The transition of childbirth practices among tribal women in Gujarat, India - a grounded theory approach

BACKGROUND Under the National Rural Health Mission, the current emphasis is on achieving universal institutional births through incentive schemes as part of reforms related to childbirth in India. There has been rapid progress in achieving this goal. To understand the choices made as well as practices and perceptions related to childbirth amongst tribal women in Gujarat and how these have been influenced by modernity in general and modernity brought in through maternal health policies. METHOD A model depicting the transition in childbirth practices amongst tribal women was constructed using the grounded theory approach with; 8 focus groups of women, 5 in depth interviews with traditional birth attendants, women, and service providers and field notes on informal discussions and observations. RESULTS A transition in childbirth practices across generations was noted, i.e. a shift from home births attended by Traditional Birth Attendants (TBAs) to hospital births. The women and their families both adapted to and shaped this transition through a constant 'trade-off between desirable and essential'- the desirable being a traditional homebirth in secure surroundings and the essential being the survival of mother and baby by going to hospital. This transition was shaped by complex multiple factors: 1) Overall economic growth and access to modern medical care influencing women's choices, 2) External context in terms of the international maternal health discourses and national policies, especially incentive schemes for promoting institutional deliveries, 3) Socialisation into medical childbirth practices, through exposure to many years of free outreach services for maternal and child health, 4) Loss of self reliance in the community as a consequence of role redefinition and deskilling of the TBAs and 5) Cultural belief that intervention is necessary during childbirth aiding easy acceptance of medical interventions. CONCLUSION In resource poor settings where choices are limited and mortality is high, hospital births are perceived as increasing the choices for women, saving lives of mothers and babies, though there is a need for region specific strategies. Modern obstetric technology is utilised and given meanings based on socio-cultural conceptualisations of birth, which need to be considered while designing policies for maternal health.