Profiles and Perceptions of Traditional Midwives in Informal Settlements in Mumbai City

 Table of Contents

 I. Literature Review

1.1 Introduction

1.2 Role of Midwives/Traditional Birth Attendants (TBA)

1.3 Profile of Midwives

1.4 Cultural Practices around Birthing

1.5 Decline of Mid-wives post independence

1.6 Maternal Mortality: A global National Assessment

1.7 Preference for home births and key role of the TBA

1.8 Value of the TBA and the need for culturally specific training programmes

1.9 Rationale for research study

1.10 Why informal settlements?

1.11 Expected Outcomes

1.12 References

II. Aim of the Study

III. Research Questions

3.1 Main Research Questions

3.2 Sub-Questions

IV. Methodology

4.1 Analyzing Previous Data Collected

4.2 Designing the Interview Schedule

4.3 Approval by SNEHA’s Research Committee

4.4 Consent and Information Sheet

4.5 Interviewer Guidelines

I.  Literature Review

1.1 Introduction                                                                       

Since time immemorial, designated women within a community have held responsibility for assisting women through child birth and providing comprehensive maternal health care. Contemporary medical establishments refer to them as midwives or traditional birth attendants (TBAs). The 1973 consultation on the role of the TBA defined the TBA as “a person (usually a woman) who assists the mother at childbirth and who initially acquired her skills delivering babies by herself or by working with other TBAs (Elizabeth Leedam, 1985). Over the years, rich cultural practices and indigenous knowledge related to the process of birthing were passed from one generation of mid-wives to the next orally. These rich oral traditions include important rituals at various stages of a woman’s pregnancy, fertility rites, goddesses invoked during the birthing process to facilitate a delivery, taboos, herbal medicines etc.

1.2 Role of Midwives/Traditional Birth Attendants (TBA)

In many countries 60 – 80% of deliveries are assisted by traditional birth attendants (Elizabeth Leedam, 1985). Responsibility for care of the newborn is assumed by the local dui or midwife who visits daily and spends hours massaging the mother and the newborn. The other women of the house look after the newborn in the absence of a dai (Choudhry, 1997). The strength of the TBA stems from the fact that she is part of the cultural and social life of the community in which she lives. Traditional medical practitioners and birth attendants are found in most societies. They are often part of the local community, culture and traditions, and continue to have high social standing in many places, exerting considerable influence on local health practices (Elizabeth Leedam, 1985).

The TBA’s role is always associated with the actual birth process, but in some instances her influence extends to prenatal and postnatal period. Prenatal care is invariably given in the form of advice or instructions. “What to do or eat” or, more usually, “what not to do or not to eat” reinforce the local beliefs. Abdominal massage is frequent, and the giving of herbal remedies for pain, sickness or discomfort. Additionally, the role of a TBA frequently extends into the intraconceptual period and involves giving advice or treatment to prevent infertility, to procuring abortions or measures to prevent conception. Her influence is sometimes felt in other aspects of community life. She may advise families on their health problems, look after children when they are ill, conduct rituals when girls reach menarche, perform rituals at weddings, circumcise female children, help with cooking and housework of her clients, particularly during the delivery and postnatal period. (Elizabeth Leedam, 1985)

1.3 Profile of Midwives

The TBA is usually an older woman, almost always past menopause, and has borne one or more children herself. She lives in the community in which she practices. She operates in a relatively restricted zone, limited to her own village and sometimes those adjacent. Her role includes everything connected with the conduct of childbirth and this is the sphere in which she holds most power and authority. Many of her beliefs and practices pertaining to the reproductive cycle are dependent on religious or mystic sanctions. They are reinforced by rituals that are performed with traditional ceremonies which are intended to ward off the causes of ill-health. She adheres rigidly to the dietary rules of her community and assumes an important role in the transmission of ideas concerning the nature and effects of food.

