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The Marianna McJimsey Award
How to Cite: Azher, S 2017 Professional Niche Dierentiation: Under-
standing Dai (Traditional Midwife) Survival in Rural Rajasthan.
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Sharmeen Azher ‘Professional Niche Dierentiation:
Understanding Dai (Traditional Midwife) Survival in Rural
Rajasthan’ (2017) 24(1), pp. 132–150
ASIANetwork Exchange
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DOI: https://doi.org/10.16995/ane.240
THE MARIANNA MCJIMSEY AWARD
Professional Niche Dierentiation:
Understanding Dai (Traditional Midwife)
Survival in Rural Rajasthan
Sharmeen Azher
Union College, US
azhers@union.edu
Prescribing medicine, providing contraception, delivering babies – although
we may turn to physicians, rural Rajasthani women turn to Barefoot Doc-
tors out of necessity. Such care is available courtesy of the Barefoot Col-
lege, a pioneering NGO that transforms the skills of the illiterate poor
into local infrastructure. Barefoot Doctors are innovative because of their
origins as dais (traditional midwives); once abundant across South Asia,
dais are mostly extinct due to government/NGO interventions emphasizing
“modernity”, like the Accredited Social Health Activist program. Why, then,
have dais survived as Barefoot Doctors when they are extinct elsewhere?
Ecological niche dierentiation refers to when competing species success-
fully coexist; one species adapts to fulll another role. Using over fty
interviews with stakeholders, I explain the persistence of Barefoot Doc-
tors as health resources using “professional niche dierentiation”. Barefoot
Doctors exemplify how health infrastructure can be sustainable in resource-
poor settings when created according to local needs and ideologies.
Keywords: dai; Barefoot Doctor; midwifery; rural healthcare development;
reproductive care
Azher: Professional Niche Dierentiation 133
Introduction
Bhanwari-devi was illiterate, spoke a mix of Hindi and Marwari that I could barely
understand, and, by North Indian standards, was quite old (she didn’t remember her
age and didn’t particularly care to). And yet today I was to accompany her, the village
dai (traditional midwife) and now “barefoot doctor”, on her daily rounds along the
dusty streets of Kadampura Village. Making visits to pregnant women and veteran
mothers alike, I watched Bhanwari-devi’s heavy metal karas, the famous bracelets
and anklets of rural Rajasthan, glimmer as she ambled along with the aid of her
wooden staff. As we sought the house of her first patient, I wondered to myself how
seriously Bhanwari-devi’s medical services could be taken. After all, Bhanwari-devi
had never been to school and had no opportunity to learn about the biology under-
lying reproduction or even basic germ theory. In terms of clinical significance, could
she offer more than midwives’ tales?
Dais, or traditional midwives, have been a major part of the rural birthing
experience for as long as local people can remember. Mostly illiterate, dais have
relied not on formal training, but on their decades of experiences as women—
daughters, sisters, and most importantly, mothers and mothers-in-law—to serve
as midwives for the women of their villages. Although dais like Bhanwari-devi
were once common throughout South Asia, in much of rural India, the dai
profession is dying due to a healthcare development movement that stresses
the importance of “modernizing” infrastructure (Das 2015, 54–56; Ghoshal 2014).
