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CHAPTER 1

The Professionalization of Obstetrics in Colonial India

The “Problem” of Childbirth in Colonial Discourse

In the late nineteenth and early twentieth centuries, the management of childbirth emerged as a key issue in colonial and nationalist discourses in India, as it did in other colonial settings around the globe from Jamaica to the Sudan to Malaya and the Pacific Islands.¹ The concern with childbirth in the colonies, particularly as it related to maternal and infant mortality, echoed anxieties arising around these issues in the European metropoles. Both in the metropole and on the periphery this heightened interest in childbirth arose due to growing awareness and pronatalist fears of depopulation trends. Depopulation, particularly among proletarians, was thought to threaten capitalist interests by shrinking the labor pool. In both the metropoles and their colonial outposts the provision of maternal and child health care was thus increasingly viewed as critical to the economic interests of the state since it held the promise of arresting depopulation.

In India colonial sympathizers and nationalists alike depicted the conditions of childbirth as deplorable and used these images to legitimize their own political and economic goals in the name of protecting the “vulnerable” members of society, i.e., women and children. Differences lay in where each placed the blame for the sorry state of the birthing woman. The colonists tended to blame Indian “custom” and “tradition,” while nationalists blamed the colonial government’s extractive economic policies and unequal distribution of health services. Some Hindu nationalists used ancient Sanskrit texts as evidence that there had previously been an advanced tradition of obstetrics in India that had been lost through historical incursions from outsiders, namely Muslims and the British.² Just as Lata Mani has argued that in colonial and nationalist debates on sati “women are neither subjects nor objects, but rather the grounds of the discourse on sati,”³ the status of women’s health can also be viewed as the “grounds” rather than the subject of the discourse on the care of Indian women during childbirth in the colonial era.

In general, colonists and nationalists both considered the professionalization of obstetrics to be an antidote to the problem. Debates in the late nineteenth and early twentieth centuries revolved around the question of how and to what extent childbirth could be brought within the ambit of the emerging allopathic medical establishment in India. The focus of these debates can be viewed as part of a larger trend away from an earlier approach that emphasized coexistence and collaboration between allopathic and indigenous systems of medicine toward the late-nineteenth-century approach, which asserted the dominance of allopathy and attempted to repress indigenous medicine throughout the colonized world.⁴ This shift was due in part to new scientific discoveries which rendered allopathy increasingly distinct from indigenous medicine. It was also precipitated by the growing popularity of the eugenics movement in Europe and the United States insofar as the exclusive use of Western-style medicine was deemed critical to asserting racial superiority. Furthermore, the “whiteness” of the initial allopathic doctors who served colonial administrative personnel ensured the physical separation of the “races” to a degree which was not considered necessary in the earlier phase of colonialism.⁵

This chapter examines debates regarding how to bring childbirth within the domain of the allopathic medical professions in colonial India. This is not intended as a full history of the biomedicalization of childbirth in India. Other scholars have begun to write pieces of such a history, and I draw a great deal from their findings as well as from materials I gathered in the Tamil Nadu State Archives in Madras.⁶ Here I focus on how the context of colonialism as well as local cultural constructions of gender and caste combined in such a way that the professionalization of childbirth in India took on a different form than it did in the United States and Europe, and differed also from the situation in other colonial contexts. Two factors of note which differentiate the situation in the United States and Europe from that in India are, first, that from the inception of obstetrics as a profession in India, it has been largely a women’s profession; and, second, hospitalized births did not become and still are not the norm in India, despite the government’s conviction of the supremacy of allopathic hospital obstetric care. Combined, these factors lead us to ponder the extent to which the kinds of power relationships described by feminist scholars writing about the history of childbirth in the West are and are not replicated in the Indian situation.

Madras played a prominent role in the professionalization of obstetrics in British India. The first “lying-in” allopathic maternity hospital in British India—and in Asia as a whole—was established in Madras in 1844. The Government Hospital for Women and Children in Egmore is still one of the preeminent maternity hospitals in India. The first training school for midwives in India opened in Madras. Madras was the first city to admit women into its medical schools, and the first city with a medical school offering a post-graduate diploma in obstetrics and gynecology. It was, therefore, no surprise that in 1936 the first All India Obstetrics and Gynaecological Congress gathered in the Museum Theatre in Egmore, Madras, just down the road from the Egmore maternity hospital. Ida Scudder, an obstetrician and gynecologist—born into a missionary family in South India—who helped to found the world-renowned Christian Medical School and associated hospital in nearby Vellore, was elected the first president of this congress. In her welcoming address, the chair of the congress, Dr. A. Lakshmanaswami Mudaliar, proudly stated:

Madras may not stand comparison in many respects with the Gateway of India or with the City of Palaces—the second largest city in the British Empire. But Madras is proud[,] and justly so, of the place it occupies in the Obstetric world of today and it is in no spirit of narrow provincialism that I venture to maintain that no other city in India could have claimed this honour with greater confidence and dignity.⁷

