Abstract
Globally, tribal women are less privileged than mainstream or non-tribal women. Noticeably, the socio-economically backward tribal women usually follow the traditional methods instead of the so-called modern medical system for childbirth in Bangladesh. Conversely, archaeologically, terracotta plaques and sculptures found from several archaeological sites in Bangladesh, and globally childbirth motifs indicate that the delivery of the baby was carried out through some special ceremonial observances in the past. This study examines women’s personified acquaintance of pregnancy and childbirth, preparations during pregnancy for trouble-free birth and the responsibility of a traditional birth attendant in Malo community birthing customs. To conduct this study, ten Malo women were interviewed extensively relating to customary and transformed beliefs and practices of pregnancy and childbirth. This study revealed that the long-established childbirth practices have not disappeared from the tribal groups inhabited in the plains in Bangladesh. However, this traditional aspect is gradually diminishing from the mainstream society of Bangladesh. Therefore, this study may assist health professionals in understanding traditional birthing systems from diverse cultures. Subsequently, a profound and in-depth analysis of the tribal tradition of childbirth can lead to new insights, enriching the range of perceptions.
Introduction
Childbirth is a significant biological event in society. Although the concept of birth knowledge is constructed within society (Lefkarites, 1992), it depends on the cultural context, perceptions, and practice of a particular culture (Steinberg, 1996). Hence, different beliefs and practices are involved in childbirth (MacCormack, 1989). Several studies have been conducted on conventional pregnancy and childbirth practices amid women of non-Western backgrounds over the past few decades (Balin, 2005; Jeffery et al., 1989; Liamputtong, 1999; McClain, 1975).
For a long time, pregnant women have used different positions during childbirth due to parturient desire (Fouly et al., 2012; Green, 1971). Still, midwife’s instructions have been followed during the childbirth (Barger, 2010; Gizzo et al., 2014). In addition to the mainstream people of Bangladesh, some ethnic communities live in the plains of Bangladesh, known as indigenous or tribal groups. Although most people in the mainstream receive so-called modern medical services, many tribal groups still follow traditional methods. Particularly in the case of childbirth, it is noteworthy that some of the methods are visible in the archaeological inscription, many of which are still followed by ethnic women.
Due to isolation from the mainstream, financial inconsistency, backwardness in education and respect for traditional notions, many tribal women seek health care from traditional birth attendant (TBA) rather than modern medical methods. Observably, the effectiveness of those traditional methods, including ritual and birth-related ceremonial, still exist among the tribal groups in Bangladesh’s plains. Besides that, the attempt compared the birth-related practices depicted in archaeological inscriptions, and the traditional childbirth experience Malo women received by following the TBA’s instruction during delivery. Furthermore, a local TBA was also interviewed to conduct an ethnographic study in Panchbibi upazila in the northern district of Joypurhat of Bangladesh.
Materials, Methods and Objectives
This study was methodologically followed by a participant’s observation approach on pregnant women who received childbirth services through TBA. Therefore, the study emphasized the traditional childbirth experience of ten Malo women who delivered a baby before July 2021 and received assistance from the TBA. Why did they receive this service? Whether or not any problem arose during the delivery? If there was complexity, what steps have been taken to solve it?—ten Malo women have been interviewed to pursue these issues.
On the other hand, one TBA—locally known as Daima—was extensively interviewed to explore how long she has been involved in this profession; did she receive any training for childbirth? what type of indigenous methods does she generally apply for childbirth? what steps does an attendant take to overcome the obstacle if any problem arises during the delivery?
Eventually, comparative analysis of childbirth methods were undertaken by observing childbirth-related traditional methods depicted in the terracotta plaques found from various archaeological sites in Bangladesh and globally. This study has been conducted keeping these questions and objectives in mind in 2021.
Childbirth Experience of Malo Women
The study, conducted on ten Malo women, found that all of them delivered babies with the help of TBA. Systematically childbirth was followed in four positions, including lying, kneeling, squatting and sitting were notable (Edwards & Waldorf, 1984). In the educational background, three of the women never received formal schooling, six women studied up to primary level, and the remaining one woman received secondary education (Table 1).
Summary of the Respondents.