Discourse on medical effectiveness, safety, and evidence-based practice is a key driver
of NGO and government attitudes on the position of dais; according to anthropolo-
gist Sara Price, such programs attempt to “re-train” dais, termed “Traditional Birth
Attendants” by the government, in favor of formally trained or “Skilled Birth
Attendants” (Price 2014, 519–522). Government interventions in rural areas of
Rajasthan, India—the site of my fieldwork— are responsible for distancing dais
from their traditional occupational roles and replacing them instead with ASHAs
(Accredited Social Health Activists) and ANMs (Auxiliary Nurse Midwives) (Ashtekar
2008, 25). These government-affiliated health workers also have rural roots and
are stationed at the village-level, with similar geographic access to local patients
Azher: Professional Niche Dierentiation134
as dais (Shyam et al. 2015, 71–72). As a result, the emotional cost-benefit for local
women seeking reproductive healthcare is complicated; although they can benefit
more quickly from government programs that provide free/low-cost medical care
through ASHAs and ANMs (Mavalankar and Vora 2008, 9–12), rural mothers are
robbed of their closest advocates and caregivers—the dais, who are arguably the
most intimately connected with a village’s social networks. The Janani Suraksha
Yojana (JSY) government scheme has also contributed to the growing obsoleteness
of dais by financially incentivizing rural women to give birth in hospitals instead
of at home under the care of a dai. JSY’s intention is to remove the birthing expe-
rience from an “unskilled” and “dangerous” setting to one that should guarantee
improved health outcomes (Gupta et al. 2011, 6–10). Although a dai is allowed to
accompany the laboring woman to the closest hospital, many times, that moral
support is replaced with the ASHA’s, who receive payment from the government
for performing this task. The dai can accompany the woman at her own expense
or stay behind in the village. This movement towards a “modern” healthcare
system not only creates a hegemony in which healthcare models built on formal
credentials undermine local health infrastructure centered on practical and
cultural experience, but also relegates dais to a passive role during the birthing
experience and risks the extinction of an already marginalized profession (Ghoshal
2016, 27).
Dais affiliated with Barefoot College, an NGO based in rural Rajasthan, however,
have been remarkably well-integrated into the NGO’s health program and are even
referred to as “barefoot doctors” by administrators. Pioneered in the early 1970s by
Bunker Roy, the Barefoot College builds on existing village interests to equip com-
munities with low literacy and formal education rates with the technical skills
needed to create infrastructure that improves access to clean water, reliable energy,
equitable education, and healthcare (Roy and Harrtigan 2008, 67–69). Commended
internationally for its model of sustainable development and for the emphasis
the NGO places on village members identifying the projects they’d like to bring to
fruition, the Barefoot College has allowed me to observe firsthand the work of
“ barefoot” pathologists, pharmacists, dentists, and doctors—all of whom are illiterate.
Azher: Professional Niche Dierentiation 135
With the NGO’s assistance, I conducted fieldwork and ethnographic interviews with
over fifty dais, Barefoot College administrators, government health personnel, and
local families in six weeks following my sophomore year of college to investigate what
made the “barefoot model” so innovative and successful in its incorporation of dais,
not only with regards to dai survival, but also in terms of local healthcare quality.
To understand the survival of dais in this region and examine their professional
trajectory, I have constructed an analytical framework based on the ecological
concept of niche differentiation. In its most simplistic form, when there are compet-
ing species in an environment, one of two outcomes may result: either one species
will out-compete the other and cause its eventual end, or both species can adapt by
specializing their roles in the environment. This latter path ultimately allows both
groups to co-exist, preventing one species from dominating the other (Hardin 1960,
1292–1293). In my case study of Barefoot College-affiliated dais in rural Rajasthan,
I draw on this framework to investigate why local dais have survived despite
government interventions that distance them from their occupational domain, and
how successfully dais have navigated the process of professional niche differentia-
tion to increase local health outcomes. This case study is an important example of
how large-scale development programs can promote effective and culturally appro-
priate health infrastructure in resource-poor settings, and ultimately improve repro-
ductive health outcomes.
Background
In Rajasthan, one of India’s 29 states, the maternal mortality rate is alarmingly high,
with 254 deaths per 1 million live births. As a standard for comparison, the same rate
is 4–20 deaths per 1 million live births for developed nations (Himani and Nautiyal
2010). Birthing is a laborious process for all parties involved and is an especially inte-
gral part of efforts to reduce maternal and infant mortalities. Many women I inter-
viewed reported becoming first-time mothers in their teens, often by seventeen
or eighteen, consistent with recent Rajasthan data suggesting that a third of rural
women first become pregnant between ages fifteen and nineteen (“Annual Health
Survey Bulletin” 2011–2012). It is important to note that this is a much later attain-
ment of motherhood than would have been reported several decades prior to the
Azher: Professional Niche Dierentiation136
success of Barefoot College’s and other government initiatives targeting education
and maternal care; older generations of women I spoke with reported first pregnan-
cies by ages fourteen and fifteen, although these were often unsuccessful. The rise
of literacy in rural Rajasthan, though still a challenge, has likely also contributed to
the delay in pregnancies; the female effective literacy rate in Rajasthan, at 54.5%,
lags behind its national counterpart at 65.5%, but is still a significant increase from
the dismal rate of 43.1% ten years prior (“State of Literacy 2011 Census” 2011). Repro-
ductive health issues in the area for women largely surround pregnancy and the post-
pregnancy period, but also include anemia, menstrual problems, and white vaginal dis-
charge suggestive of Reproductive Tract Infections (RTIs) (Desai and Patel 2011, 48–49).
