This section explores the existing notions and understandings of childbirth that women have within the low income household communities of Mirpur. Drawing out their narratives and tracing the construction of those narratives allows us to see how women view their place in their own and in other women’s reproductive lives and to understand the intentions, motivations, desires and influences that lie behind their decisions of where to give birth, how much to rely on formal or informal healthcare providers, etc. (Unnithan, 2002; Rozario and Samuel, 2002; Afsana and Rashid, 2009).
As Jordan (1983) argues, 'birth is everywhere socially marked and shaped”. Like many other cultures, there are many notions regarding childbirth practices in Bangladeshi society. In order to understand the existing birthing practices in Bangladesh, it is necessary to locate it within its larger social and cultural context. It is also paramount to look at dominant conceptions of birth and to consider how these are challenged by midwifery interventions, the likes of the birthing chair.
Where to give birth: What constructs women’s choices about where to deliver?
7 out of 10 mothers initially wanted to give birth either at home or in their natal homes in villages. Women also mentioned that in an ideal scenario, they would chose to go into the clinic as late as possible, when they are in the final stages of labor. The reasons cited for this preference included: feeling stressed and anxious due to the environment at the clinic, facing greater emotional distress, or feeling uncomfortable staying there for long hours or distressed that they cannot move about freely like they can in their homes.
Aklima, 35, mother: “I never go to the hospital [for checkups] before my delivery... I only go during the last stage...I don't like staying at hospitals much... I don’t like the use of medicines at all... They said there are risks at home... you don't always get safe deliveries at home. I was scared... they said that if I face any problems then I will need to go to the clinic either ways. If there is any problem I could take immediate help (in the clinic).”
From observations during interviews, it is seen that the urban space in the Mirpur 1 and 2 areas is congested with structures both legal and illegal. Large apartments, half constructed building and small shanty houses have been developed side by side. Here, most families live in one room homes within these half constructed building or shanty areas and those who are more economically well off are able to rent two or three room flats where families live together. The space makes it increasingly difficult for women to opt for home births, even if they desire to. In this context, the issues of privacy, comfort and ease of delivery have a significant influence in shaping the expectations and decisions these women take on regarding their deliveries. Keeping the congested urban landscape of Mirpur in mind, many expectant mothers chose to give birth in the clinic- as they did not feel that giving birth at home was a feasible option for them. Further conversations revealed that this idea stemmed from - the lack of family members to support them even if they wanted to give birth at home or they faced problems of prolonged labor or their membrane was ruptured.
Nasima, 30, mother: No, no I didn't think about home (the rented place in Mirpur). I would have gone back to my village. But going to the village means going through a lot of trouble. The doctors are far away in the village, aren't they? It gets too late to reach to them when there's problem with delivery. (Over here)If I feel pain I can go anytime (to the doctor), so I stayed in Dhaka…But I'm alone here if I do delivery at home who's going to clean up and manage everything, who is here, you tell me? In Dhaka, where do I find a dai-matari? If I had an acquaintance I would not have had a problem because then if I did face a problem (during birth) they would have been there on standby and I could ask them for help. But I don't know anybody here, it's not like that for me.
Ranjin, 17, mother: “My water broke at home. My mother-in-law had wanted (me) to deliver at home. It was my first time so I didn’t understand a lot of things. She had told me to deliver at home. Then when she saw that there is no pain, she took me to BRAC. I could feel the water trickling down. I told [the baby’s] grandmother that, ‘Ma this is what is happening’. She didn’t say anything, just went and called her khala. Her Khala came and said that her water is broken. They saw that throughout the night, there was no pain. The day after at 12 noon, I went to the medical, the medical at Golartek, they took me over there to do an ultrasonography.”
Afsana and Rashid (2009) reported that when delivering at home in the village, women narrated that they were allowed to walk freely, change positions, and hold onto a rope or pole while giving birth upright. The TBA, the “dai-ni”, provide physical and emotional support, but try not to take over the birthing experience, allowing women family members to play a role by physically holding the woman or telling stories to keep her calm. In the current context of urban slums or low income households, Bangladeshi expectant mothers usually have less information on delivery, a decreased support network by living in a nuclear family (in slums), and because of cultural reasons, a spouse that might not be involved in the birth at all) (Edmond, Paul and Sibley, 2011; Amin 1988).