Among the ten, six women are housewives, two work as day labour, one woman works in the agricultural land, and the remaining one is a maid. The nine participants used to work in the farming land beside their husbands. Notably, nine of the participants gave birth at their maternal parents’ house. Among the participants, four women experienced birthing in the attic, locally known as Aachi, which was generally built for the delivery of the baby. As a material, bamboo or straw is typically used to make the attic. In addition to the birth attendant, particularly the mother or sister, assist the pregnant woman in the attic during childbirth. In case of the remaining six women, the baby was delivered in the bedroom. Notably, it was customary for Bangladeshi childbearing women to stay in their maternal parents’ house during the delivery of the baby. This tradition also exists in the context of childbirth in the Malo community; however, this traditional culture is gradually transforming over time.
The ten women who participated in the study found out by themselves that they were pregnant. Nevertheless, they asked their mothers-in-law or sister-in-law or experienced neighbouring women to make sure about the pregnancy. Additionally, the local birth attendant assisted in ensuring the pregnancy. The family, particularly the parents and husband of the pregnant women, selected the birth attendant from the beginning of the pregnancy to assist the childbearing mother and deliver the baby. The birth attendant is contracted to provide money or other materials such as rice or other agricultural grains as much as they could afford for her delivery fees.
The birth attendant advises the pregnant woman until the baby is delivered. Lately though, most pregnant women seek a TBA’s advice; however, they get the vaccine at a local medical centre to prevent tetanus (Maral et al., 2001). In the Malo community, the vaccine has not been widely used in the past to protect against tetanus. However, over time, many have realized that modern medical methods can be helpful besides the traditional notions of childbirth. Therefore, the current trend of vaccination among childbearing mothers is noticeable. Besides that, the respondents delivered their baby by following four methods, including lying, kneeling, sitting and squatting. Finally, they shared their experiences on how the TBA applied the traditional methods during their childbirth.
Lying Position
In the lying position, usually pregnant women are kept lying down, and the birth attendant delivers the baby. Five of the respondents have experienced delivering a baby in this position. A pregnant woman is usually laid on the bed or floor in the attic or room in this position (Figure 1). Then TBA starts her activities with the assistance of the pregnant woman’s mother or sister or female relatives for the delivery of the baby. Comparatively, this method is now most commonly used in Malo women.
Speculatively, the lying position is being used more in modern systems (Jansen et al., 2019). Several archaeological inscriptions depict the lying childbirth method (Fouly et al., 2012). The archaeological inscriptions indicate that the lying childbirth method is not a new practice; instead, this traditional approach has been widely used long ago (Figure 2). However, interviewing five Malo women who experienced this method, they found that the technique was effective.
Kneeling Position
Two respondents followed the kneeling position in delivering the baby (Figure 3). According to the experience of those women, the kneeling position helped relieve their back pain. The image of kneeling position in childbirth is depicted in a pre-Columbian Jalisco statue (Figure 4). The kneeling position was also effective for rotating the baby in a favourable position (Dabral et al., 2018; Zhang et al., 2016). Besides that, this method has also been found to be beneficial in relieving haemorrhoids (Hashim & Adekanmi, 2007).
In this case, when pushing or giving birth on the knees by a woman, it is probably effective to reduce back pain and encourage the baby’s movement (Hodnett et al., 2013). During contraction, the woman flexes her hips and lower buttocks slightly as the attendant pushes (Green, 1971). Pregnant women at this time sit on their knees and put their head on their hands or grab any other object with their hands (Hunter et al., 2007).
Sitting Position
The sitting position is another effective method of delivery of the baby applied during the childbirth of three Malo women. Five of the participants experienced delivering the baby in a sitting position (Figure 5). The archaeological inscription also depicts squatting position, found from ancient Egypt, while the mother is holding onto attendants each side (Figure 6). This method uses gravity to help the baby’s descent, allows rest between contractions (Kolarkar et al., 2014; Stewart & Spiby, 1989). The upright sitting position is a variation in birthing when the mother is curled forward around her baby, with her elbows out as she pushes (Huang et al., 2019). In this case, the head of the pregnant woman raise high, and the foot of the sitting place is lowered, and the position is like that of the stool (Stewart & Spiby, 1989). This method helps the woman use gravity effectively (Huang et al., 2019). Leaning with the support of a place make it relatively more manageable for the mother to deliver the baby (Kolarkar et al., 2014).