The interplay of social determinants such as socioeconomic status and gender,
among others, greatly influences both the access to and use of reproductive care
(Sanneving et al. 2013). In rural areas, communities have historically attempted to
address the resource-poor nature of their settings by creating functional health infra-
structure of their own founded on a primary caregiver: the dai. Discourse around dais
and their role in enabling motherhood in rural Indian communities frames dais as
“traditional birth attendants” (TBAs), but this term is less accurate and arguably less
empowering than “midwife” due to its implication of a passive role; in reality, dais
serve in equal parts as affectionate grandmothers and gynecologists. For decades,
they have served as midwives in the very thick of the rural birthing experience
(Jeffrey and Jeffrey 1999).
The hierarchal and socioeconomic positions of dais vary across India; in many
states, dais are low-caste older women, often Dalits (Untouchables) due to the
“impure” nature of their work, which places them in close contact with bodily
fluids and a general state of female bodily disgrace (Kirkham 2007). However, in
Barefoot College–affiliated parts of rural Rajasthan, I found that dais receive respect
and appreciation by virtue of the constant need for their services. As one dai suc-
cinctly stated, “Children will always [of course] be born” (Bachche toh hamesha pedahi
huinge.) Likewise, rather than belonging exclusively to poorer, lower castes, Barefoot
College–affiliated dais hail from a variety of social and economic positions, with
many belonging to higher castes. Initiation into Barefoot College’s program enables
Azher: Professional Niche Dierentiation 137
local dais to become “barefoot doctors” and paid employees of the NGO, although
they are still referred to as dais in their communities. Under Dr. Ram, the program’s
medical director, and Dr. Vikram, another NGO physician who sometimes visits, dais
participate in brief seminars on pregnancy, birth, and the post-delivery period.
A thorough examination of the current roles of dais also warrants investigation into
how the presence of government personnel has impacted their occupational domain,
and whether relationships between NGO and government health workers are collabo-
rative or friction-prone. Almost 70% of India’s population lives in rural areas (“Rural
Urban Population Distribution 2011 Census” 2011); already constrained by poverty, gen-
der inequity, and limited educational and employment opportunities, rural Indians are
also limited by inadequate access to healthcare. In general, India suffers from a shortage
of formal doctors, and this lack of human capital is exacerbated in rural areas (Rao et
al. 2011, 592–595). In response, the national government has established a system of
Primary Health Centers (PHCs) (Malik 2009) to provide crucial health services to the
public at free or minimal costs, although the success of this health infrastructure is
infamously limited by worker absenteeism (Iyengar et al. 2009, 303).
Affiliated with each PHC are several Auxiliary Nurse Midwifes (ANMs). Chosen
through a rigorous application process after ensuring the appropriate age and gen-
der (women 25 to 45 years in age), potential ANMs undergo medical training for two
years before assuming posts in rural areas, where they operate ANM health subcent-
ers (Mavalankar and Vora 2008, 2–4). Courtesy of the National Rural Health Mission’s
expansion of the program, as a salaried worker the ANM is the primary provider of clini-
cal services such as immunizations, drug administration, and sometimes even the deliv-
ery of babies in rural areas; her subcenter is the only nearby clinical setting for many
villages. The ANM’s literacy is crucial to her record-keeping, enabling her to record
births, deaths, diseases, and other significant life events that she relays to the oversee-
ing government-affiliated physician at the nearest PHC (Anantraman et al. 2002).