Furthermore, the social networks women reported that they have built in and around their homes are an important factor that shapes their understanding of their own childbirth, their knowledge regarding birthing beliefs and practices – which eventually leads to how their attitudes towards innovation in the birthing space are shaped:
Shamima, 30, mother: R: Yes I wanted to do it at home. I didn't know I would be taken there, I wanted to try giving birth at home. I told the Apa, then she said no I will take you to the center....so that's why we did not inform any dais. My mother wanted to call a dai, I did not want to go anywhere...my mother gave birth at home and I wanted to do the same. But then who would call a dai at late night…”
The networks that “Kormi” and “Shekbika” establish around their communities is the most effective way in which BRAC has been able to change health seeking behavior of pregnant women in the (Mirpur -1) area in the past decade:
Asma, 35, SK: People are more hospital leaning than before, even if they go somewhere else (other than BRAC) at least they are going, that is what i like. Wherever it is less expensive, they go, they don't do it at home. One thing we have been able to make then understand is that it is not right to deliver at home, it isn't safe. This is my believe, that even though I am not in office, so you can ask anyone at the office, in my area, the ones I work with, home births are very low.
Current community messaging about the chair is limited to meetings for pregnant mothers (who are in their last trimester):
Asma, 35, SK: You'll need to understand one thing here apa, if I do talk about this when I go to their homes, it's a matter of seeing it with their own eyes. Someone who has never seen the chair before in her life, even if I try to make her understand in a thousand ways she will not be able to understand. But when she comes to this place, then I can show it to her. When a mother comes in, and we are present there, we take her to the labour room and show it to her telling her that apa come and see the delivery room, this is where we do the deliveries. We do it like this, take a look would you be able to get this at your home?
Midwives are only able to communicate about the chair during fieldwork, which is limited scope because they’re approaching only one person at a time. Community messaging efforts could potentially make people aware of the chair and make their duties of counselling and information dissemination during deliveries or high stress delivery situations much easier.
Apart from notions of privacy, cleanliness was an important factor as explained by women when choosing where to give birth. Nasrin, a 22yrs old woman with three children we interviewed, mentioned opting for birthing at the clinic because of the lack of resources at hand in her home and neighborhood.
Nasrin, 22, mother: I mean we go to BRAC because the normal delivery happens there and you can leave everything behind and come home clean …it’s nearby so it’s easier and more people go there.
The lack of privacy, the need for cleaning up after birth and the fact that most of these women do not have a family network to rely on during births, leads them to opt for the clinic. This problem seems particular to women (those interviewed) who cannot commute to their villages, where they usually give birth at home with a dai/dai-ni in attendance. Nasima (30, mother) who narrated that her issues of back pain and postpartum issues were a result of using the chair during her delivery, mentioned that it would be easier for her to be able to deliver at her home, in her village, but she decided not to go since she has two other children to look after and her husband had been recently ill. Delivering in the clinic then, comes from the sense of not having enough resources at hands, which reduce the risk that they sense and that they have come to become aware of regarding deliveries at home: support of family members, easy access to transport in case of an emergency, enough space within homes.
Furthermore, pollution or uncleanliness has been shown to imply risk of attack by malevolent spirits or “kalo drishti” in researches on delivery practices in Bangladesh (Afsana and Rashid, 2001). The emphasis on pollution is found consistently in birth stories in Bangladesh, including the numerous studies carried out by researchers (Rozario, 1998; Blanchet, 1983). Rozario and Samuel’s (2002) paper state that the need for separation from others becomes critical for women during birth, since people who are perceived to be polluted will transmit their state of pollution to others, placing them at risk. So women who perceived to be in a state of pollution have to be kept apart from those who are not. In previous studies by the same author, it has also been noted that childbirth pollution is the most severe pollution of all, far greater than menstruation, sexual intercourse, defecation or death. Consequently, touching the amniotic sac, placenta/ umbilical cord and delivering the baby, cutting the cord and cleaning up the blood are considered “the most disgusting of tasks” in reproductive discourses of South Asia (Rozario, 1995). These ideas are present within the groups of women interviewed during this study, and that the removal of pollution is at least one of the major functions of the TBA (or in this MLC’s case, the support staff) assisting the births.