The TBA is often an accomplished herbalist, whose knowledge and use of herbs, roots and barks may be quite extensive. lnfusions of herbs are frequently prescribed to relieve discomfort during pregnancy, to speed up delivery, as abortifacient and for treating dysmenorrhoea and certain types of illness. To common problems she works out solutions within a framework of values and beliefs shared with her client. She participates in the same cycle of cultural activity and is a recognized member of the same social universe.

Typically the TBA is illiterate and has had no formal training. She has learned her craft from a member of her family or kin group or under the tutelage of an older TBA. Probably her first clients come from her own kinswomen and close friends. Her reputation once established within the circle of her family, she may be called by women outside her immediate group. As a rule she inherits, as clients, the daughters of the women attended by her TBA sponsor.

The case load of the TBAs will vary depending on the geographical setting, the population density and what form of transport is available. The urban-based TBA, for instance, may have 70 or more deliveries a month whereas the rural one will probably have no more than 5. In countries where it is the custom for a mother to be delivered by a family member, the case load could be as low as 5 per year. The working life of a TBA, when her practice starts after menopause, is probably about lo- 15 years. (Elizabeth Leedam, 1985)

1.4 Cultural Practices around Birthing                  

“Childbirth is an intimate and complex transaction whose topic is physiological and whose language is culture” (Jordan, 1982, p. 182). The cultural context in which childbirth occurs provides norms that influence attitudes, values, and interpretations of personal and interpersonal experiences (Mercer & Stainton, 1984). Pregnancy and childbirth are thus almost universally associated with culturally based ceremonies and rituals. Mead and Newton (1967) reviewed the literature on 222 cultures and found that all had beliefs about appropriate behavior during pregnancy, labor, and the postpartum period. Foods to eat, activities to avoid, and care and behavior during delivery and the postpartum period are all culturally prescribed (Choudhry, 1997). Ceremonies play a major part in the prenatal care and give the mother a sense of security as she too shares the beliefs of the TBA (Elizabeth Leedam, 1985).  Cultural beliefs and practices thus influence the woman’s experience and shape mothering behavior (Choudhry, 1997).

In India, cultural traditions vary across communities. However, some common trends have been identified. Women usually are isolated during labor, delivery, and for a specified postpartum period. A sickle, fire, and water commonly are kept near the delivery bed to ward off the evil spirit (Walia, 1982). The placenta may be disposed of by burying it with the garbage, under the floor of the room where the birth occurred, or in the courtyard of the house. The placenta is buried to keep an enemy or evil spirit from seizing it and influencing the well-being and longevity of the child. Furthermore, Walia (1982) reports that many families pat the burial site of the placenta whenever the infant falls sick in order to help his or her recovery. Interestingly, these practices are not observed if a woman delivers in a hospital (Choudhry, 1997). Additionally, there are frequently, traditional methods for predicting the date of delivery. (Elizabeth Leedam, 1985)

1.5 Decline of Mid-wives post independence

Post – Independence period saw a sharp decline of the role of midwives on account of several State health policies and rural initiatives. India had well-trained European and indigenous midwives during the time of British rule. The strong midwifery profession lost its importance after independence for various reasons. As a result maternal mortality remains high in India. Evidence shows that maternal deaths can be averted by the presence of a skilled birth attendant at the time of childbirth. In spite of global evidence of effectiveness of well-trained midwives and skilled birth attendants in reducing maternal mortality, the Government of India has chosen to provide a short (two to three weeks) refresher course to female multipurpose-workers. Historically, these workers were trained for 18 months as auxiliary nurse midwives (ANMs) and conducted deliveries. However, since the 1970s, their role has changed; few of them conduct births on a regular basis in the community, and most focus on family planning and immunisation. As a result, most have lost their skills for conducting births. Under British rule, India started to develop a good midwifery- based maternal health-care system. In those days, doctors were infrequently available in rural areas and had similar expertise as skilled midwives in birth care. However, independent India veered away from the midwifery-based maternal health system (Mavalankar, Raman, Vora; 2010)

Reasons for the dilution in the midwifery profession, include amended regulations, lack of social or political priorities, and change in health programme directions. A fairly strong and independent profession of midwifery gradually got diluted and merged with the cadre of nurses. Thus, their contribution to maternal health was neglected, one of the reasons for persistently high MMR and the poor quality of maternity care. Thus, Indian midwives are ‘missing in action’ and a large number births are still being conducted by TBAs at home (International Institute of Population Sciences, 2006).