Subordinate to the ANM is the ASHA (Accredited Social Health Activist).
Recognizing the need for public health engagement at the village level, India’s
National Health Mission launched its ASHA program to ensure that communities
participate in public health initiatives when prompted by women from their own
Azher: Professional Niche Dierentiation138
villages (Nirupam and Dholakia 2011, 3–5). The ASHA is meant to serve as the first
point of contact for local women and children, diligently connecting them with the
ANM and other healthcare services. Although the ASHA’s role parallels the dai’s with
regards to health outreach and education, her literacy and government networks
enable her to connect patients more easily to the formal healthcare system. However,
the local populace is sometimes skeptical of an ASHA’s motivations since she is often
a young woman whose pay is based on the volume of referrals she makes. In contrast,
Barefoot College-affiliated dais are often well-integrated into their communities, and
because they receive a comparatively meager salary, warrant little suspicion from
local women. Since trust seems to play such a vital role in reproductive care for rural
women, in the following sections I will explore the professional niche differentiation
of dais with regard to how they are perceived by community stakeholders.
Interactions with Government Health Workers—Support
or Competition?
Keeping in mind that in many regions of India, the rise of ASHAs and ANMs has
helped to eliminate the dai profession (Sadgopal 2009, 25–59), I conducted field
visits to examine the nature of interactions between the government and NGO
healthcare–model providers. My first visit to the village of Hamda provided the
clearest insight as to how some ASHAs perceived Barefoot College’s dais:
Yes, the dai also does what we do. . . [when asked what the differences were
between ASHAs and dais]. . . look sister, [the dai] is so old, until where will
she walk? It’s good that she has knowledge from Barefoot College. But I
know how to read. So it’s up to the [pregnant] girl—who knows? (Haan, voh
[dai-ma] bhi karte jo hum bhi karte hai. . . dekhiye bhen-a, voh tho boodhi hai,
kahan chalegi vho? Sanstha se jaankari hai, achi baat hai. Lekin mujhe tho
parne aata hai. Tho ladki ki marzi, kisko patha?)
Twenty-four-year-old Mansi had been an ASHA for two years, and although their job
descriptions overlapped, Mansi felt her literacy placed her above any competition
with dais. To be fair, there were many villages I encountered which had either an
Azher: Professional Niche Dierentiation 139
Positive Perceptions Negative Perceptions
Barefoot
College’s Dais
Experts
Affectionately termed
“grandmothers”
More “genuine” and less motivated
by money (they are (under)paid
through a monthly salary)
Outdated
“Too old” for home visits/village
rounds
Not credible due to lack of formal
medical knowledge/use of
appropriate terminology, illiteracy
ASHAs Formally trained by the
government, thus credible
Literate, good record-keepers
Modern
Younger, able to visit frequently
Selfish and conniving (volume-
based payment by the government)
Table 1: Perceptions of local women regarding dais and ASHAs. Information was
compiled through interviews with more than twenty patients.
ASHA or a dai, but not both—because the roles of both ASHAs and dais centered on
health education and awareness-building, having both in a village was not perceived
as necessary. However, dai and ASHA networks sometimes overlapped because both
also served hamlets neighboring the villages under their domain. In these cases,
whether a dai or ASHA was favored varied across localities, with women indicating
their preferences based on the perceived expertise, soundness of education, and
sincerity of both (Table 1). Expecting mothers were especially suspicious of ASHAs
who “harassed” them about timely vaccinations, viewing them—and occasionally
even vaccination programs—as money-making schemes: “She only wants money, why
should we listen to her?” (Usko tho sirf paise chaiye. Kyun sune?)
Because an ASHA was only paid her monthly income of between 3,000–5,000
Indian rupees if she ensured that local women received vaccinations according to
the provided schedule (Table 2), she had strong financial incentive to insist on ANM
visits as frequently as possible. In contrast, Barefoot College’s dais, who received a
relatively paltry monthly salary of Rs. 600, struck many as more courteous and genuine.