Support networks and birthing knowledge
Intimacy, friendship and social solidarity within one’s family are important dimensions to consider in understanding the motivations underlying women’s health-related actions or health seeking behaviors (Unnithan, 2002). They explain why, for example, for certain women their female neighbor rather than their mothers or mother-in-laws become more important influences in what they decide during deliveries. Or even, how they form expectations of and experience their own childbirths. Since most women interviewed in the study lived in urban spaces, in nuclear families away from their natal kin and often held less bargaining and decision making power within their nuclear household structures (unless they have some level of financial solvency). In this context, their networks are formed depending on their relationships with other women in the local neighborhood (Chowdhury et. al, 2009). As a consequence, there are varied forms of networks of support and a group of familiar, older and experienced women.
Rabbi, 16, mother: R: Yes I wanted to do it at home. I didn't know I would be taken there, I wanted to try giving birth at home. I told the Apa about this (SS), but then she said no I will take you to the center....so that's why we did not inform any dais. My mother had wanted to call a dai … I did not want to go anywhere...my mother gave birth at home and I wanted to do the same. But then who would call a dai at late night? Thinking about all of this, then also since Apa had advised against it… we went to the center.
The role and presence of health workers, in this case, BRAC SKs/SSs in the area are critical to their decisions as to where they seek care for delivery as well.
Shamima, 30, mother: “I knew about BRAC from those who had their deliveries there. Ujjol's mother offered to take me there. After seeing me she informed them. The landlord's granddaughter and Lovely Apa were called. They told Lovely Apa that there is a pregnant lady here and you should come and see her. I didn't even know about it. 3-4 people came afterwards. Then they asked me a lot of questions, gave me advice. I told them I won't do my delivery there but they told me to give it a try. They told me there would be a lot of advantages to using the chair. They told me to sit down in the chair and try it out for myself. Otherwise I would have gone back to my village. I just stayed due to Lovely Apu's insistence. She was adamant about me staying at the clinic. She told me she will take care of me, even if (worst case scenario) I have to do a C- section… See I didn't know anything but those who had gone before me told me, “Bhabi there is a Dai [midwife] there who is very good. Everybody in that clinic is good. You stay here instead of going to the village, you will have a good experience. If you don't trust me try it yourself once”. So yeah I think they were right'.
It is evident from informal discussions with women and observations around the MLC’s area, that it is particularly middle-aged and elderly women (usually aged 50 – 65 and have migrated from rural communities in the past few decades) and Shastho Kormi/Shebika within the community are deemed to have the most knowledge (attained from their own experience of birthing, delivering or their knowledge and positions as BRAC employees, respectively).
As other research on birthing practices in India and Bangladesh show, woman’s kin-peer group is possibly the most influential when it comes to decisions about whom to consult for reproductive ailments – and in this case, childbirth (Unnithan, 2002; Chowdhury et. al, 2009).
Bithi, 27, mother: I go to drop my child to a private tuition, over there. A khala (aunt) had faced this situation - her placenta was stuck, she was taken to Dhaka Medical and they didn't give the injection at first. They used their hands and it was torturous. Then they gave an injection. She said that it was more painful than her delivery, because they put their hands inside and pulled too much. They took her to Dhaka Medical and her placenta was half out, and they wrapped it around their hands and went to the hospital. She told me that if you have the delivery, tell them to take the placenta out as soon as they can. She had told me this.”
Later during delivery, Bithi narrates, that she had asked the ‘khala’ to give her an injection before they proceeded with her placenta delivery. While this is a normal medical procedure that they would have done regardless of her request, for most women it is not common knowledge that injections are given to help with the placenta delivery. Bithi’s conversation with her neighboring women had shaped her understandings of the possible dangers and risks of her second childbirth and its associated precautions from the stories of other women that were relayed onto her.
Literature reports that support networks within women’s communities provide access to birthing knowledge for young women and young expectant mothers. Birth in South Asian countries is typically seen as ‘women’s business’ and is generally not discussed outside the networks of birthing women. Knowledge is passed on verbally to those who ‘have a right to know’ (Davids and Chesney, n.d). Previous studies on social networks for new mothers found that only a small percentage living in the urban slum areas had post-partum and delivery support systems beyond the poor settlement in which they resided (8%), or outside of Dhaka (3%). Their primary support network included family members, friends, husbands and the community health workers (CHWs), who became the main source of information and a noted source of emotional support when available (Adams et. al, 2015). These networks have to be regarded in terms of the shifting power and politics among members of the women’s household, their landladies, among their neighborhood women, their peers and in some cases - their natal households. Whether these networks are successful or unsuccessful, depends on various factors.