Prior to the 1844 opening of the Government Hospital for Women and Children, women in India had all been delivering their babies at home, usually in either their natal home or their husband’s family’s home. There were medical institutions for indigenous medical traditions (such as Ayurveda, Unani, and Siddha), and these traditions did have well-developed theories of reproduction and birth.⁸ However, these indigenous medical institutions and practitioners were not involved in providing services to women during the actual birth. Some have suggested that this is largely due to the fact the practitioners were almost all men and it was inappropriate for a man to be present at a birth.⁹

Many of the home deliveries were overseen by senior female members of the extended family who had experience in assisting births. Other deliveries were attended by lay midwives who were called from outside the family. In South Asia these midwives are often referred to collectively as dais by people writing about the region as a whole. This term is most widely used in the northern regions of South Asia and is thought to be of Arabic origin.¹⁰ Some scholars have chosen to use the term “traditional birth attendant,” or “TBA,” which is taken from the international development discourse, because the term “dai” is deemed condescending in the communities they are studying.¹¹ Indeed, in much of the literature on midwifery in India the primary role of the dai is thought to be the removal of ritual “pollution” associated with childbirth. In particular, writers mention that the cutting of the umbilical cord and the disposal of the placenta and blood are the primary tasks performed by dais and that these tasks are deemed defiling. In general, specialized dais belong to low-caste Hindu or poor Muslim communities. Many dais are members of the “barber” castes, which participated in an extensive network of patron-client, or jajmani, relationships in the precolonial era.¹² The work of the dai is often hereditary, passed on from mother-in-law to daughter-in-law.

Unfortunately, discussions about the deprecating connotations of the term “dai” have not looked carefully into the history of the dai’s role in South Asian societies and the extent to which colonial representations of the dai and the very process of the professionalization of obstetrics in South Asia may have significantly transformed these women’s status. Patricia Jeffery et al. refer briefly to the possibility of a historically shifting status of dais when they write:

The few historical sources that feature dais and women’s experiences of childbearing are often written by doctors patently biased against their competitors. Thus we cannot be sure about how dais’ skills and status might have changed, especially in the wake of the major secular changes since the mid-60s. Possibly in the face of what are probably more restricted employment opportunities for women in the poorest classes, proportionately more women are being pauperized and more women with families without traditions of dai practice may be resorting to an occupation that is becoming increasingly de-skilled. Further, as urban medical facilities have expanded, any ante-natal, abortion, and infertility work of dais may have declined, and dais may have become more restricted to delivery work.¹³

Yet Jeffery et al. do not pursue this line of thinking further. Such historical contextualization is critical for a more complete understanding of the dai’s role in India and the role of the so-called TBAs in any society. This chapter will emphasize colonial representations of dais and of local childbirth practices in the contexts of attempts to professionalize obstetrics in India and of the colonial civilizing process more generally.

The historical vilification of midwives in Europe and America has been well documented.¹⁴ In Europe female healers were accused of witchcraft by the emergent elite male biomedical establishment as early as the thirteenth century, when medicine was becoming a secular science and profession. By the seventeenth and eighteenth centuries, midwives were singled out as a danger to society.¹⁵ This clearly had an impact on colonial representations of dais in South Asia, and such negative representations continue to stigmatize dais in India today. Recently, some scholars have attempted to excavate the history of the social and cultural significance of dais in India, highlighting both their authority as ritual specialists and their expertise in many areas of the physical management of birth.¹⁶

Anthropologists working in other areas of the world have discovered that prior to colonial contact and the concomitant spread of biomedicine, lay midwives often garnered a great deal of respect and held positions of political authority. This was apparently the case for the nanas in Jamaica and members of the Sande society, who traditionally provided maternal and child health care, in Sierra Leone.¹⁷ We should not, however, assume that in precolonial India lay midwives must have held similar positions of respect. To do so would be to fall into the trap of romanticizing about the “traditional other.” Indeed, it may well be that in the precolonial era lay midwives in many parts of South Asia were viewed as unskilled, menial, and “polluted” members of society, as they are often considered today.¹⁸ Both assertions need to be investigated rather than assumed. The problem is, of course, that this is an extremely difficult history to recover.

During the late nineteenth century, colonial administrators, missionaries, and medical professionals began to lump a variety of traditional midwives together under the term “dai,” applying it to midwives throughout colonial India (including contemporary Bangladesh and Pakistan) and to midwives of different religious communities. Stacey Pigg has pointed out that in contemporary international development projects undertaken in Nepal, the term “traditional birth attendant” is similarly used as a homogenizing gloss for a wide variety of local healers.After this category of TBA had been created, the Nepali word chosen to translate the category was sudeni, which originally referred to only one kind of healer involved in childbirth. Consequently, the word “sudeni” itself has come to have new meaning in Nepali society.¹⁹ An important and difficult task for historians of South Asia is, therefore, to begin to tease apart the regional and religious differences in the roles and representations of midwives prior to the colonial encounter. Remnants of these differences still exist today and must be studied more carefully by anthropologists and other social scientists.