1.6 Maternal Mortality: A global National Assessment

Worldwide, about half a million mothers lose their lives every year, due to child birth and from related complications (Koblinsky and Campbell, 2003). About 90% of these maternal deaths are in the developing world (WHO, 2007). In other words, every minute of every day, somewhere in the world and most often in a developing country, a woman dies from complications related to pregnancy or childbirth. That is 515,000 women, at a minimum, dying every year. Making maternal mortality the health statistic with the largest disparity between developed and developing countries. (Maine, 2009)

India’s maternal deaths account for 25% of the total global maternal deaths (WHO, 2007). Tragically, India has a high MMR inspite of a long history of programmes to improve maternal health, which is primarily due to lack of consistent policies and absence of focus on evidence-based interventions (Ved and Dua,2005). Along with these policy-level issues, certain background factors have also contributed to the increase in maternal mortality, including anemia, malaria, malnutrition, poverty, low status of women, and low education levels among women, etc. (International Institute of Population Sciences,1999; Rush, 2000;UNICEF,2000). Most of these deaths are due to preventable causes such as hemorrhage, sepsis, pregnancy-induced hypertension and abortion-related complications.

1.7 Preference for home births and key role of the TBA

As previously stated, in many developing countries it is normal for childbirth to occur at home. Studies have shown that mothers particularly in rural areas, tend to prefer the services of TBAs for delivery of their babies and that in some countries the formal maternity health care services are underutilized. Of the 27 million births that take place in India every year, more than 12 million births (52 percent) take place at home (Koblinsky, Campbell, Heichelheim; 1997). There is ample evidence showing that labouring at home increases a woman’ likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.

However, there is no question that skilled maternity care has lower maternal and infant mortality and morbidity rates than the practice of TBAs, whether trained or untrained. Maternal mortality is high in countries with high incidence of home births, reflecting the difficulty of achieving success with this model. Nevertheless, it is clearly desirable to make this model work, since nearly half the women in developing countries give birth at home in the presence of unskilled attendants. Good results have been obtained on a large scale in rural China and at project level in Forteleza, Brazil. (Koblinsky, Campbell, Heichelheim; 1997). If the service is provided by midwives committed to this type of practice within continuity of care schemes and appropriately supported, outcomes are likely to be optimal.

Increasingly countries are recognizing that the TBA will represent a major resource where women do not have access to services for either cultural or geographic barriers. The effective use of this resource will require an understanding and appreciation of the TBAS role and contribution by all health authorities, flexibility in the development of training programs and the cooperation of the TBAs themselves. (Elizabeth Leedam, 1985). Recognizing and respecting traditional practices and including family and friends will enhance the woman’s sense of well-being. (Choudhry, 1997)

1.8 Value of the TBA and the need for culturally specific training programmes

The value of the TBA to health care lies in the fact that she is an individual whose roots are embedded deep in the traditional, cultural and social life of the community. These roots should not be disturbed by in cautious intervention, which risks distancing her from the community. Her articulation with the health services must strive to achieve the correct balance between the TBA’s traditional setting and the needs of scientifically- based formal health care. (Elizabeth Leedam, 1985)

The development of midwifery-based maternal care could not only reduce maternal mortality but will support a reduction in the over-medicalisation of birth, and the increasing caesarean section rate which is happening in parts of India, especially urban private sector(Mishra andRamanathan,2002). Midwives can also provide reproductive and neonatal care services where they are badly needed at low cost (Hatem et al.,2009).  We have in fact more and more evidence that medicalising birth has serious consequences, both physical and psychological. The VGDHS10 into postpartum haemorrhage showed a concerning rise in placenta praevia and hysterectomy and these are strongly linked to the rising caesarean section rate (Dahlen, 2006). Developed countries such as Sweden were able to reduce maternal mortality using the midwifery model of care before industrialization. The development of an effective midwifery led maternal health and women’s health service could reduce the burden on obstetricians so that they could focus on more complicated health problems in pregnancy and labour. (Mavalankar, Raman, Vora; 2010)