Squatting Position
Two of the respondents in the study have experienced delivering a baby in a squatting position (Figure 7). The squatting position uses gravity to help the baby’s descent and open the pelvis to provide more space (Dokmak et al., 2020; Gupta et al., 1989). Widely used, the benefit of this method of delivering the baby in a squatting position is that the position tilts the uterus and pelvis forward, placing the baby in proper alignment for delivery (Gardosi et al., 1989). The squatting position strengthens the intensity of contractions which can also relieve pressure in the flipside (Desseauve et al., 2019). This position also reduces the need for episiotomy, as it relaxes and stretches the pelvic floor muscle (Dokmak et al., 2020; Gupta et al., 2012).
An inscription from the Aztec goddess states that this classic birth statue pushes out her baby while squatting. It seems to reflect her knees are not widely spread (Figure 8), and her face shows the intensity of pushing the baby (Townsend, 2009).
Another inscription found from South India depicts the delivery of the baby in a squatting position. The image shows a pregnant woman with her hands on two women’s shoulders on both sides in a squatting position. Below, the midwife is conducting the delivery (Figure 9). From such an image, it is conceivable that the practice of delivering a baby in a squatting position is not new, but this method of giving birth to a baby has been used for a long time (Hollen & Coale, 2003).
Traditional Birth Attendant
Historians believe that the midwifery idea was prevalent in ancient Egypt (Baines & Málek, 2000). At that time, the midwife was determined according to her social status (Kemp, 2006). For peasants, the midwife was usually their companion or neighbour or family member who assisted in delivering the baby. In the case of elite classes such as noblemen and wealthier classes, house nurses performed this duty (Darnell & Manassa, 2007). It is undeniable that midwives at that time had no formal training in childbirth (Montserrat, 2000). However, it is thought that there were many specialized doctors in Egypt at the time, most of whom were men, and they did not attend to women during labour and childbirth because childbirth was entirely female-centric (Faulkner & Goelet, 2015; O’Neill et al., 1999).
One TBA was interviewed in this study. She is almost 70 years old and has been involved in this work for 45–50 years. In her opinion, she has delivered hundreds of babies. However, a few years back, she received formal training from a non-governmental organization called World Vision. At present, she uses indigenous methods besides modern methods while delivering a baby. Before receiving the training, she put the pregnant women in different positions and delivered the baby. But, at present, she mostly follows the lying down position. However, if necessary, sometimes follow the kneeling forward position and squatting position.
As a birth attendant, she takes special care of the newborn and mother after delivery. To reduce the pain after delivery, she massages the mother’s abdomen and back with a kind of leaf, locally known as Vendri heated by fire (Figure 10). Also, she uses refine natural oil, particularly mustard oil, to care for the baby. Currently, she enjoys the job a lot. As a result, even though she has another job, she likes this job a lot. She said, as long as she lives, she will keep herself involved in this work.
The hieroglyphic script of around 3100 BC presents Egyptian medical practices, including Egyptian knowledge on pregnancy and childbirth (Abugideiri, 2008; Ghalioungui et al., 1963; Haimov-Kochman et al., 2005). These written documents are used to discover several aspects of ancient healthcare with similarities in the current modern medical system, especially childbirth and midwifery practice mentioned as significant issues (Brewer & Teeter, 2007; Sullivan, 1997).
It is believed that people have been aware of childbearing women since ancient times. Nuclear families constituted the core of society, and the family was a very significant institute in the past culture; subsequently, they cared a lot about birth giving women (Brewer & Teeter, 2007; Chamberlain, 2004).
The study found that some women wore amulets around their necks and hands to protect the baby from evil throughout the pregnancy. Also, one woman responded that she tied the Arjuna fruit around her waist to get rid of evil. Another important point is that after the baby’s delivery, a coin is put at the cord stamp. They believe that the child would become more prosperous if they put coin at the cord stump. However, according to TBA, coins are used to cut the navel properly as it requires hard substance.