Despite these reported conflicts, my interviews also included narratives that
stressed collaboration and mutual respect between the government-health-worker
Azher: Professional Niche Dierentiation140
Time Vaccination/Shot
Birth BCG
Hepatitis B Birth Dose
Polio Dose 0
1.5 months Penta Dose 1
Polio Dose 1
2.5 months Penta Dose 2
Polio Dose 2
3.5 months Penta and Polio Dose 3
9 months Measles Dose 1
Vitamin A
1.5 years DPT Booster
Polio Booster
Measles Dose 2
Vitamin A Dose 2
5 years DPT Booster Dose 2
Polio Booster Dose 2
Vitamin A Booster
10 years TT 1
16 years TT 2
Table 2: Timeline of vaccinations performed by ANMs for infants at and post-birth.
Information was compiled through interviews at the government-run Harmada
Primary Health Centre.
system and Barefoot College’s dai program. Although much of this paper focuses on
NGO and government moves to distance dais from the birthing experience, surpris-
ingly enough, the most obvious appreciation for dai expertise was from ANMs when
dais were retained in the clinical setting. The following is a description of my visit to
the Burjispura ANM subcenter immediately after a 21-year-old’s successful delivery:
The ANM subcenter consists of a small waiting room, an office, and a medical
room with one metal bed. The medical room has been converted to a delivery
room and the new mother, Seema, lies resting away from the half-moon inden-
tation in the bed meant for vaginal examinations and facilitating birth. She
Azher: Professional Niche Dierentiation 141
looks exhausted, having given birth a mere five minutes ago, and the dai wipes
down her face and gently covers her partially naked body while talking with
me about her vitals. The dai checks the IV solution hanging on a nearby stand
to ensure that it is still properly connected to Sita’s arm, cleans the newborn,
and brusquely begins washing the blood-stained mats in the room. Meanwhile,
she reminds the ANM, who is standing next to me and explaining Sita’s medi-
cal history, that it is time to check the newborn’s weight and do a preliminary
checkup of mother and baby to make sure they have survived birth in optimal
health. The ANM thanks her for the reminder and pauses chatting with me to
assist the dai. . . The birth is successful, with both mother and baby stable.
A hierarchy favoring the ANM was evident in this instance—the dai, who earlier advised
me to think of her as the ANM’s assistant, deferred to the ANM’s instructions—but
also negotiable with regards to clinical expertise. Although the dai began to clean
the new mother, baby, and birthing room, her role was more expansive than just
handling the “pollution” surrounding birth; it also included opportunity for clinical
input. The dai was not only entrusted with greater contact time with the patient,
but collaborated with the ANM to provide care. This ANM was particularly apprecia-
tive of the dai’s assistance in deliveries, attributing her clinical prowess to her years
of experience. Although I didn’t witness additional deliveries during my fieldwork,
other ANMs and dais I interviewed expressed mutual appreciation for one another
with regard to the birthing experience, especially in areas like Barawara, where access
to larger health facilities is rare.
The birthing room is the major link between dais and their original purpose, and
the first bond to be broken as healthcare “modernizes”. Although “modern” health-
care distances dais from the birthing room, the survival of Barefoot College-affiliated
dais is likely due to their productive collaboration with ANMs in even this clinical
setting. Furthermore, that many women distrust ASHAs and favor dais indicates that
government personnel simply cannot occupy the cultural niche fulfilled by Barefoot
College–affiliated dais.
Azher: Professional Niche Dierentiation142
Dais as Health Educators
Bhanwari-devi taught me that there was more to a dai than delivering babies—birth
was important, but so too were the prior months, especially with regards to preven-
tative care. Walking through Kadampura Village with Bhanwari-devi, I learned that
a dai’s intensive care spanned almost a year; upon suspecting a pregnancy, women
wait for about a month after their first missed period, and only then reach out to
their mothers-in-law and local dais. From this point, Bhanwari-devi told me, it was
crucial to prevent pregnancy complications by carefully advising proper diet and life-
style adjustments, and of course, reminding women to be vaccinated in a timely
manner. Our visit to Seema in her second trimester exemplified the dai’s importance
in educating local women—and not only with regard to maternal care, I learned.