1.9 Rationale for research study

Research studies indicate a need to understand TBA profiles and plan training programmes accordingly. If India continues to focus on ineffective strategies for training TBAs and community volunteers, or short training of ANM without providing of rural midwifery services, maternal and neonatal mortality rates will not decline (Mavalankar, Raman, Vora; 2010). Till date is no answer to what activities a TBA should  undertake, the best means of teaching her, the type of support care she needs. This will vary from one TBA to another, from one country to another. There is need for valid assessment of her work as a basis for decision making in the future. (Elizabeth Leedam, 1985)

In order to increase this understanding of midwives, it is imperative to document and thus highlight their traditional health practices. This study aims to document oral histories of Mid-wives pre-post independent India residing in informal urban settlements of Mumbai so as to highlight maternal health related belief systems, indigenous to each community covered under the project. Additionally, it will aim to document cultural practices and indigenous knowledge related to the process of birthing that are traditionally passed from one generation of mid-wives to the next orally so as to collate this rich knowledge base that is being severely eroded by forces of migration, globalization and State health policies. To retrieve material related to important rituals, fertility rites, goddesses, taboos, herbal medicines etc. used by midwives from communities covered under the project, in an attempt to preserve these otherwise oral traditions. The research study will also analyze the impact of State health care policies, globalization and migration on the traditional practices of midwives

1.10 Why informal settlements?

A 2010 a SNEHA study in 48 slums estimated that over 32 000 annual home births took place in Mumbai’s slums. Seventy percent of home deliveries were assisted by a traditional birth attendant (dai), and 6% by skilled health personnel. In an adjusted multivariable regression model, the odds of home delivery increased with illiteracy, parity, socioeconomic poverty, poorer housing, lack of water supply, population transience, and hazardous location (Das, Bapat, More, Chordhekar, Joshi , Osrin; 2010). Given this disparity, the study will focus on informal urban settlements comprising primarily of unregistered slums across Mumbai, given that these areas do not receive the level of facilities and services provided to slums on Bombay Municipal Corporation land established before 2000. As a result, these communities largely access informal health services and care providers. Research indicates that traditional midwifery practices are more deeply engrained within such communities as opposed to formal settlements with access to institutional health facilities.

1.11 Expected Outcome

This research study aims to document existing yet informal knowledge that women have about their own health, specifically maternal and reproductive health practices – that is largely devalued by current formal health systems. It aims to do so by highlighting the rich tradition of midwifery through documenting maternal health related belief systems, traditional cultural practices and indigenous knowledge related to the process of birthing that are orally passed from one generation of mid-wives to the next – of dais covered through the project.

 