In Tamil Nadu, for example, a hereditary Hindu midwife is most commonly referred to as a maruttuvacci, and a hereditary Muslim midwife is usually called a nācuvar or an ampaacci. In both cases these are generally women from “barber” caste communities, which are considered low castes and are associated with the removal of pollution. These terms may also be applied to women from other low-caste communities who are engaged in this work. For example, Nagamma, a hereditary midwife from the Pattinavar caste in Nochikuppam, is also referred to as a maruttuvacci. As I discuss in depth in Chapter Six, however, the removal of the “pollution” of childbirth is not the major concern of families I met in Tamil Nadu and is not considered to be the primary role of the maruttuvacci. Kalpana Ram has come to the same conclusion based on her research among the Mukkuvar fishing community on the southern tip of Tamil Nadu. The traditional midwives studied by myself and Ram in Tamil Nadu seem to have somewhat higher status within their communities than do those in parts of rural Uttar Pradesh, where Jeffery et al. conducted their study, or in contemporary Bangladesh, where Santi Rozario did her research.²⁰ Is this difference due to precolonial cultural differences between the north and south, or is it more restricted to the historical role of the midwife in fishing communities in Tamil Nadu? These issues need to be pursued further for a deeper understanding of the politics of gender in precolonial, colonial, and postcolonial South Asia.

Due to the establishment of government “dai-training” programs, in Tamil Nadu the term “maruttuvacci” has come to be associated with those who have not been officially “trained” and thus to connote a lack of scientific knowledge and state recognition. Women who go through dai-training programs, whether they are hereditary maruttuvaccis or not, tend to prefer the label “dai” to “maruttuvacci,” since they feel this gives them greater legitimacy in relation to the communities they serve and, more important, to government and nongovernmental health workers. I try, therefore, to maintain distinctions between such terms as “maruttuvacci” and “dai” in order to highlight the meanings that various terms come to have for people in different contexts. When speaking of India as a whole, I use the term “dai” because that is how most people refer to midwives, even, or perhaps particularly, when they are speaking English.

In colonial discourses the practices of the dai were repeatedly decried as “barbaric,” and the dai herself was represented as the primary cause of high rates of infant and maternal mortality and as an obstacle to “progress,” which the colonial government was promising. Once again, concerns about mortality rates were tied to anxieties about depopulation of the labor force. Two tactics were taken to rectify the situation and to bring Western medical care to Indian women during childbirth. On the one hand, efforts were made to increase the number of Western-trained doctors, nurses, and nurse-midwives who provided services to Indian women primarily in institutional settings. This effort was initiated throughout India under the Countess of Dufferin Fund in 1885. On the other hand, the Victoria Memorial Scholarship Fund was initiated in 1903 to provide training to the hereditary dais already working in communities throughout India.

THE COUNTESS OF DUFFERIN FUND

The first woman doctor trained in biomedicine to work in India was an American missionary named Clara Swain who arrived in India in 1869.²¹ For some time following her arrival, missionary women made up the bulk of the women doctors in India. It appears that the first woman doctor to be employed by the government was Elizabeth Beilby, who began working in Lahore in 1885. It was in this year that the Countess of Dufferin Fund (known in full as the National Association for Supplying Female Medical Aid to the Women of India but generally referred to as the Dufferin Fund) was established, setting the stage for a nation-wide, nonsectarian project to employ women in the medical services. Queen Victoria herself issued a plea for the formation of this fund.²²

The Dufferin Fund and the Victoria Memorial Scholarship Fund were initiated by then-vicereine of India, Lady Curzon. Both funds, as well as subsequent funds for women’s medical care in India such as those initiated by Lady Chelmsford in 1920 and by Lady Reading in 1924, received support from the colonial government, but they were independent of the government in terms of administration and policy and had to raise much of their money from individual philanthropists. This lack of full government funding demonstrates that ultimately the government did not consider maternal health to be an issue of the state, and without full government support it was difficult for these funds to survive.

The stated purpose of the Dufferin Fund was “to bring medical knowledge and medical relief to the women of India.”²³ Maneesha Lal writes that this goal was to be achieved through the provision of:

(1) medical tuition, including the teaching and training of women as physicians, hospital assistants, nurses, and midwives, the education to be supplied first by England and America but then by India; (2) medical relief, which included establishing, under female superintendence, dispensaries and cottage hospitals for the treatment of women and children, opening female wards under female supervision in existing hospitals and dispensaries, providing female medical officers and attendants for existing female wards, and founding hospitals for women where funds were forthcoming; and (3) provision of trained female nurses and midwives to care for women and children in hospitals and private houses.²⁴

It is important to note that the Dufferin Fund, unlike the Victoria Memorial Scholarship Fund, was intent on training a new cadre of midwives who were not hereditary dais. In fact, as discussed below, most of the midwives initially trained and employed through the Dufferin Fund were of European descent.