Birthing at the center or at home?
During our interviews and observations at the clinic, we came across preconceived notions about delivery practices (this encompasses hygiene, medication, support from the MLC staff, among other things), which create gaps in how the center runs versus how mothers in labor expect it to run.
Afrin, 24, Midwife: The challenging part is, not all the patients and their attendants have the same mentality. Many (mothers and their relatives) come with a preconceived notion that giving an “injection and saline” (oxytocin to induce labor) are critical in order for a woman to be able to go through a normal delivery. That's what the mentality is and it's not new founded either. It's been long since it has been around and this often comes up as a challenge for us. As part of our knowledge of normal physiology, we understand that there is no need to do conduct a delivery with an induction. A mother's body has hormones which is enough to do a normal delivery. But in order to clear this misconception, we have to do a lot of counseling. So this is a challenging issue for us, as patient attendants create a ruckus if we try to do a normal delivery without any induction. Some understand after we explain to them, some don't. Then we have to really give them proper counselling, still we don't opt for induction. We want to improve our care that's why we don't do induction. After I joined here, the deliveries that have taken place have been completely without induction, just simple normal deliveries in the normal process. So this is a challenging aspect for us, since the attendants and even the patients at times scream and shout about this. Some patients even leave, when they see we are not giving them any injection or saline, after creating a big scene. We allow those who want to go, to leave, we don't create a fuss.
In the case of women we interviewed living in Mirpur, they go into the MLC with the expectation being met with a specific series of experiences of which they have gained some knowledge (from community and kin-groups) and also what those experiences would do to their bodies and the extent to which they can control the events of their own delivery. Women shared that when were first introduced to the birthing chair at the onset of their deliveries, they experienced gaps in their expectations and the actual experience, with many resisting the chair. Which is because they went into the delivery center with completely no knowledge of the birthing chair and the clinic’s shift to more normal delivery focused midwifery practices. Thus, most women initial resisted the chair out of fear.
Unnithan’s (2002) work on childbirth experiences in rural Rajisthan had critically looked into the motivations of women (and the community) to prefer home births over hospital births. She suggested that resort to home births is more a result of helplessness and an inability to command the resources (finances, transport, and company) which would be needed for birth in clinics and hospitals
However, the longer the birthing chair is utilized by women and remains as the main option for delivery at the clinic, the more it can become a part of the community knowledge through the midwives’ monthly door to door community activities.
Afrin, 24, midwife: (I: So when you visit the expectant mothers to counsel them, what kind of advice do you give them?) Then, we tell them “Apa, your delivery date is near, the date is this week or this month, so if you get labor pain do not try anything at home. If you try at home, there might be unnecessary complications for both the mother and the child. There can be a life risk”. Somebody at home might unknowingly give you an injection or an IV saline, which is bad for the child as it can affect the heartbeat of the child or the child may die inside the womb. Obviously we can't say that directly, so we say the baby might become sick inside. For the child as well as for one's own life, she must come to the hospital. It is my life and my child's life, it needs to be saved. So like this we do counseling to not do home delivery. She might have relatives or elders who prefer home delivery, who say that you already did checkup so you don't need to go the hospital anymore, the delivery will be done at home. Then if there are elders at home we try to make them understand that during home delivery if the mother starts bleeding then she might die and you won't be able to do anything, you can't take her to the hospital from home. During delivery if you need immediate help, example if the baby's head gets stuck or the placenta gets stuck, then if they are in the hospital we can immediately manage the situation. There will be less problems in the hospitals. We try to make them understand how risky home deliveries can be. They might not come to us, they might go someplace else but they should at least go to a hospital for delivery. That is how you have to do counselling. Majority of the times, the mothers plan on doing a normal delivery by coming here and they are ready about it. Those who are a previous case of CS [cesarean] also want to do a normal delivery here but then we get afraid since they have previously done a cesarean and how can we manage if something happens, we don't have proper management here… We talk very openly about the services we provide for a normal delivery (during fieldwork), we talk about the chair, the birthing ball. Due to exercise with these [equipment/apparatus], delivery without induction is possible. If there is [labor] pain then there is no need for induction. The mothers have to be coached like this, otherwise they ask for injections. So if we tell them from before then they have a concept that if they come here to the clinic, the Apas can do a normal delivery and the baby will stay healthy.
