Birth on the Threshold. Cecilia Van Hollen
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shows that due to the practice of infibulation and the need to open and restitch the scars from infibulation during delivery, midwifery there can hardly be viewed as noninterventionist.45 In this book, I am not engaging in a debate about whether hospital deliveries are fundamentally controlling or liberating. They may of course be both, just as home deliveries may be experienced as repressive, comforting, or both. Rather, my interest is in demonstrating the historical and cultural specificity of the transformations in the experience of childbirth for working-class women of Tamil Nadu in the late twentieth century.
It is important to underscore the fact that just as the nature of modern birth is unique, forms of resistance will, of course, also be distinct. Due to international and local political-economic structures and cultural processes, biomedical births have not become hegemonic in Tamil Nadu, even in urban areas such as Madras, where almost all births take place in the hospital. And obstetrics has never been the domain of medical men in India as it is in the United States. Following Jean and John Comaroff’s interpretation of Gramsci, I use the term “hegemony” to mean those systems of knowledge, symbols, and practices which are culturally constructed in the context of relations of power and which “come to be taken for granted as the natural and received shape of the world and everything that inhabits it.”46 It is the apparent “natural” quality of hegemony which gives it its profound power. Although allopathy may indeed be the dominant form of maternal and child health care in urban India, it is not taken for granted as the only naturally legitimate form of care. Its apparent superiority must still be publicly articulated. It, therefore, cannot be viewed as hegemonic. Unlike the woman-centered, natural, home-birth movement in America, resistance to biomedical birth in Tamil Nadu is not counterhegemonic; it is based on a critique of the discriminatory ways in which allopathic services are (or are not) provided rather than on a critique of allopathy itself. Resistance to the biomedicalization of birth among the poor of Tamil Nadu, therefore, reflects an effort at bricolage rather than an effort to replace one system of birth with another, wholesale.
Recalling the opening story of Mumtaz, who says she gave birth to her child right on the threshold of her home, we can, following James Scott, view her action and inaction as one of those partial, everyday forms of resistance that are the “weapons of the weak.”47 But a far more interesting and significant form of resistance is taking shape in Tamil Nadu today. Some women want new technologies offered by allopathy but they want to avoid forms of discrimination which they face in public hospitals. Increasingly, these women are opting to bring allopathy and allopathic practitioners back across the threshold into their homes. In some ways, this appears to be a creative and positive solution to their predicament. But, as we see in the coming chapters, there are also potentially serious health risks involved in partially administering biomedical technologies at home without immediate access to full-fledged biomedical emergency care.
TAMIL NADU: URBAN AND SEMIRURAL FIELD SITES
The state of Tamil Nadu, in the southeast corner of India (see Map 1), is often considered one of India’s model states with respect to the provision and use of allopathic maternal-child health (MCH) care. A 1994 government of Tamil Nadu publication showed that 60.6 percent of all reported deliveries in the state were institutionalized; the remainder took place in homes.48 A separate 1993 government of Tamil Nadu report stated that hospital deliveries accounted for “more than 90 percent” of all deliveries in urban areas and “about 50 percent” of all deliveries in rural areas.49 In 1993 the World Bank reported that in the capital city of Madras 99 percent of all deliveries were in hospitals.50 And, by the beginning of 1995, the director of the World Bank–funded India Population Project-V (IPP-V) for Madras reported that 99.9 percent of all deliveries in Madras were conducted in hospitals.51 Because a number of home deliveries go unreported, these figures reflect a somewhat unrealistically high percentage of hospital deliveries. Nevertheless, they demonstrate that the rates of hospital deliveries in Tamil Nadu are significantly greater than those for India as a whole, for which it was reported in 1995 that no more than 20 percent of all deliveries took place in hospitals.52 Yet very little scholarly attention has been given to the cultural and political processes by which MCH care, specifically for childbirth, is being incorporated into allopathic systems of knowledge and institutions in this region or to the quality of that care.53
Map 1. The states of India, 2001.
My initial decision to carry out this research in Tamil Nadu, however, had more to do with my own personal history in the state than with a purely scholarly interest in filling a lacuna in academic research. As a child, I spent three and a half impressionable years, from the ages of eight to twelve, living in Sri Lanka, where my father was posted with the Foreign Service. During much of that time, my older brother and sister were attending an international boarding school in what had once been a colonial hill station in Kodaikanal, Tamil Nadu. I remember spending many vacations with my mother visiting my brother and sister on Kodai Lake and sightseeing in the temple towns and wildlife preserves in the plains and jungles of Tamil Nadu. And I, too, attended the same school briefly in 1976 before our family was posted back to Washington, D.C. During that time, I was captivated by the hustle and bustle of even this small bazaar, by the crispy texture of dosais and the sweetness of the sesame seed candies, and by the thrill of sneaking off to the mist-covered slope of Coaker’s Walk to smoke beedis while contemplating the vast spread of the plains, barely visible below.
Ten years later, I found myself returning to the plains of Tamil Nadu in 1986 as a college senior participating in the University of Wisconsin, Madison, Year in India Program in Madurai, one of India’s most important centers of Hindu pilgrimage. It was on that program that I first began to struggle with and delight in the innumerable retroflexes and alliterations in the Tamil language. And it was during that year that I began to explore issues of gender in India through visits to a Gandhian women’s development project in nearby Gandhigram, through the practice of Bharatanatyam dance, and through a fieldwork project on women’s roles in my own neighborhood’s nocturnal festival for Mariamman, the goddess of smallpox.
I returned to India and Tamil Nadu again briefly in 1991 and 1993 as an anthropology graduate student trying to formulate a dissertation project which would combine my interest in issues of gender and class and which I felt would have social relevance to people involved in the Indian women’s movement.54 It was during these visits that I was drawn into the field of maternal and child health care and decided to focus on childbirth. And it was this topic which led me to become a medical anthropologist. Once again personal experience was influencing my intellectual agenda. In this case, my own stage in the life cycle was a motivating factor, since I was recently married and contemplating having a child myself.
Finally, in January 1995 I returned to Tamil Nadu with my husband and our six-month-old daughter to begin my dissertation fieldwork.55 We set up home in Besant Nagar, a quiet, newly developed residential neighborhood on the southern edge of Madras. This location enabled me to split my research time between the city of Madras and the semirural community of Kaanathur-Reddikuppam, which lies directly south of Madras, one hour away by bus. Since most of the studies on childbirth in India had been conducted in rural areas, I wanted to look at an urban situation and a semirural community like Kaanathur-Reddikuppam, which was going through a rapid transition in the availability and use of modern MCH services. I spent the year of 1995 in Tamil Nadu, and we all returned to the United States in January of 1996. I then returned to India for a one-month follow-up research trip in May of 1997.56
Urban Landscapes: Nochikuppam, Madras
My research in Madras (now officially called Chennai) was greatly facilitated by my affiliation with the Working Women’s Forum (WWF), a women’s NGO based in Mylapore, Madras, which has branches throughout Tamil Nadu and beyond. It was through the WWF health supervisors and health workers that I was introduced to the residents of Nochikuppam and Bapu Mastan Dargha (BM Dargha), low-income neighborhoods in south and central Madras, respectively. I decided to focus much of my research