1.12 References

1. Choudhry UK. Traditional practices of women from India: pregnancy, childbirth, and newborn care. J Obstet Gynecol Neonatal Nurs. 1997 Sep-Oct;26(5):533-9.
2. Birthing Practices of Traditional Birth Attendants in South Asia in the Context of Training Programmes. Journal of Health Management. June, 2010 12: 93-121
3. Bahl, Taru. Bring the Midwife Back into the NRHM Model. LiveMint.com, Wall Street Journal. 14 Aug. 2008.
4. Chawla, Janet, ed. Birth and Birthgivers: The power behind the shame. New Delhi, India: Shakti Books, 2006. 11-312.
5. Hearing Dais’ Voices: Learning About Traditional Birth Knowledge and Practice. MATRIKA, Plan International.
6. Janani Suraksha Yojana: Features & Frequently Asked Questions and Answers. Ministry of Health and Family Welfare. Maternal Health Division, Government of India. New Delhi, 2006.
7. Janani Suraksha Yojana: Guidlines for Implementation. Ministry of Health and Family Welfare. Government of India. 2004.
8. Dahlen H. Midwifery: at the edge of history. RPA Women and Babies. Missenden Road, Camperdown, NSW 2050, Australia. 2006 Mar;19(1):3-10.
9. Mavalankar D, Sankara Raman P, Vora K. Midwives of India: Missing in action. Public Systems Group, Indian Institute of Management. Ahmedabad, India.
10. Piper CJ. Is there a place for traditional midwives in the provision of community-health services? Ann Trop Med Parasitol. 1997 Apr;91(3):237-45.
11. Koblinsky MA, Campbell O, Heichelheim J. Organizing delivery care: what works for safe motherhood? Bull World Health Organ. 1999;77(5):399-406. MotherCare/JSI, Arlington, Virginia 22209-3100, USA.
12. Sundari TK. The untold story: how the health care systems in developing countries contribute to maternal mortality. Int J Health Serv. 1992;22(3):513-28. Centre for Development Studies, Trivandrum, Kerala, India.
13. Leedam E.  Traditional birth attendants.  Int J Gynaecol Obstet. 1985 Sep;23(4):249-74.
14. Extending quality maternity care further into the community. Safe Mother. 1993 Feb;(10):4-5. Indian J Matern Child Health. 1990 Jan-Mar;1(1):29-30.
15. Bhardwaj N, Yunus M, Hasan SB, Zaheer M. Role of traditional birth attendants in maternal care services — a rural study.
16. Das S, Bapat U, More NS, Chordhekar L, Joshi W, Osrin D. Prospective study of determinants and costs of home births in Mumbai slums. Society for Nutrition, Education and Health Action (SNEHA), Urban Health Centre, Chota Sion Hospital, 60 Feet Road, Shahunagar, Dharavi, Mumbai 400017.
    

 

II. Aim of the Study

A.  To document life stories of Mid-wives residing in informal urban settlements of Mumbai

B.  To document cultural practices and indigenous knowledge related to the process of birthing that are traditionally passed from one generation of mid-wives to the next

C.  To highlight maternal health related belief systems, indigenous to each community covered under the study

D.  To document the contribution that dais make to the maternal health of their communities

E.   Analyzing the impact of State health care policies on the traditional practices of midwives

 III. Research Questions

The study will seek information along the lines of primarily 5 Research Questions and their related sub-questions. These have been listed below:

3.1 Main Research Questions

• What are the factors that contributed to women becoming daies?
• How do daies receive their training or information in delivery practices and pass these on to the next generation?
• What are the specific community based maternal health related belief systems, cultural practices and indigenous knowledge of birthing?
• What is the contribution that daies make to the maternal health of their communities?
• What has been the impact of State health care policies on midwives from these communities?

3.2 Sub-Questions

• What are the socio-economic conditions of dais residing in informal urban settlements of Mumbai?
• What are the dais own experiences of child birth and maternal health?
• What has been her experience of delivering women?
• What are the dais own perceptions of the value of their knowledge?
• What services does she provide to women in the basti?
• What information does she provide to women in terms of maternal and new born health?
  

IV. Methodology

The primary method of data collection will be in-depth interviews of mid-wives from 4 informal urban settlements in M (E) ward of Mumbai, Ghatkopar, where SNEHA runs the Surestart Project. These 4 slums of N-ward include: Kirol Village, Kamraj Nagar, Vikhroli Parksite and Varsh Nagar covering a population of 203,167.

4.1 Analyzing Previous Data Collected

The primary method of data collection will be in-depth interviews of mid-wives from 4 informal urban settlements in N ward of Mumbai, Ghatkopar, where SNEHA runs the Surestart Project. These 4 slums of N-ward include: Kirol Village, Kamraj Nagar, Vikhroli Parksite and Varsh Nagar covering a population of 203,167.

4.2 Designing the Interview Schedule

When designing the interview schedule inputs were taken from various experts including those at RCWS, SNEHA, University College London and Jeevan Project. In the process, the interview schedule was revised several times. In order to hone the focus of my enquiry even further, I reverted the original methodology of ‘Oral Histories’ to an Interview Schedule with open-ended questions based on 5 key themes related to each research objective and question.