But acceptance is critical to the birthing chair’s success in Mirpur and other nearby neighborhoods. As literature finds, when other women deliver in a facility, they diffuse their experiences to the greater community (Afsana and Rashid, 2011). As urbanization spreads and changes the landscape of these women's lives, delivering in their natal home becomes only a distant possibility for most. Yet the feeling and idea that hospitals in general are not to be trusted with something as intimate to these women as childbirth, remains. A study of practices of childbirth in urban slums in Dhaka in 2007 found that 84% of respondents, married women aged 15-29, preferred to give birth at home with most choosing an untrained TBA (Choudhury et. al, 2012). This paper was the baseline survey for the MANOSHI program of BRAC, another paper that analyzed the situation of urban slum births noted that “women were found to have no clear idea about the delivery process until they experienced it themselves,” relying on TBAs, other women and landladies for advice (Ahmed et. al, 2010).
Childbirth: Pain, endurance and “feels like death'
Nasrin, 22, mother: It is like a searing pain which starts from your spine... when it settles on to the lower abdomen the pain increases a lot. It stays for a minute and then it subsides, and so it continues like that... The pain you have when it is a girl is different than a boy’s. The people who stay here as tenants, they told me as well that the pain differs. They say when you have a girl, the abdomen becomes round and you have a lot of hair fall, become thin, etc. When I was having my son, I became dark but when I was pregnant with my girls I became fairer and was healthy since I could eat properly...during his time I couldn't even eat. When you have a son, your body becomes dark and thin…
The majority of women experience pain during labor and childbirth. For many women, they shared that it is the most significant pain they experienced in their life. However, despite it being associated with the same fundamental physiological process, not all women experience labor pain in the same way. Women’s evaluations of labor pain can range from excruciating to pleasurable in different individuals or on different occasions. Some women manage the pain well, requiring minimal assistance and reporting positive experiences, whilst others do not cope well and request intervention in order to avoid or alleviate the pain. Curiously, women have reported labor pain as a paradoxical experience of pain – one that is both excruciating but also desirable because of its positive outcome of the birth of their child. It is thus clear that labor pain is a complex and unique experience of pain and, consequently, is challenging to manage.
The 10 women interviewed constructed their notions of pain, endurance and the threat of birthing mainly through the knowledge they found from mothers, mother in laws, and their neighbors. Women’s ideas of pain, endurance and beliefs of birthing to be a risky, life threatening process has been explored in past and existing researches on maternal health and well-being. Representations of birthing that these women see and experience around themselves, reflect and construct the regimes of truths and beliefs that they carry with them to their own experiences of childbirth (and pregnancy) (based on arguments of body policing; Ussher, 2006). Women interviewed similarly based it on what they saw around them in their neighborhood and stories they heard of women nearly dying during delivery.
Bithi, 28, Mirpur: Well you see sometimes your placenta could get stuck. If it gets stuck inside you, the person will die. Or if you have low blood pressure or there is too much blood loss or mistreatment. If they handle it improperly, the placenta goes up. My mother had told me this. I was tensed about that but also about other things. I have heard that the delivery goes well and even then people die. A neighborhood woman’s baby had been delivered 10 days ago, the woman still has very low pressure. And then the child survived and mother died. But after a few days the baby also died. Her pressure was low that's why. The baby didn't get enough milk. Mother's care is critical…I heard the news a few days before my delivery date. I had taken a walk along that house, that’s when I heard it. I've seen it in many places. I know of home births, sometimes they couldn't get a hold of the placenta properly, and that's why the placenta rides up their organs. And they die because of it. I've heard from two people, they were neighbors, that's why.
Fear formed in the women interviewed were very specific and contextual, derived from stories of ill managed births, accidents during deliveries and ill-managed pregnancies around their network of women. However, the context of the fears around death during childbirth have a more underlying, national narrative.