Once we arrived at the house’s entrance, Bhanwari-devi pried open the metal
gate with the ease of someone long familiar with the home and pulled me inside,
calling out to Seema and her mother-in-law. In Rajasthan, as in many parts of India,
a typical household features an older couple, their adult sons and spouses, and
grandchildren; social relations and kinship structure are built on patrilineally related
groups in which male relatives dominate the decision-making process over their
wives, as do mothers-in-law over their daughters-in-law (Dyson and Moore 1983).
An older woman herself, the dai is additionally trusted when she cares for local
women by visiting them in the comfort and privacy of their homes. Such famili-
arity not only enhances trust between dai and patient, but also allows the
dai to engage with the woman’s mother-in-law, the second most important
stakeholder in such visits after the patient herself. Many women in rural Rajasthan
labor daily in the fields out of necessity, even well into their pregnancy; the
complications that arise in pregnancy, labor, or the post-delivery period stem from
related factors that on the surface are avoidable. Fortunately, Bhanwari-devi was
acutely aware of such concerns, and did well to counsel Seema and her mother-in-
law on the importance of a good, thorough diet and relatively less-stressful lifestyle.
While still playing the part of an affectionate, concerned grandmother, as a dai often
Azher: Professional Niche Dierentiation 143
does, Bhanwari-devi’s conversation grew more clinical in nature, as her training as a
barefoot doctor enabled.
I asked Seema and her mother-in-law about tikakarn, or vaccinations; the
government had subsidized and mandated a host of vaccines for each woman and
her infant in order to reduce disease prevalence through the help of rural health
workers (Datar et al. 2007). Although Bhanwari-devi could not read the vaccination
schedule that was released by the government, she had ensured that Seema was
up to date with her TT shots and at least aware that folic acid and iron tablets were
available through the government. These were meant to combat the severe anemia
in the region, and by extension prevent adverse outcomes for mother and/or baby
(Gautam et al. 2008, 283). In general, the experiences differed from a typical doctor’s
check-up in the United States in terms of the actors, setting, and emphasis. Initial
conversation patterns were circumlocutory and conducted at home to respect the
privacy of the pregnant woman and her family, to prevent embarrassment, and to
provide comfort. Gradually, talk became more specific and clinical, although
appropriate medical knowledge was still communicated in ways that were accessible
to the primary stakeholders: pregnant women.
Interestingly, I learned that interactions with the dai often began well before
pregnancy, with some as early as menarche (the first occurrence of menstruation),
which marks the transition from “girl” to “woman”. In many cases, the changing
domestic and societal expectations accompanying such an evolution also mean less
access to education, healthcare, and better livelihoods (Singh 2006, 10). In parts of
Rajasthan, the use of old fabric as menstrual cloths is quite common—both due to
the high cost of sanitary napkins and also strong cultural rules that mandate keep-
ing any sign of menstruation private (Rajesh, Shobha, and Gupta 2012, 767–770).
Rags used by some local women carry with them a high risk of infection, as they
are difficult to clean given the scarcity of water and taboos that prevent women
from drying their menstrual cloths outside “for the world to see” (Garg, Goyal, and
Gupta 2012). In fact, during one of my site visits for Barefoot College, a woman
even reported having used sewage water to clean her menstrual cloths—although
Azher: Professional Niche Dierentiation144
uncommon, her case was an obvious health disaster in the making. Fortunately, “The
dai has achieved understanding [about the topic]. She tells both adolescent girls and
grown women about sanitary napkin use”. (Dai ko tho samaj aagayi hai. Voh toh
kishori ladki aur mahila koh bathathi hai sanitary napkins ke bareme.)