The detailed interview schedule along with these research objectives and questions has been listed below:

Interview guideline – Dais

I would like to start by asking you about yourself. There are no right or wrong answers and all of your thoughts and feelings are valuable.

Objective:

A] To document life stories of Mid-wives residing in informal urban settlements of Mumbai

B] To document cultural practices and indigenous knowledge related to the process of birthing that are traditionally passed from one generation of mid-wives to the next

Related Research Questions:

• What are the socio-economic conditions of dais residing in informal urban settlements of Mumbai?
• What are the dais own experiences of child birth and maternal health?
• What are the factors that contributed to women becoming daies?
• How do daies receive their training or information in delivery practices and pass these on to the next generation?
• What has been her experience of delivering women?
• What are the dais own perceptions of the value of their knowledge?

Section A.1: Identification

Date of Interview _________________                 Referred by:

Ward _________

Name of Dai _______________                      Dai number _____________

Household address _____________________________________________________________

_____________________________________________________________

Section A.2 : Background Details

• How old are you? (Completed years/Don’t know)
• What is your current marital status? (Married/Widowed/Separated/Deserted/Divorced/Never married)
• How old were you when you got married? (Years/Not married/Don’t know)
• How old were you when you first became pregnant? (Years/Never been pregnant/Don’t know)
• Can you read? (Yes/No)
• What sort of education have you had? (No education at all/Informal education/School up to class/College)
• What is your occupation? (Only dai/CHV/Aayabai/Maid servant/Other)
• How many hours do you work apart from dai? (Few hours/Half day/Full day)
• What is your religion? (Hindu/Muslim/Christian/Sikh/Buddhist/Jain)
• What is your caste? (SC/BC/OBC/Other……………………………………………)
• Do you currently live with your husband? (Yes /No)
• Do you live in a Nuclear, Joint or Extended family? (Nuclear/Joint/Extended)
• Do you have children? How many? (Yes/No)
• Total household members
• How long have you been living in this basti?            (____months /____ Yrs/All her life)
• Where are you from?         (Mumbai/Outside Mumbai)
• Write the name of State and place if outside Mumbai  ………………………………………………….
• Do you own this house?       (Yes /No)
• Type of house (Interviewer to observe)       (Pucca/Semi-pucca/semi-kacha/Kacha)
• Does your household have a ration card? (White/Yellow/Orange/No card)
• Does the card have your name on it?          (Yes/No)
• Do you possess the following items? (Mattress/Pressure cooker/Gas cylinder/Chula/Stove/Chair/Cot or bed/Table/Clock/Electric fan/Bicycle/Radio/Sewing machine/Telephone or mobile/Refrigerator/TV/Moped, scooter or motorcycle/Car)
• Is your electricity supply legal or illegal?      (Legal/Illegal/No supply)
• Is your water supply legal or illegal? (Legal/Illegal/From another basti/Bought)
• Is your water supply private or public/shared? (Private/Public/shared/From another basti/Well/Other/what……………..)
• Is your toilet facility private or public/shared? (Private/Public/shared/No toilet facility/Open Ground/Seaside/Railway Track/Other ……………..)
• What is her experience of migrating to the city?
• What is her experience of living in Mumbai city?

Section A.3: Maternity History

• Total Pregnancies
• Miscarriage
• MTP
• Birth (Born alive/Born dead)
• Children alive (Now alive/Now dead)
• Place of delivery (Home/Hospital)
• Have you and your husband ever used any family planning method? (Yes/No)
• If yes, then which method you used? ———————————————————————————–
• Her experience of motherhood
• Her experience of her own deliveries

Section B: Profession:

Section B.1: How she became a Dai

• Reason for choosing or getting into this profession
• Who introduced her to the profession
• What age she started working as a dai
• Number of years as a dai,
• Her experience of becoming a Dai

Section B.2: Training she received

• What type of training did she received?
• Whom did she receive this from?
• How long was her training for?
• Has she trained anyone else?
• Does she plan to hand over her training to others at a later stage, if so how?
• What was her experience during this training?

