The dai, or traditional birth attendant (TBA), remains the primary health care provider during pregnancy and childbirth in much of rural India. Typically an older or widowed woman, the dai draws upon years of experience and generations of traditional knowledge for her delivery practice.
Despite current monetary incentives by the Indian government for institutional delivery, many women in remote areas in India continue to prefer home deliveries conducted by a dai. This is supported by a survey conducted by us in 2006, where 77 of the 159 women surveyed had delivered at home. The preference of home delivery is due to a variety of factors, including accessibility of care, community trust, and negative perceptions of government health facilities. Yet despite the high utilization of the dais’ services, dais are often left out of current maternal and child health programs due to their home-based practice as well as the fact that they are considered “unskilled” due to their illiteracy and lack of formal training.
Recognizing the continued importance of the dai in many communities in which it works, we decided to implement a training in which dais were instructed in the practice of safe delivery and formally connected to the surrounding health care system. In April 2006, we started by training dais practicing in and around Bahmni subcentre. Since then, trainings have expanded to Shivtarai and Simariya subcentres. As of 2015, we have a group of 101 dais from 54 programme villages, for whom we conduct training once in every 2 months.
The objectives for the dai training at JSS are as follows:
1) to decrease maternal and neonatal mortality and morbidity
2) to encourage institutional deliveries
3) to ensure safe delivery for those unwilling or unable to go to health institutions
4) to identify danger signs and promptly refer to a higher center when necessary
Dais are taught by skilled gynecologists and pediatricians at JSS. They are encouraged to refer their patients to an institution and are trained to recognize the danger signs for when institutional care is essential. For deliveries that must happen in the home, dais are trained in safe delivery techniques and are provided with a safe delivery kit containing sterilized materials necessary for aseptic practice. The TBAs are able to manage a few emergencies, the most common one being management of post-partum haemorrhage by applying uterine compression as they have been taught. These skills are life-saving when rapid transport to a hospital is not possible.
“Rajeshwari, the Sarpanch of our village delivered last week,” reported Milki Bai and Jaymati, TBAs from Atariya village. “A boy baby, and then she started bleeding and it would not stop, and she was feeling faint and cold. We remembered what we had learnt here and compressed the uterus with one hand fisted in the vagina and another on her abdomen. We held it like that for 15 minutes, and the bleeding stopped. She recovered after that and is fine now. This was something we would not have been able to manage a year ago.”
The implementation of the dai training has resulted in widespread improvements in maternal and neonatal health. The occurrence of unsafe practices such as the overuse of oxytocin, a drug used to increase uterine contraction, has greatly decreased in programme villages. Infection of the umbilical cord has also declined as more dais have taken responsibility for cutting the cord rather than another village member, as was common practice. Through nutritional training on the importance of food and water post-delivery, the nutritional status of both mother and infant has improved. Furthermore, there have been no cases of prolapsed uterus since the start of the dai training program, and overall neonatal mortality has been on the decline.