Historians writing on the Dufferin Fund have highlighted two key interrelated issues which influenced the motivation for and structure of the fund: purdah (seclusion of women) and caste.²⁵ The main reason given for the need to train medical women in India was that cultural practices of purdah prevented Indian women from going to see male doctors. Indeed, cross-cultural studies in many parts of the world suggest that women prefer to be attended by women doctors during childbirth due to cultural notions of modesty, regardless of whether or not women are secluded for religious purposes such as in purdah.²⁶ The emphasis placed on purdah as a cultural practice in the colonial discourse may have served to legitimize the dominance of male obstetricians in Europe and the United States, where purdah is not prevalent. In colonial discourse not only was purdah represented as problematic insofar as it barred women from medical care, but the practice of purdah in and of itself was viewed as dangerous to women’s health because it kept women away from sunlight and fresh air, and it was blamed for excessive female morbidity and mortality. In an official memorandum on maternity and child welfare relief, the director of public health for Madras Presidency (a British colonial province that included most of the contemporary state of Tamil Nadu and portions of the three states that border Tamil Nadu) in 1923 articulated all these anxieties about the effects of purdah on maternal health. In a discussion on maternal mortality he wrote:

Amongst purdah women conditions are even worse, tuberculosis being particularly common. Under this system, the women are prevented from availing themselves of skilled medical advice in the absence of properly qualified medical women, and are also prohibited from taking advantage of the maternity hospitals. Even among the better educated classes the woman in travail is shut up in a dark dirty room where neither light nor fresh air can gain admittance, and she is usually surrounded by a crowd of female relations all prepared to resist to the utmost the introduction of any new-fangled notions of sanitation and hygiene. It is not surprising that the mother, weak and unhealthy to start with, very often succumbs in giving birth to a puny child.²⁷

Indeed, purdah was an important Orientalist trope in constructing the colonized “other” society as repressive toward women, thereby legitimizing colonial authority.

Since in India purdah was primarily practiced by upper-caste Muslims and Hindus, the unstated implication was that the Dufferin Fund was intended to serve upper-caste women so as to make allopathic maternity care respectable and, ultimately, hegemonic. In fact, when female-supervised maternity wards in large hospitals did begin to open up, those women who tended to come at first were Hindu women from the lower castes and classes as well as some less-affluent European and Anglo-Indians.²⁸

In order to lure high-caste Hindus and Muslims, therefore, hospitals began to establish separate wards for these communities. For example, in 1890 the Victoria Hospital for Caste and Gosha Women was established in Madras. Today the official name of this hospital is the Kasthurba Gandhi Hospital, though it is still colloquially referred to as Gosha Hospital. Gosha refers to the practice of veiling among Muslim women. Much of the ethnographic material in this book refers to this hospital. In 1904 a report put out by the Victoria Hospital for Caste and Gosha Women stated:

We have much pleasure in noting the increasing popularity of the hospital. No pressure or inducement is now needed; patients come of their own free will, asking admission into the hospital. In fact during certain seasons of the year, it becomes necessary, from want of accommodation, to refuse admission to patients and they are advised to go to other hospitals. The influx of mofussil²⁹ patients is high as usual…. It is very satisfactory to find that there is a steady increase in the maternity every year. We are also pleased to state that several of the better class come into the hospital for their confinements. We have had no less than 33 Brahmin and respectable Hindu cases. There is no doubt that the new delivery ward, the gift of Lady Bashyam Iyengar,³⁰ will prove a special attraction as the accommodation and sanitary conditions are far superior to those of the old delivery ward.³¹

Lal points out the contradiction which this created in British policy. Colonial discourse represented purdah as a sign of India’s barbarism and something to be reformed, yet the Dufferin Fund was structured to accommodate the practice.³² By the same token, in the interest of attracting an elite clientele, hospitals supported by the Dufferin Fund were structured along caste lines at the same time that caste was rhetorically touted by the colonial regime as inimical to civilized society. Maternity hospitals were established in other colonies at the same time with the same intent of luring elite women, for example the Victoria Jubilee Hospital which opened in Jamaica in 1894. Victoria Jubilee, however, was staffed with male physicians, following the model established in maternity hospitals in Britain.³³

Despite some reports that more high-caste women were using these maternity wards established under the Dufferin Fund, attendance remained low up through World War I. Within India, the Madras Presidency was known to be making greater strides in the provision of Western medical care for women than governments in most other provinces of the colony. Nevertheless, David Arnold reports that even by 1913, less than one-fifth of all registered births in the city of Madras took place in hospitals, and in rural areas of the Madras Presidency maternity hospitals were scarce.³⁴

Despite the official rhetoric which emphasized purdah as the reason for the need to employ female medical practitioners in India, Lal makes the important point that there was also an imperialistic logic to this demand, which has often been ignored by historians. Lal argues that the rhetoric of purdah was used as justification for the establishment of the Dufferin Fund, but the fund initially provided employment and educational opportunities almost exclusively to women from Great Britain. Women interested in breaking into the medical establishment in Great Britain at the time faced fierce competition from male medical professionals. The “need” for women medical professionals in India, therefore, provided an alternative for British women who could not successfully compete with their male counterparts at home.³⁵ As Arnold writes, “Western medicine in India was a colonial science and not simply an extension or transference of Western science to a colonial outpost.”³⁶ In reality, Lal and others suggest, most Indian women were prevented from accessing male medical practitioners primarily due to cost and patriarchal structures which rendered women’s health care secondary to men’s.³⁷ Furthermore, Meredith Borthwick’s study of high-caste Bengali bhadramahilas suggests that even high-caste women were in fact willing to see male doctors, and that male doctors even entered zenanas to provide their services to women.³⁸