Section B.3: Her experiences of delivering women

• What type of people call her (religion & caste)
• Average number of deliveries in a year or month
• Incentive  (cash or kind) for delivering- what & how much
• Does she prepare before a delivery, if so what kind of preparation does she undertake?
• How has this changed/altered over the years? Specific examples.
• Assistance- does anybody assist her? If yes, who and what assistance does she receive?
• Five cleans- what she practices, five cleans
• Bathing – bathing/wiping, wrapping
• Difficulties- both for mother and baby, during and after delivery-what type, how tackles, help provides, accompanies, whose help
• Refusal- in what situations she refuses/reasons for refusing to deliver
• What has been her most memorable delivery
• Which delivery took the longest and was the most complicated that she remembers

Section B.4: Daie’s own perception of the value of her knowledge?

• Does she see it as requiring skill?
• Does she relate to her knowledge as a gift, a talent etc.?
• How does the community perceive her knowledge?
• Does the community give her any special status on account of her role?

Objective:

C] To highlight maternal health related belief systems, indigenous to each community covered under the study

Related Research Questions:

• What are the specific community based maternal health related belief systems, cultural practices and indigenous knowledge of birthing?

Section C: Cultural variations in her knowledge of and birthing practices

• Examples of traditional practices that she follows as a dai that are specific to her community
• Where did she learn these from?
• Are they still practiced in her native place?
• Changes/modifications in these practices that have occurred over time
• Traditional practices specific to her community that are no longer practiced
• Her experience of performing these rituals/ not performing rituals traditional to her community

Objective:

D] To document the contribution that daies make to the maternal health of their communities

Related Research Questions:

• What is the contribution that daies make to the maternal health of their communities?
• What services does she provide to women in the basti?
• What information does she provide to women in terms of maternal and new born health?
  

Section D: What is the contribution that daies make to the maternal health of their communities?

Section D.1: What services does she provide to women in a basti?

• During pregnancy- abortions, morbidities,
• After delivery- follow up of mother and baby, ND , mallish to mother & baby
• Her experience of providing these services

Section D.2: What information does she provide to women in terms of maternal and new born health?

• Breast feeding: colostrums, when to feed, frequency of feeding
• Immunization: self awareness of the schedule by age, guide on it, where to access
• Diet: what to eat, food intake
• Family planning: FP methods, its availability, when and what to use, motivate
• Birth certificate: guide the procedure, help in getting, charges
• Janani Surkasha Yogana: (self awareness, what she suggest etc)
• Any other:

Objective:

E] Analyzing the impact of State health care policies on the traditional practices of midwives

Related Research Questions:

• What has been the impact of State health care policies on midwives from these communities?

Section E: Changes encountered in her profession over the years

• Government schemes that she’s aware of related to hospital births

• Have these had an impact on her profession?
• Changes in the city/community that have had an impact on her profession
• Training that she’s received that has altered her practice in anyway?
• Changes in post-delivery care that she offers to mothers
• Changes in her own delivery practices?
• Her experience of changes that have occurred
  

Thank you very much for sharing your experiences with me.

 Is there anything else you would like to tell me before we finish the interview?

4.3 Approval by SNEHA’s Research Committee

On June 10, 2011 the above version of the Research tool was presented to SNEHA’s Research Committee for their approval. Securing this approval is a requirement for any research project conducted in collaboration with SNEHA. The Committee appreciated the Interview Schedule and approved the same.

To ensure that ethical practices are followed, the committee requires that both a consent and information sheet be given to each participant interviewed through the research study. These have been listed below. The former seeks the Dai’s consent in all aspects of data retrieval, storage and usage. The latter explains the study’s objectives, gives background details of the interviewer and how the information will be utilized. Both these have been listed below:

4.4 Consent Form and Information Sheet

Title of study:

Profiles of Traditional Midwives in informal urban settlements of Mumbai city

 

Name of Participant:

Respondent ID: __ __ __ __

Thank you for your interest in taking part in this research. Before you agree to take part, the person conducting the research must explain the study to you.

