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.