According to Barefoot College’s Dr. Ram, dais deserve significant credit for
improving local menstrual practices, which are major contributors to reproductive
infections in the region. Most pregnant women I interviewed had been consistently
using pads, or if they had used menstrual cloths, cleaned them under the dai’s
guidance. The improved health and social implications are obvious; the increased
availability of and knowledge about pads (due to government subsidies and the NGO’s
menstrual hygiene campaign) has also helped to ensure that girls experience fewer
interruptions in their schooling, and women in their chores. Although other actors,
such as teachers and ASHAs and ANMs, also perform outreach on menstruation,
the dais have been most effective in engaging women involved with kethi-badi
(field labor), whose rigorous work leaves them vulnerable to complicated repro-
ductive issues and pregnancies. Poorer, illiterate, and more isolated, these women
only adopted healthier behaviors upon the recommendation of dais. Kavita, a field
laborer I interviewed, told me that when the dai had first taught her to use pads, she
didn’t like how uncomfortable they were, but gradually accepted their importance.
Sometimes, she told me, she used menstrual cloths because she couldn’t afford
even the subsidized pads, but was careful to clean them with the rigor the dai had
prescribed. My interview with Kavita and women like her reinforced my findings
that dais succeed where ASHAs and ANMs cannot; as older women, dais are “more
trustworthy” than their younger ASHA counterparts and therefore crucial to
increasing health awareness.
Professional Niche Dierentiation:
Dais as Care Coordinators
Despite the positive impacts dais have on local women, many interviewees implied
that, like elsewhere, dais would eventually become obsolete as a result of the
Janani Suraksha Yojana (JSY) government scheme, which pays women to give birth
Azher: Professional Niche Dierentiation 145
in hospitals instead of at home with a dai. Kusum, a health supervisor at one of
Barefoot College’s Field Centers, narrated how dai survival depended on the NGO:
“I understand them, as if I’m their daughter. They are old, what will the poor
things do? Yes, they do good work, but they also worry [about their jobs]. I reassure
them—no worries.” (Mein unko samajthi hoon, unki beti ki thara. Voh budhe hai, kya
karinge bichare? Voh kaam tho karthe hain lekin pareshaan bi hote hai. Mein
samjhathi hoon, koi kr nahin.)
In Rajasthan, children and husbands are vital in old age. Because they are elderly,
widows, and often do not have children who are close to them or financially successful
enough to support them, dais are vulnerable members of society. Barefoot College pro-
vides dais with a small but stable income, and enables them to continue contributing
to a village’s socioeconomic networks. Dais depend on NGOs to continue their tradi-
tion of connecting women across generations, ultimately allowing them to foster a sub-
community based on the experience of motherhood in rural Rajasthan. The role of dais
as midwives was less contested in Kusum’s Field Center, which is more isolated than
many others. Although transportation to the nearest hospital is available through the
Janani Suraksha Yojana scheme, the journey is arduous, and thus unattractive to women
soon to undergo labor, Kusum pointed out. “The dai still has work to do. It’s difficult to
travel in these parts. How will [a woman] give birth? Here [not at the hospital]. These are
health matters, and health work will always be present [referring to the continuing need
of dais].” (Dai ka kaam phir bhi hai. Yahan tho aana-jaana mushkil. Bacha paida karegi
[mahila] kaise? Yahan pe. Voh toh health ka kaam hai or health tho hamesha rahega.)
As the principal actors of their story, dais were cognizant of their evolving roles, and
surprisingly satisfied with the development-modernity movement that had been under-
mining their presence during labor. As part of my work with Barefoot College, I compiled
data on local health indicators and found that in the past five years alone, maternal and
infant mortality rates had drastically fallen, likely due to the increased access to healthcare.
Dais were unsurprised—they felt that their contribution lay in the extensive education and
outreach they had done, a less hands-on process, but still very rewarding.