Due to the colonial context, race was central to how the Dufferin Fund was executed. Initially, women doctors working in India all originated from and were trained in the West and then sent to India. Women began entering medical colleges in India in 1875 at Madras Medical College, but still these were mostly British and American or Anglo-Indian women. The Indian women who did enter the medical profession at the time came primarily from Christian communities. Hindu and Muslim women, particularly from the upper castes, tended to stay out of the women’s medical professions just as they had stayed away from maternity wards as patients. The reason given for the lack of representation from these communities was that work associated with childbirth was culturally considered “polluting.”³⁹ But racist attitudes in the recruiting policies of medical colleges must also be held responsible for this imbalance that existed up until the 1930s.⁴⁰

One of the ways that women of European descent attempted to hold onto their privileged positions in nursing and midwifery was by arguing that better quality of care could be guaranteed only by providing training (and stipends for training) in the English language, as opposed to vernacular languages. In Madras Presidency this issue was, however, hotly debated in the 1930s, and the Madras government began to establish stipends and training programs in vernacular languages with the intent of spreading allopathic care to a wider population.⁴¹

By 1939 the Madras government explicitly stated that preference for candidates in midwifery would be given to “natives of the Province.” Key restrictions for such candidates, however, were applied. First, candidates had to be between the ages of eighteen and thirty-five. And, in addition to the preference given to candidates who had received higher education, unmarried candidates were also preferred. Candidates who were pregnant or nursing would not be considered. And a student who married during the course of training would be considered to have resigned her training and would be penalized.⁴² The combination of family and professional work was clearly viewed as inimical for women in the colonies, as it was for women in Britain. But such restrictions for candidates may have been particularly problematic in the Indian context, where marriage and maternity were expected at a younger age for most Indian women than for European women. Such restrictions may therefore have favored single European women seeking work in the colonies.

Proponents of the Dufferin Fund felt that part of their mission was to rid childbirth and medical care at birth of what they perceived to be a dominant cultural association of childbirth with “pollution,” and therefore with untouchability in India. The profession of obstetrics thus had to be presented as both sanitary and noble. The success of the Dufferin Fund relied in many ways on the vilification of the dai as unsanitary and on the representation of home birth as inherently dangerous. Over time, however, it became eminently clear that due to the economic condition of colonial India it was not realistic to expect that all birthing women could be served by medical professionals in the short term. It was felt that intermediary measures had to be taken to improve the practices of the dais. It was to this end that the Victoria Memorial Scholarship Fund was established in 1903.

VICTORIA MEMORIAL SCHOLARSHIP FUND

Although individual civil surgeons and missionaries had provided training to dais as early as the 1860s,⁴³ the Victoria Memorial Scholarship Fund (hereafter called the Victoria Fund) represented the first systematic effort to train dais throughout India. Like the Dufferin Fund, the Victoria Fund was run by a voluntary organization consisting primarily of the wives of colonial administrators and headed by Lady Dufferin. Although it had government support, it was not a government program.

In 1918 a major report on the Victoria Fund, entitled Improvement of the Condition of Childbirth in India, reviewed the goals of the fund and assessed the extent to which these goals had been achieved. Civil surgeons, inspectors general of civil hospitals, and medical officers from several provinces, as well as “medical women” and “qualified midwives” all contributed papers to the report. Almost all contributors were men and women of British descent. An analysis of this report reveals the extent to which this project was conceived of as part of the civilizing process and was riddled with the contradictions regarding the question of whether this process would occur voluntarily or by force. These contradictions were played out in the representation of the dai, who was simultaneously depicted as a victim of “custom” and caste and as a criminal agent acting with free will. The question, therefore, was whether the dai could be enlightened and reformed, or whether she represented a threat to civility and should therefore be forbidden from engaging in her work assisting births.

The report states that the primary objective of the Victoria Fund was “to train midwives in the female wards of hospitals and female training schools in such a manner as will enable them to carry on their hereditary calling in harmony with the religious feelings of the people, and gradually to improve their traditional methods in light of modern sanitation and medical knowledge.”⁴⁴ The emphasis on the gradual pace at which this transformation should take place was further underscored by Colonel C. Mactaggart, the inspector general of civil hospitals in the United Provinces, who wrote:

I am strongly of the opinion that in all sanitary and medical matters in this country progress can only be made by carrying the people with us, and not by driving them. Progress in such matters can only be very slow and gradual and it can only be made as the result of a general advance in education and a gradual increase of the confidence of the people in the methods of Western medicine. No greater mistake can be made than to attempt to do too much and to endeavor to advance our methods by compulsion.⁴⁵

The notion that the best way to achieve desired changes is through education so that the public comes to desire change of its own will reflects what Foucault has noted as a change from juridical power to discursive power that has been a hallmark of the discourse of civil society.⁴⁶

This attitude also reflects a general change in colonial policy in India following the Mutiny of 1857, after which the colonial government felt that it had moved too quickly to establish British-style institutions and morality under the leadership of Lord William Bentinck, and that it was too removed from the social lives of Indians to understand them and therefore to rule effectively.

