This is the second part of the three-part series on ‘institutional blindspots in sanitation in India’ as a part of the Justicemakers’ Writer’s Training Program, run in partnership with Agami and Ashoka’s Law For All Initiative. The first and third parts can be found here and here.
“Who will I teach? They all tell me, ‘Who will do this hellish work? It is dirty and I feel disgusted,’” Moohiya Devi explains to me as I sit outside her family’s small kaccha house with a thatched roof, “They can’t tolerate the blood and the mess.” She’s a 60-something-year-old woman, a native of the village of Sarari, in Jamui, Bihar.
Moohiya Devi, a Manjhi (scheduled caste), has been a dai for what she estimates is the last 50 years. A dai or a traditional birth attendant (TBA), as is commonly understood, is a person (usually a woman) who provides delivery, postnatal and newborn care within her community.
“This is what our caste does,” explained Puja Devi, “It is in my family.” The woman in her late 20s belongs to the Manjhi community and lives in Hasdih, a village in Jamui, Bihar. She herself has seen three generations of family elders working as dais.
They may be called dais in Bihar, but TBAs exist all around India and have, for centuries, been a crucial community resource. Across time and place, this has largely been a caste-based occupation. Public conversations about dais, whether in academic, social or public sectors, have often revolved around the compatibility of indigenous knowledge and formal healthcare systems, but not beyond that.
None of the dais I spoke with received any formal training. “God taught me, so did experience,” said Moohiya Devi. Puja said, “I saw what my mother-in-law did to help me with my first child, and I used the same things.”
She, like so many others, began to work as a dai only after coming to her marital home and experiencing childbirth herself. Each of the dais I spoke to catered to pregnant women in the nearby 4-5 villages, where her services can be demanded at the drop of a hat.
A Dai’s Duties Are More Than Meets The Eye
What services does a dai provide, exactly? They examine pregnant women in the event that their water breaks, to understand, through their dilation, if they are in active labour. In the case that mother is too dilated or opted for a home birth, the dai is the primary birth attendant. She helps deliver the baby, cuts and ties the umbilical cord, cleans the baby and helps the mother bathe.
After ensuring that the placenta has been discharged, she must dispose of waste and clean all bodily fluids dispelled during delivery (“primarily blood and amniotic fluid, and usually urine,” Moohiya Devi explained).
“We wash the room with water, and then usually cover the floor with a new layer of the cow dung and mud mixture,” explained Laljitiya Devi, a resident of the Manjhi tola in Masaudi, Jamui, and a dai with more than 40 years of experience under her belt.
Postnatal care includes massaging the mother and the newborn with oils and guiding mothers with breastfeeding.
Cleanliness is also a big facet of their work. But an essential component to understanding their responsibilities is caste.
Dais, Caste And The Accident Of Birth
Caste is a system of social stratification based on notions of purity and pollution. Your purity affords you privilege in where you live, who you are able to marry, what you eat and what work you do.
At the top of the pecking order, according to the four-tier Varna system, are Brahmins, considered pure because of their dharma (duty) and karma (work); those at the bottom are called Shudras. Dalits, previously known as the Untouchables, fall outside the four-tier system, considered by this system deeply impure and tasked with working with that which is considered “polluting”–like a mother’s body.
The system outlined clearly valorizes the mind–that is why being a Brahmin allows you to do intellectual work related to scripture. Brahminical thinking disdains the body–that is why it assigns physical labour to lower castes and considers bodily waste polluting. When Brahminical casteism interacts with patriarchy, it is not difficult to imagine its disdain for the woman’s body–a body that a dai has to work very closely with.
After the baby is delivered, the dai must keep an eye on the fact that all of the placenta–or the “second child” as Moohiya Devi calls it–is expelled by the vagina. If it isn’t, she can choose to use her hand, covered with a cloth, to physically remove it. Even the postnatal massages that a dai provides a new mother involve massaging the vaginal opening that has been stretched during childbirth.
While these dais were vocal in recognising traditional wisdom that allows them to help people in their communities (“bhala ka kaam”), they were also not hesitant to point out the work’s association with waste.
“Doing home births is very dirty work,” said Laljitya Devi. “All the responsibility for cleanliness is on me. I face a lot of difficulty during it and afterwards–I lose my appetite, I don’t feel good,” she adds.
Moohiya Devi does not believe that birthing is polluting work, the way that others do.“If I thought this work was ashleel (vulgar), then how would I have done it?” she says. But she does not deny that it can be repulsive to do this work.
“I’ll ask for a swig of alcohol from the household’s men if they can provide it. It helps keep me awake, fight the cold and be in the right headspace. If one doesn’t drink, they will be disgusted,“ she says.
