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Stanford undergrad uncovers importance of traditional midwives in India

IMG_0348Lara Mitra grew up taking regular vacations with her family in her ancestral home, the state of Gujarat in India, but those short trips barely prepared her for her first long-term stay. She says the 10 weeks she spent studying maternal delivery practices were eye opening in many ways. The work she did while there made a big enough impact that it landed her on a list of 15 impressive Stanford students featured in Business Insider last month.

During the summer between her sophomore and junior years, in 2012, Mitra secured a human rights summer fellowship through the Stanford McCoy Family Center for Ethics in Society. She worked with the Self-Employed Womens Association (SEWA), a large non-profit organization in India that helps women become economically self-sufficient, but also gathers other information about the well-being of women in the country. Mitra worked with SEWA officials to design a study looking at how often women in Gujarati villages used hospitals to deliver their newborns instead of delivering at home. Most home deliveries are carried out with the help of a dai, a village local who acts as a midwife but usually doesn't have formal training.

Maternal mortality rates in India are still alarmingly high, so government agencies have started incentive programs such as offering free ambulance service to and from hospitals for laboring mothers and paying mothers to deliver in a hospital instead of at home, and pays dais to bring laboring mothers to hospitals. In light of all these incentives, it was unclear how often women were still delivering at home. And if they weren't, Mitra says the question was "Are these dais, these midwife figures still useful? Is there still a job for them?" Mitra was excited to be doing the critical research and says, "It was the first time I wasn't working in someone else's lab and designed my own study."

She found that women were in fact taking advantage of the government programs and delivering more often in hospitals, but the dais still played a critical role. In some situations, such as emergency deliveries, dias stepped in and delivered the children before mother and child were taken to the hospital for examination. Also, unlike in Western countries, husbands don't play as intimate a role in the delivery, so the dai served as "birth coach" at the hospital, too. Dais also helped with prenatal and post-delivery care. Out of 70 women Mitra interviewed in 15 villages surrounding the Gujarati city of Ahmedabad, 69 said dais still served a useful role.

"More significantly, the trust women had in the dai couldn't be replicated in doctors," says Mitra. "Dais were part of a support system for women. The dai would do informal check-ups, and could tell if a C-section would be necessary."

IMG_0339Dais are usually trained by their own mothers or female relatives, becoming part of a long maternal chain. But as economic opportunities have grown in India over recent decades, more families are sending their daughters to school and fewer are training them as dais. And the current corps of dais is quickly aging. "Most of these dais are all 75 or 80 years old," says Mitra. Although they are respected figures in the village, "dais don't get paid [by the women they help], they get gifts, like saris. They can't monetize that." So a new generation of dais hasn't replaced the aging one. Mitra notes that an alternative system could be set up, but it's too early to know what it would look like. Is the figure who replaces the dai a community health worker? Or should dais be promoted to be on the government payroll, she wonders. However India answers that question, the face of maternal care in the country is already changing as aging dais are passing away and villages are unable to replace them.

"Modern medicine, as much as it advances and helps health, is not a replacement for these traditional practices, " Mitra noted. "The question is, how can these two can work together to provide more complete care for the woman? Is it prenatal care by the dai followed by a professional delivery? Finding a more integrated solution that bridges these two is the key question."

Mitra says she plans to continue working on related questions. She interned at the White House last summer. As a senior human biology major with a focus on human rights and maternal health, she wants to craft a career that combines health policy and human rights.

Previously: Stanford undergrad works to redistribute unused medications and reduce health-care costs, In poorest countries, increase in midwives could save lives of mothers and their babies and A reminder that prenatal care is key to a healthy pregnancy
Photos courtesy of Lara Mitra (in top photo, Mitra is fourth from the left; in bottom photo, Mitra is second from the right)

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