Indian society was primarily conceived of in religious terms as “Hindu” society, and although there was a move to understand that society, there was also a retrenchment from becoming involved in or directly transforming “Hindu” institutions. Hence the reference above to the importance of training dais in such a way that their work is “in harmony with the religious feelings of the people.” The post-Mutiny policy was to move into the inner spaces of Indian society in order to gradually transform and reform those spaces, to “carry the people with us” toward progress. Nevertheless, Christian missionary activity in India during this time continued to actively seek out converts in part through the provision of biomedical maternal and child health care.⁴⁷

The private sphere of women, and in particular of mothers, became a great new frontier for colonists during this period of High Empire following the Mutiny. The “dark,” “inner recesses” of women’s space had to be penetrated in order to change the Indian public’s attitudes about medicine and “sanitation.” The representation of these spaces as “dark” in and of itself equated them with bad sanitation, and in the context of childbirth, the darkness and stuffiness of the space in which women delivered was repeatedly cited as a cause for disease. But by penetrating this space and bringing to it knowledge of Western medicine and sanitation, not only the private space but the entire nation could become enlightened. In short, embedded in the discourse on childbirth was the notion that the hope for the progress of the nation lay in the minds and bodies of India’s women, who were homogeneously referred to as “the Indian woman.” As the Scottish doctor Dagmar Florence Curjel, working with the Women’s Medical Service in India, wrote in the Victoria Fund report:

[T]he real solution to the problem lies in educating the Indian woman in the case of her own health, and that of her offspring, and in the elements of domestic hygiene, by every possible means. It seems to me that the question is truly one of home rule—for the woman is the heart of the Indian home, and it is she who will be the decisive factor in improving the conditions of childbirth in India.⁴⁸

In the passage above, “home rule” refers to the growing nationalist movements for independence and in particular to the Indian Congress party’s Home Rule campaigns, which were instigated by Balgangadhar Tilak and Annie Besant in 1916. Partha Chatterjee has argued that for Bengali nationalists during this time, Indian women—and the clothes draped around their bodies—became powerful symbols of superior Indian spirituality which was protected within the confines of the home and could thus resist internal colonization.⁴⁹ In colonial medical discourse, however, Indian women’s desire and ability to improve the conditions of childbirth were construed as a prerequisite for political autonomy. As Scottish Dr. G. J. Campbell from Rainy Hospital in Madras wrote:

Much requires to be done in the way of improving conditions of childbirth by securing legislation to raise the marriage age for girls in the country to 15 or 16…. This want of readiness for social reforms should be taken into consideration when claims for home rule are made. As I have said before, if some political genius of Indian birth would devise a scheme whereby in each section of the community the attainment of self-government could be made to depend on its ability to do this and other elementary acts of justice to its own weaker members, a useful stimulus to progress would be given. Then when every section of the community had achieved internal reform India would be ready to take her place with honour, as an equal, in the council of nations.⁵⁰

It is important to note that although Indian mothers were constructed as being ignorant, they were also viewed as innocent victims of Indian “custom” who were eminently malleable. Like children, they could be reformed if given the right direction. It was the younger women in particular who were viewed as more inclined to accept and adopt Western notions of “progress,” whereas their mothers-in-law were often viewed as conservative elements which had to be overcome or bypassed. Kathleen Patch, an English nurse working in the Winchester Mission in Mandalay, wrote:

It has been said that the Burmese woman is one of the most charming of women, the best bargain-driver in the world, but the very worst mother. Just as we do not expect much in the way of self-help from young children so we cannot at present look for self-help from the native mothers. We have to help them to help themselves, and the gradual introduction of European methods can be best effected by giving the native midwives a first-class training and sparing no effort to inspire them with high ideals for their very important vocation.⁵¹

This infantalization of Indians was a central part of the psychological force of colonialism, as Ashis Nandy has argued.⁵²

In the above passage the point is that “native” women are bad mothers because they are ignorant, not because they are immoral. This distinction between morality and knowledge was repeatedly used in judging “the Indian woman.” As one woman doctor wrote, “The Indian woman is usually a good mother to her children, but her lack of knowledge often leads her to show her affection in ways inimical to the baby’s well-being.”⁵³ The colonial construction of “the Indian woman” as moral differed from constructions of womanhood in some other colonial contexts, such as in Jamaica, where high rates of infant mortality were attributed to the illegitimacy of the children and thus the immorality of the mothers.⁵⁴ Colonial notions of “the Indian woman” as moral were based on colonial and nationalist perceptions of upper-class, upper-caste propriety. In other colonial contexts where Indian women made up an important part of the indentured labor force on plantations and mines, such as in Fiji and Malaya, “the Indian mother” was in fact treated with greater disdain than her other colonized counterparts.⁵⁵

