor who took a quick look at Meera, asked when she delivered, and left. This was in stark contrast to the way Dhuli Bhai spent many hours speaking to Meera about how to care for her baby and sharing ways to take care of her own health post-pregnancy.

In watching Meera’s delivery that day, I realized that birthing practices, even in a private hospital setting, did not meet my expectations and that conditions were often hurried and painful. Despite these conditions, Dhuli Bhai and the other Daimaas provided support and a last resort when the hospitals weren’t working.

As a future physician, I recognize that global health delivery is complicated. Physicians and public health practitioners grapple with encouraging women to go to a hospital where they may receive less than optimal quality of care or stay at home where they might face the risk of a complication. At the hospital level, there is also a constant economic conundrum as to whether it is better to hurriedly perform 100 or more deliveries in a day to meet the vast demand, or to take time and give each woman quality care. Essentially, while India has progressed in enabling women the opportunity to deliver at hospitals, quality still often lags behind.

In the interim, as we develop healthcare infrastructure and increase the excellence of hospital care, one thing we can do is partner with women like Dhuli Bhai who are intelligent, compassionate, have immense hands-on knowledge, and are willing to learn and improve the care women receive. Training Daimaas is especially important given than nearly 60% of deliveries in India continue to occur at home, despite India’s push for hospital-based deliveries. Ultimately, a Daimaa may be the only person to provide medical assistance. (3)

According to a recent UNFPA study, trained midwives have the unique capability to fulfill 87 percent of essential interventions needed by mothers and newborns. In a study based in Pakistan, Jokhio et. al found a 20% reduction in perinatal death when traditional birth attendants were trained appropriately. (3) Additionally, it has been noted that a 25% increase in effective midwifery can reduce maternal mortality by 50 percent. (4) In light of these findings, we must capitalize on the contextual knowledge that Dai’s possess and provide them with appropriate and safe midwifery training that builds on their existing knowledge. Instead of discarding the role of Dai’s, we must empower and provide them the tools to improve the delivery of care.

Throughout the world, childbirth is not equal; it is contextually defined, and bound by access to quality healthcare and trained health personnel. In spite of these complexities, by forming partnerships with the right people, there is a path forward.

Priya Shankar is an MD/MPH candidate at the Boston University School of Medicine and Harvard School of Public Health.
*Names have been changed to protect patient identity

Works Cited:
(1) Maternal Health in 1990-2013. World Health Organization.
(2) How Midwives Can Answer the World’s Maternal Health Woes. May 2015. The Wilson Center New Security Beat.…
(3) Madhivanan, P et. Al. Traditional Birth Attendants Lack basic information on HIV and safe delivery in rural Mysore, India. March 2010. BMC Public Health.
(4) Kennedy, Holly. The Lancet Series: The intersection of global and local midwifery. The Wilson Center.>

Happy Holidays!

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I love this season – maybe it’s because it is my birth month, but I’ve always loved the color of the leaves, the sound of Christmas music, and the feel of the crisp winter air on my skin.

The winter also heralds my next trip to India – this trip is particularly special for me for a number of reasons. I will be working on creating an initiative for girls which my fiancé and I will pilot. My fiancé, another student and I have spent months of effort designing and working on it with the help of many physicians, the Maternal Health Task Force, the Public Health Research Institute of India, and the Women and Health Initiative.  For me, this project is the culmination of over ten years of learning about India and understanding the health of girls and women.

I have no idea where it will go, but I’m excited to give it a shot! Winter will involve the start of this project, tons of shopping, and a lot of yoga!

Wish you all a wonderful holiday and safe travels!


Baby steps

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Sometimes the greatest progress is not tangible.

It is that which changes within us or the day to day changes we make in our lives.

Sometimes it’s in our mindset, or in our perception about ourselves and others. Sometimes it’s in the people we choose to surround ourselves by or collaborate with. Sometimes it’s in the acceptance of ourselves as we are.

This last few months have given me the progress I’ve been needing on many of the maternal and child health-related projects I have started, but what I’m most proud of is the day to day changes and the improvements I keep working towards within.

Wishing you all another many months of self reflection, personal empowerment and improvement!

Wellness: gratitude

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I am grateful. Period.

I don’t think I say that enough. There were days during my first, second, and third years of medical school when I wondered if I was on the right path.

Somehow at those moments of despair, the right people have always entered my life –
Encouraging, motivating, collaborating, and willing to allow me to dream.

– for all of the love in my life: those people who provide strength and nurturing, and the ones who I get to shower love onto.

– to the heaviness of dreams. I love the idea of the years ahead balancing a career as a public health practitioner and a physician focusing on maternal and child health.

It all seems so real now and it is almost scary! All of the things that I have said I will do, can happen sooner than I ever imagined. Providing hands on medical care to a child or young woman is going to be possible faster than I thought it would be. The combination of research with action seems attainable finally.

– to passionate public health classmates and medical students who push me to follow through with ideas and to collaborate.

– to dance and the work ethic, focus, and persistence it has always taught me.

– to the uplifting force of family

Here’s to being willing to take a leap forward and for the many steps and people who have made a journey!

Empowerment: feeling ready

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“It’s a terrible thing, I think, in life to wait until you’re ready. I have this feeling now that actually no one is ever ready to do anything. There’s almost no such thing as ready. There’s only now. And you may as well do it now. I mean, I say that confidently as if I’m about to go bunjee jumping or something – I’m not. I’m not a crazed risk taker. But I do think that, generally speaking, now is as good a time as any.” -Hugh Laurie, actor, more popularly known as Dr. Gregory House

I’ve had a certain dream that I’ve held onto for ages – since I was a little girl. I’ve always told myself I’ll make it happen when I’m older and ready.

I am older – and I am beginning to realize that the time is now.

Health: Boston trauma

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Just saw that they’ve created a show on BMC trauma, and I swelled with pride. I spent four of the best weeks of medical school on trauma surgery and absolutely loved it – it made me fall in love with the practice of surgery and develop an incredible respect for these doctors. It’s the only rotation which has pulled me, even slightly, away from my passion in maternal and child health.

Below you’ll find two of the people I love and who inspired me so much during my time in the OR.
image– Dr Tracy Dechert and Dr Chinwe Kapaduwa.

Wellness: Words on a Page

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A poet’s work is to name the unnameable, to point at frauds, to take sides, start arguments, shape the world, and stop it going to sleep. – Salman Rushdie

In the past few months, I have found small and big ways to work on the art of writing. I try and spend 15 minutes a day outside with a piece of paper and a pen, sometimes writing new things, sometimes editing things I have written.

Many, in fact, probably all of these initial scribbles are bad, poorly written, and not worth sharing.

At times, though, I find myself transported deep into my memories. When I am at the heart of a memory, I can feel the pain, emotion, fear and joy intensely.

I remember my exact grimace, and the goose bumps that slithered up my arms.

I remember how tears were the secret ingredient in the food my mother made that morning.

I remember the way my heart felt choked by the hands of another; how I tried to focus on the sound of the cars passing by.

I can see the dark blue sky that day, and the way the clouds cried in the night. I can smell the scent of wilted daffodils. I can feel the warmth of an embrace, and the presence of people – hundreds of them – flocking in and out of my house.

I can hear the cruelty of silence.

When it all seems too real, I wake up from my reverie to find my eyes coated in tears. And this, is when the words flow freely.