“Work for us can mean only this or daily wage labour,” said Moohiya Devi. Working as a dai is a source of income–currently ranging between Rs. 500 and Rs. 2000 per delivery or for a massage, sometimes given with saris, a few kilos of rice and/or dal. But its ad-hoc nature is equally challenging. She says, “If there are deliveries, I earn. If there aren’t, I don’t. In the meantime, I just sit here.”
When Hospitals Come, Where Do Dais Go?
With active ASHA workers in their villages and access to both private and government-run hospitals in the town of Jamui, many have begun opting for institutional deliveries.
According to the National Family Health Survey, home births assisted by dais in rural Bihar have fallen from 68% in 2005-6 to 12% in 2019-21.
Puja’s mother-in-law says, “People think that if the child is delivered at home, everything will become polluted. Usually, if it is possible, they go to the hospital, to avoid the filth.”
Some like Laljitiya Devi don’t believe in modern systems of childbirth, stating, “Doctors lack the patience required for natural deliveries. They are trigger-happy in conducting the small operation (episiotomies) or the big one (C-Section).” Her daughter, Neelam Kumari, added, “The people who operate are driven by a desire to earn money more than anything else.”
But other dais have found ways to become associated with the formal system.
The eldest woman and most experienced dai in Puja Devi’s family, Dulhari Devi, joined the Jamui district hospital as a mamta in 2010. Only open to women from the SC community, mamtas (paramedical workers) were recruited for the first time in 2008 but they aren’t considered medically trained staff capable of managing childbirth.
Neelam Devi, a mamta from the town of Jamui, explained, “The nurse hands us the baby after cutting the umbilical cord. We pat the baby dry and remove any waste blocking his nose and throat. And then we place the baby immediately on the mother’s chest. It is our job to explain to the mother the importance of breastfeeding and the methods she can use.”
Mamtas earn Rs.300 for every newborn they assist. The mamtas in Jamui came to an agreement to split the pay evenly across the three duty shifts, an arrangement that could potentially mean they earn as little as Rs. 200 in a day, explained Neelam.
The Hidden ‘Illness’ In Hospitals
Slowly but surely it becomes apparent that the hierarchy of hospital employees maps onto the hierarchy of caste and of waste management relatively well.
Take the on-duty nurse in the labour room, for example. All parts of the delivery process, barring any complications that require a doctor’s intervention, are her responsibility. But the mamtas reported that the Grade I nurse would hand off the more ‘dirty’ parts, such as handling the umbilical cord and the placenta, to the Grade IV nurses.
Similarly, mamtas, who are from the SC community, will offhandedly be asked by superior staff members to assist in cleanliness activities, even if it is not strictly in the scope of their work.
All of the 40-odd cleaners across the hospital premises belong to very marginalised communities like the Mestar and Dom castes from in and around Jamui. Usha has travelled 10 km every day from her village, Katauna, for the last 20-odd years that she’s been working as a ‘super in the hospital.
She belongs to the Mestar or Mehtar community, a caste that is commonly associated with scavenging. As she headed off into the delivery room to clean up after a mother delivered her newborn, Usha shrugged and said, “It is dirty work, but what else can I do? Blood, water, amniotic fluid, urine, faeces, and vomit. We have to clean everything.”
As much as an upper-caste nurse may try to differentiate herself from the Manjhi mamta who tries to differentiate herself from Mestar cleaner–they all help deliver children.
What Does The Future Hold?
Will traditional methods of birthing still have a place in the future? Sita Devi, a dai in Hasdih, is certain that it will. She says, “I have spent 30 years birthing children who are hale and hearty. The demand for this work will always exist, whatever hospitals might come and go.”
Others, like Moohiya Devi, laugh at her continued legacy. Her daughters-in-law have distanced themselves from a work they find personally repulsive.
When Laljitiya Devi is asked the same question, she smiles wryly and says, “Look, I don’t want to become a ghost before I die.” She says that one cannot guarantee that the seeds you sow will bear sweet fruit, but that one can only hope so. Similarly, when she dies, she hopes someone else will understand the need for this work and continue it.
Her daughter Neelam is a young woman but eager to carry forward this legacy and she says, “I see every day how many people–big people, Rajputs, doctors–come looking for my mother. Before doctor check-ups and after. Before delivery and after. I can see how valuable she is.”
She is eager to learn, practising by birthing goats’ kids when gently advised by her mother to use her brain and learn by trying. Determined, she says, “I will do good in my community, at least. I will earn a name for myself, just like my mother has.”