In late-colonial India, in order to teach the moral but ignorant Indian woman how to become a “good mother,” colonialists began to run classes in “mothercraft” and to disseminate information about “mothercraft” through public lectures, pamphlets, magic lantern shows, exhibitions, and baby shows. “Mothercraft” classes went beyond lectures on feeding and rearing children to include such things as the “art of housewifery,” cooking, and needlework.⁵⁶ Beginning in the early 1920s, National Health and Baby Week celebrations were carefully organized to take place in districts throughout India simultaneously. As part of these shows, babies were entered into competitions for “most healthy” baby. A report of a 1928 celebration in Madras Presidency shows that all babies entered in these competitions were given such things as free baths, biscuits, and sweets. Winning babies were treated to prizes in the form of silk jackets, silver cups, soap, Horlicks malted milk, and toys, and their mothers sometimes received new saris. And “poor feedings” were distributed to all who attended.⁵⁷ Many of these “mothercraft” programs were modeled on similar projects being carried out in England and the United States.⁵⁸ A key goal of the “mothercraft” programs in the West and in the colonies was to get women to view their babies as “citizens” and therefore to care about their well-being not only on a personal level but for the sake of the future of the nation.⁵⁹ In the colonial context this was of course rife with irony: for India to become eligible for nation status, “the Indian mother” had to view her baby as a citizen even before the mother or baby was in fact granted citizens’ rights.

Some colonists also argued that messages about such things as hygiene and “mothercraft” could only be imparted to Indian women through Indian men, who, because they were more often given English educations, were viewed as more accepting of Western “scientific” knowledge. As Dr. K. O. Vaughan, stationed in Srinagar, wrote, “In England women can and do manage their own affairs and those of other people too, intelligently, efficiently, and well. Without them where would be our educational system, our hospitals, our orphanages and a thousand other activities essential to the welfare of a great nation. Out here not only are the women not educated, but they have no power to reform things.”⁶⁰

Although the “Indian mother” in this report is generally constructed as ignorant but malleable and potentially reformable, the construction of the dai which emerges in this report is much more ambiguous. On the one hand, dais are represented as ignorant products of the “traditional” society within which they must live and work. On the other hand, they are depicted as self-serving criminal agents who are rigid in their opinions and are thus obstructing progress. Most of the dais at the time were at least forty years old, and their age was viewed as a marker of their conservatism. Some distinctions were made between rural and urban dais. Urban dais, it was felt, were more malleable, whereas rural dais were rigid in their ways and a force to be reckoned with.⁶¹ But generally the report refers to dais as a homogenous category—sometimes calling them a “caste,” an “institution,” a “class,” or a “race.” Whichever label was used, they were always viewed as the lower rung of the social order, without access to education. Their low status itself was thought to preclude the possibility of their adopting Western knowledge and practices.

The dai was always depicted as dirty. In introducing two dais to the reader, Dr. Vaughan writes, “Their clothes filthy, their hands begrimed with dirt, their heads alive with vermin, they explain that they are midwives, that the patient has been in labour for three days and they cannot get the child out. They are rubbing their hands on the floor previous to making another effort.”⁶²

In fact, dais were constructed as being inherently dirty due to their low caste position. Thus, while most colonial reformers claimed that caste was an obstacle to building a civil society, they employed their view of the logic of caste to condemn the practice of the dais. In addition to being dirty, the dais were often referred to as “evil” and construed as being “meddlesome,” echoing the condemnation of midwives in Europe and America by the church as well as the state and the medical profession.

In 1923, the director of public health for Madras Presidency even suggested that it was safer to deliver with no assistance at all than to be attended on by a dai. As he wrote:

Excluding the few fortunate women who are delivered without any assistance or intervention, there still remains some 10 lakhs [one lakh is 100,000] of labor cases which are managed by barber midwives or dhais [sic]. Their ignorance of hygiene, or even of cleanliness, is stupendous, as may be recognized when it is stated that the duties of physician, midwife, and scavenger are all performed by them. Their methods, the instruments used by them, and the medicaments given to both mother and child are so revolting that no language sufficiently strong can be used to condemn them. It cannot therefore be a matter of great surprise that maternal deaths amount to the colossal figure of 25,000 annually.⁶³

The introduction to the Victoria Fund report acknowledges that the dai-training schemes had not been wholly successful and attributes the lack of success to the active resistance of the dais:

Many of the women were forty, fifty, sixty, or even seventy years of age: some were deaf, some were blind: none had any previous education or had ever exercised their mental faculties: they were very prejudiced and jealous of their reputation and in addition honestly convinced that no one could teach them anything as regards normal labour. They believed that doctors were required in abnormal cases, but they also believed that they themselves were the proper judges as to when a doctor should be called in. This was and is the general opinion of their patients and it is the attitude of the people of India at the present day. They are only very slowly beginning to realise that the great mass of the abnormal cases are due to neglect and ignorance in the treatment of normal labour.⁶⁴

In the end, this report reflects extreme ambivalence about the value of working with hereditary dais through the Victoria Fund. Nevertheless, throughout the report there is a sense that despite the innumerable obstacles faced in training hereditary dais and in reforming “the Indian woman,” the continuation of the work of the Victoria Fund remained essential to the stated goals of reducing infant and maternal mortality in India. The dai-training programs were viewed as necessary stopgap measures, while the long-term goals lay in the development of a cadre of professionally trained women doctors, nurses, and even midwives who would oversee deliveries in hospitals.