To explain the survival of Barefoot College’s dais despite occupational overlap
with local ASHAs, I frame professional niche differentiation in the context of care
Azher: Professional Niche Dierentiation146
coordination. International recommendations increasingly emphasize the impor-
tance of care coordination in ensuring healthcare quality and access. In theory, a
primary health worker should be able to recognize needs that are outside of her
capacity to address, and refer patients to more knowledgeable personnel in
succession until the concern is addressed (Gupta and Gupta 2008, 6–15). The
primary actors in Barefoot College’s referral system are dais, the first point of contact
for local women. Since dais serve as health educators and as advocates, they are in
an optimal position to make “referrals” to the nearest lab facility, ANM subcenter, or
even government hospital, depending on the needs of their patients. The knowledge
and power differential between local women and formally trained health personnel
causes considerable confusion with regard to how successfully patient needs can
be met; ideally, the dai serves as a medium between both, with enough medical
knowledge to recognize when complications in either the mother or baby are
outside of her expertise, and enough colloquial understanding to provide comfort
to expecting mothers. As Gauri-devi, a local dai, put it, “When there’s a breech
presentation (the baby is upside-down) or the womb ‘moves’. . .we don’t handle these
cases. We take them to the doctor”. (Jab breech hoti hai ya konk hilthi hai. . . nahi karte
hai. Doctor ke paas lekejaate hain.)
Dais also understand the importance of coordinating care in accordance with
logistical issues; because they are illiterate, they cannot complete birth, vaccination,
and illness records on behalf of patients. Surprisingly, the dai’s referral system also
includes ASHAs, who are required to be literate. Because their government post
expands their networks and contacts, ASHAs can set in motion a payment model for
mothers looking to benefit from the Janani Suraksha Yojana scheme. A dai, because
of her affiliation with Barefoot College, though a highly respected NGO, does not
belong to the same organizational hierarchy that enables her to effect economic
change on behalf of her patients. Consequently, she makes it a point to connect local
mothers with government health workers to ensure cash and security. This implies
that although ASHAs are supposed to serve as the first line of available health
resources, dais often precede them; with regard to professional niche differentiation,
dais cannot be “outcompeted” because of their importance for effective referrals.
Azher: Professional Niche Dierentiation 147
Conclusion
Previous literature has established that the demise of the dai profession in much
of India is due to government interventions such as ASHAs, ANMs, and the Janani
Suraksha Yojana scheme. Despite significant occupational overlap between dais
and ASHAs, Barefoot College–affiliated dais have successfully differentiated their
professional niches, enabling their survival. My interviews suggest that interactions
between government health workers and Barefoot College–affiliated dais are actually
collaborative, disproving the notion that dais compromise medical efficiency.
Rather than despair over the loss of their role in the birthing room, dais regard their
subsequent professional trajectory with ambivalence, and are content to increase
positive health outcomes among local women in other ways. Because they are closely
tied to the traditional history of their communities and occupy positions that warrant
trust and respect within the socioeconomic networks of their villages, dais have been
able to serve vital roles as health educators and care coordinators more successfully
than ASHAs and ANMS, who simply cannot attain the same cultural significance.
Ultimately, the partnership between government and the Barefoot College–affiliated
health infrastructure, a product of professional niche differentiation, effectively links
local mothers with appropriate healthcare. This case study carries important lessons
for government and NGO agencies seeking to increase health outcomes in resource-
poor settings. The “barefoot” model is innovative because its foundations are old;
thus, large-scale programs can enhance reproductive care by realizing the immense
clinical and cultural importance of dais to rural landscapes.
Competing Interests
The author has no competing interests to declare.
Author Information
Sharmeen Azher studies Biology and Anthropology at Union College and is also
an MBA candidate at Clarkson University’s Capital Region Campus. Passionate about
disease and healthcare management in resource-poor settings, Sharmeen will start
Azher: Professional Niche Dierentiation148
medical school in the fall. Sharmeen is immensely grateful to her alma mater for their
Summer Research Grant (2015), as well as to Dr. Jeffrey Witsoe, her master-of-all-trades
mentor for teaching her that good ethnography requires curiosity and adventure.
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How to cite this article: Azher, S 2017 Professional Niche Dierentiation: Understanding
Dai (Traditional Midwife) Survival in Rural Rajasthan.
ASIANetwork Exchange
, 24(1),
pp. 132–150, DOI: https://doi.org/10.16995/ane.240
Published: 05 April 2017
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