Bangladesh: authoritative knowledge and associated practices

Notions of authoritative knowledge and associated practices that shape

women’s expectations and experiences of pregnancy and childbirth in the

UK stand in sharp contrast to those in Bangladesh and the Solomon

Islands. The cultural patterning of pregnancy and childbirth practices

in these different contexts once again demonstrates the variation in

acceptable ways of knowing about birth, and the different ways in which

what counts as authoritative knowledge is constructed and practiced

(Sarge nt and Bascop e, 1997 ; Jordan , 1997 ). Banglade sh is a beaut iful

and largely rural country, which is frequently tested by the ravages of

natural (and man-made) disasters. It has a population of 126 million and

a per capita income of US $370 per annum, which means that many

families live in acute poverty. Most girls marry by the age of 18 years and

begin to have children whilst still in their teens (Yasmin et al., 2001). In

the 1980s fewer than 2 per cent of women gave birth in a hospital

(McConville, 1988). This figure has now risen and figures for 1997

record that 5 per cent of all births took place in an institution (Unicef,

1997). As noted earlier, I lived in Bangladesh in the 1980s and worked in

a children’s hospital carrying out a follow-up study of malnourished

children in the urban slum areas of Dhaka (Miller et al., 1983). During

my time at the hospital my work brought me into close contact with

women and their (often critically ill) children. The tenuous nature of

lives lived in profound poverty was brought home to me on a daily basis.

Children brought to the hospital regularly died, from poverty-induced

malnutrition, in their mothers’ arms before admission could be arranged.

The death of a child was always accompanied by painful, heartfelt

wailing, mixed with a stoical resolve that it was Allah’s will: ‘inshala’.

The cultural and religious practices that existed around death and

bereavement again were in stark contrast to the practices I was familiar

with in the West.

Bangladesh is a highly patriarchal society in which a woman’s status is

inextricably linked to her fertility and the birth of a healthy (male) child is

highly prized (McConville, 1988). The practices around pregnancy and

childbirth are shaped in and by this context, together with the pervasive

beliefs in pollution that exist around women’s bodies, particularly during

menstruation and childbirth. Pregnancy and childbirth in Bangladesh

have ‘for centuries been shrouded in the mystery of the women in

‘‘purdah’’ ’ (McConville, 1988:135). Similarly, ‘the associated concepts

of ‘‘pollution’’ ’ and shame, and in many rural areas ‘the belief in evil

spirits or ‘bhuts’’ ’ have been a defining feature of folklore and childbirth

in Banglades h (Mc Convi lle, 1988:13 5; Islam, 1980 ). These spirits and

bhuts are believed to be particularly attracted to pregnant and breastfeeding

women. In this culture, pregnancy and childbearing continue to be

considered as part of a natural, non-medicalised process, and men are

largely excluded from all matters relating to it. Indeed, it is one area of

women’s lives over which they can exercise some control. Any knowledge

a womanmay possess about childbearing will usually have been gained in

the private domain, passed on to her from her mother, mother-in-law or

by another female relative. The activities and diet that characterise the

pre- and postnatal periods continue to be shaped by traditional practices

and religious beliefs. During the birth, which for most women takes place

in the home, the vast majority of women will either be alone or attended

by female relatives and/or other women experienced in helping during

labour and childbirth (Islam, 1980). McConville has described a hierarchy

of those who attend women during birth in the following way:

doctors, nurse-midwives, family welfare visitors, traditional birth attendants,

dai s, and then the relative s of the wome n in labour (1988 :141).

More recently there have been concerted efforts by aid organisations to

train traditional birth attendants in an attempt to reduce high maternal

mortality rates (see chapter 7). The village dai has traditionally been

of low-status and uneducated, present at a birth in order to perform

menial tasks specifically related to the removal of pollution, rather than

as someone with expert knowledge or skills. Interestingly, and in a very

different context, the concerns with risks of pollution that Okley found

amongst the gypsy society she studied in the UK in the 1970s have

resonance with those in Bangladesh (Callaway, 1983).

The different practices, both positive and harmful, that surround birth

in Bangladesh have been documented by anthropologist The´re`se

Blanchet (1984) and midwife Frances McConville (1988). They show

the ways in which overriding concerns with pollution and, importantly,

the removal of pollution, together with perceptions of ‘shame’, underpin

many traditional practices and reinforce particular cultural constructions

of women’s bodies. It is also important to note that there is rich cultural

variation within areas of Bangladesh. Whilst for Hindu women (who form

a minority in a country that is predominately Muslim) the attendance of a

dai at a birth has been an essential practice as she will transfer the

pollution to herself (Blanchet, 1984), some Muslim women continue to

give birth unattended because of the ‘shame’ associated with childbirth

 (McConville, 1988). Birth, then, is considered a dirty event, surrounded

by superstitions and concerns over ‘pollution’ and the ‘shame’ that would

result should others become polluted. For up to forty days following the

birth of a baby, a woman is considered to be in a polluted state.

The practices that surround pregnancy and childbirth in Bangladesh

clearly shape expectations and experiences and, as subsequent chapters

show, are different from those in the Western world. Whilst working

in the Children’s Nutrition Unit in Dhaka, I helped to put together

‘maternity kits’ to sell to the pregnant women who came to the hospital.

This was undertaken in a bid to try to reduce the infection that could

accompany the delivery of a baby, particularly in the bustee (slum) areas.

The kits consisted of a small square of plastic sheet (as many women give

birth onto earth floors), some clean cord, half a razor blade (such were the

levels of poverty that a complete, new razor blade may be sold at market

and not used for the intended purpose) and some antiseptic cream. I only

later came to fully appreciate the basic nature of these kits, and the

different cultural constructions of the ‘tools’ necessary for the management

of birth. This realisation dawned when I returned to Bangladesh

following the birth of my first child in a UK hospital; the contrast was

profound. The ways in which authoritative knowledge around childbearing

operates in Bangladesh is, then, as in other cultures, complex and

varied. The exclusion of men from matters related to pregnancy and

childbirth points to contrasting patterns of power and authoritative

knowledge when compared to those that exist in the West. For example,

in the UK the processes of medicalisation have led to men’s increased

professional participation in all aspects of reproduction and childbirth.

However, the powerful associations of pollution and evil spirits, noted

above, may help to explain why men in Bangladesh have not sought to

intervene in, or control, this particular aspect of women’s lives.

Reproduction and childbearing continue to be areas of female expertise

in which more horizontal forms of authoritative knowledge dominate.