 

About the Researcher: My name is Ara Johannes and I’m conducting this research study as part of a fellowship from SNDT University. I am interested in women’s health especially home births and hence want to interview women who deliver babies at homes.

 

About the Study: This is a study about Dias in informal urban settlements of Mumbai. I will be interviewing 18 Dais in M (E) ward about their experiences of being Dais. The main objectives of this research are as follows:

A.  To document life stories of Mid-wives residing in informal urban settlements of Mumbai

B.  To document cultural practices and indigenous knowledge related to the process of birthing that are traditionally passed from one generation of mid-wives to the next

C.  To highlight maternal health related belief systems, indigenous to each community covered under the study

D.  To document the contribution that dais make to the maternal health of their communities

E.   Analyzing the impact of State health care policies on the traditional practices of midwives

This study will be conducted over the next 3 months in partnership with SNEHA.

 

About the use of this information: The entire interview will be available at SNDT for use by other researchers/students. A copy will also be kept with SNEHA and might be published in a report/paper. However, confidentiality and anonymity will be maintained and it will not be possible to identify you from any publications.

If you have any questions please ask the researcher before you to decide to participate. You will be given a copy of this Participant Information Sheet and Consent Form to keep and refer to at any time.

Please read the following before putting your signature below:

Sr. No.	Statements by respondent	(tick or cross)R or S
1	I have read the Participant Information Sheet (PIS) or had it read out to me.
2	I have been given a copy of the participant information sheet (PIS ) and consent form(CF) to keep.
3	I have been informed by the interviewer about the study and I have understood them.
4	I have been given the opportunity to ask questions and replies were given to all the questions to my satisfaction.
5	I am free to participate or not to participate in this study without any penalty.
6	I understand that I can withdraw at any point during the interview /study without any penalty.
7	I understand that in case of my withdrawal at any point, all information I have shared will be destroyed and not used.
8	I understand that my information will be treated as strictly confidential, and that my name will be removed from any data that will be kept and used after entry into a computer.
9	I also know that although the hard copy of my interview will be destroyed, the information I provide will be continued to be stored without my name and may be used by SNDT and SNEHA for future work
10	I know that my name was referred by a SNEHA project representative and I understand that the information I share will not be shared with him/her.
11	I understand that the information I provide will be published in a report or paper. Confidentiality and anonymity will be maintained and it will not be possible to identify me from any publications.
12	I consent for clicking photos of interview and for the use of these photos in describing the study to other people.
13	I understand that I can seek and receive help in the form of information and guidance from SNEHA for any problem that I may have

Consent for interview and study:

Signature/thumbprint of participant: ………………………………  Date __ __ / __ __ / 20 __ __

Name of Participant:…………………………………………………………………………………

Signature of interviewer: ……………………………… Date __ __ / __ __ / 20 __ __

Name of interviewer:………………………………………………………………………………..

4.5 Interviewer Guidelines

These sub-headings were included in the interview schedule to guide those conducting interviews.

Introduction

• Introduce yourself and thank the participant for agreeing to meet you.
• Explain the purpose of the study and how the interview will be conducted (why she was selected, recording, what the information will be used for).
• Before you start the interview, give or read the information sheet to the participant. Obtain signed consent when you are sure that she has understood the study and what her participation entails.

 

Observation checklist

Write down the following observations as soon as possible after the interview:

• A description of the interview setting (room size, household items, privacy).
• Respondent (physical appearance, behaviour, personality: shy, confident, concerned, reluctant etc).
• Conduct of the interview (location, duration, other people present etc).
• Reflections after the interview (your opinions, flow of questions, interaction with participant, participant’s willingness to discuss issues, appropriateness of questions etc).
• After the interview ended (other issues discussed, how did the respondent seem? Did she ask questions, have any concerns or ask for help? What did you say or do?).
• Any other observations or comments you think might be useful.

Presentation on Research Findings, made at AWA Second Anniversary, SNDT University, Mumbai.

Dai Presentation