The director of public health for the Madras Presidency in 1923, quoted above, was less willing to concede that short-term government support of hereditary dais should be continued. He sought to prevent dais from practicing in the presidency and proposed to do so through the passage of a government act modeled after the Midwives Act of 1902 in England, which required all midwives to be licensed and penalized all midwives practicing without licenses. Through such an act, he felt that all dais would be replaced by certified midwives who would not be drawn from the pool of hereditary dais.⁶⁵

In 1926 the government of Madras Presidency passed the Madras Nurses and Midwives Act requiring certification and registration of all nurses, midwives, health visitors, auxiliary nurse midwives, and dais.⁶⁶ Under this act, anyone working without a certificate of registration could be fined, as could anyone issuing false certificates or anyone falsely using such titles as “registered nurse” or “registered dai.” Applicants who wished to be put on the register had to pass standardized exams and had to provide testimonials of both their professional competency from medical personnel and their “good moral character” from persons of “good social standing.” The council deciding who could and could not be on the register included representatives from all the above categories of practitioners except dais. Obviously, the administrative difficulty of officially training all dais and penalizing all those dais practicing without certification was insurmountable. Additionally, it would be interesting to know, although impossible to ascertain, how councils voted on the “moral” qualifications of dais given the construction of dais as inherently immoral. Clearly this legislation was more symbolic than pragmatic. Many dais then, just as today, of course continued to practice without any government training or licensing. Nevertheless, this act did represent the government’s ongoing efforts to publicly condemn the traditional practices of the dais while simultaneously demonstrating a commitment to officially recognize and sanction the work of those dais who went through dai-training programs.

Throughout the Victoria Fund report, and in the numerous other government reports on maternal and child health at the time, the high rates of infant and maternal mortality are attributed to the general ignorance of the Indian population and specifically to the evils of the untrained dai in her (mis)management of birth. The report does not consider how maternal health during pregnancy results in high rates of infant and maternal mortality as well as miscarriages and stillbirths. A 1928 study of maternal mortality in India reported that 31 percent of “abnormal” obstetric cases and 54 percent of maternal deaths were caused by “diseases of pregnancy,” whereas in Britain only 7 percent of “abnormal” obstetric cases and 35 percent of maternal deaths were caused by “diseases of pregnancy.”⁶⁷ Poor maternal health during pregnancy is, of course, directly related to poverty and thus to broader structures of political economy.

The Victoria Fund report does not, however, consider how the political-economic structures under colonialism might have negatively impacted women’s health. For example, colonial systems of labor and wage structures rendered women increasingly economically dependent on men, thereby diminishing their ability to take advantage of whatever medical services might be available.⁶⁸ Furthermore, colonialism was directly implicated in the spread of deadly epidemics of smallpox, cholera, and the plague, and was responsible for famines which devastated communities throughout the subcontinent. In the face of these man-made disasters, it was the health of women and children which suffered the most.

In sum, when we consider these two funds together—the Dufferin Fund and the Victoria Fund—it is clear that the status of health of Indian women and children served as the “grounds” for a discourse on childbirth in colonial India. Many goals were sought and achieved through this discourse, including the establishment of a network of allopathic institutions for maternal and child health (including hospitals and medical colleges); securing employment for European and Anglo-Indian women; providing the rationale for colonial administrators to move into the private sphere of Indian domestic life; and legitimizing the “civilizing” rule of the British. This is not to imply that individuals involved in these projects were not sincerely dedicated to the improvement of women’s health; nor do I mean to deny that some Indian women benefited from the new forms of allopathic maternal health care available. But it is important to point out which other, unstated colonial interests were served through these projects.

These funds were structured by colonial interests and limitations as well as by local issues of caste and gender, which resulted in a very different scenario of the professionalization of obstetrics in India than in the United States and Europe. The first critical difference is that due to the intersection of imperialist and local interests, women dominated the profession of obstetrics in India from the beginning. Even in urban centers of India where childbirth has become heavily biomedicalized, it has not been accompanied by the domination of male doctors, as is the case historically in the West. Second, despite ongoing efforts to slander the dais, their central role in overseeing deliveries in India was viewed as inevitable in the short term by the colonial administration, and continues to be viewed this way today. Although ever since the Victoria Fund, many have decried the failures of the dai-training programs, these programs continue to be supported (to some degree) by national and state governments in India today. Unlike the situation in the United States and many parts of Europe, the biomedical establishment’s control over childbirth in India can by no means be viewed as hegemonic.

Due to the combination of these two factors—the predominance of female obstetricians and the continued widespread practice of local midwives—the critiques which women have about the status of childbirth in India today differ significantly from the antihegemonic feminist critiques of the condition of childbirth in the West. The fact that women have dominated the field of obstetrics in India does not preclude the possibility that their practices are as saturated by patriarchal values as those of their male counterparts, since such values are to some extent inherent in biomedical obstetric training throughout the world. But the absence of male dominance in obstetrics in India does have important repercussions on the nature of the critiques of the professionalization of obstetrics in India. There is no significant “natural,” “female-centered” home-birth movement in India today, even among the urban middle and upper classes. Rather, based on ethnographic material presented in the remaining chapters, I will argue that the contemporary criticisms waged by the lower-class women whom I met in Tamil Nadu are less concerned with issues of male domination in the hospitals and with the birthing woman’s individual experience of birth, and more concerned with collectively experienced forms of class, caste, and gender discrimination which often prevented these women from getting the allopathic care they wanted.