Early Representation of Fertility and Childbirth
Childbirth is an endearing subject for human society and plays an important role. The conception of pregnancy and childbirth has turn into an object of study within manifold disciplines, ranging from past inquiries and the humanities to natural sciences (Downe et al., 2018). Almost all the early text on anatomy and Medicine has detailed descriptions of the physiology of reproduction, complications during pregnancy, management of labour pain, care of pregnant women, and so on. They also describe various realms of midwifery (Ladur et al., 2021). Except the Egyptian Medicine, Indian Medicine is one of the earliest Medicine sciences in human history based on Ayurveda (Narayana & Durg, 2021). Among the Ayurvedic text, Sushruta-Samhita and Charak-Samhita are notable (Bagde, 2017). The original text of Sushruta-Samhita was said to be composed in 600 BC (Grzybowski & Ascaso, 2014).
In contrast, Charak, the court physician of Kanishka-Gupta, composed his commentary on Medicine, Charak-Samhita in the early part of the second century CE. Thus, Sushruta and Charak give an idea of the medical practice prevalent in the period from 600 BC to 150 CE (Grzybowski & Ascaso, 2014). Both of the texts contained a detailed description of midwifery and the childbirth process (Sharma et al., 2013). Besides, childbirth has also become a sacred subject of sculpture, panting from the prehistoric period worldwide (Narvekar, 1966). The earliest representation of fertility and childbirth could be traced in the ‘mother goddess’ figurine of the prehistoric period. They are also called ‘Venus’ in Western culture. These sculptures are handmade and crude. Usually, they are similar in size, appearing full-fleshed with large bellies and breasts, board hip and little facial detail. Archaeologists debate whether these small sculptures represent fertility or are a religious symbol of the time (Cleeton, 2001).
Hundreds of such terracotta Mother Goddess figurine has also been found from Indus Valley Civilization (Clark, 2003). From the later period, the most popular subject in art related to childbirth is the birth of Jesus Christ, the birth of Gautama Buddha and the birth of Krishna. Interestingly, the mother figure is never represented as a pregnant woman, and the process of giving birth is showed obscurely. Such as in the nativity scene of Gautama, Maya Devi is always represented as delivering in a standing position, holding the branch of the Ashoka tree with one hand. In some sculptures, she supports a female who attended with her other hand to get relief from the labour pain (Figure 11).
Captivatingly, the baby was delivered from the right portion of her belly, not from the vagina. Usually, a woman showed standing, cloth in hand to receive the newborn baby (Figure 12). In most examples, she is surrounded by more than one male and female attendant (midwife?). These attendants are also fully clothed like Maya Devi; no messiness of the childbirth process is ever depicted. Such numerous kinds of sculptures have been discovered from Gandhara and Mathura region to Bengal (Rowland, 1956).
These reliefs provide some valuable information about the contemporary childbirth process—first, the standing position for giving birth, and second, the requirement of midwives. The necessity and importance of midwives also have been described in the archaic medicine texts. For example, the tenth chapter of Sushruta-Samhita describes the important art of midwifery at great length. According to Sushruta, the pregnant woman should transfer to a special home for delivery called Suthika-Griha on an auspicious day (Grzybowski & Ascaso, 2014). When the delivery time approached, four midwives were summoned; Sushruta specially mentions that the fingernails of midwives must be well-trimmed, and they must wear clean, white garments (Narvekar, 1966). The importance of midwives and their physical cleanness is also described in an early Roman text, ‘Gynecology’ written by Soranus of Ephesus. He was a physician of Asia Minor and active during the first and second century AD (Karamanou et al., 2013). According to the book, the midwife should be ‘endowed with long, slim fingers and short nails at her fingertips’, and she should be ‘literate, with her wits about her, possessed of a good memory, loving work’. In the ancient world, the childbirth process was a women’s job; female midwives and family members brought the child into the world and attended to care for the newborn (Totelin, 2011).
But in the Indian subcontinent, the nativity scene of Gautama Buddha gave information about the male midwife too. Giving birth in a supported standing position is also depicted in some other early medieval sculptures and paintings, except Gautama Buddha. For example, the twelfth century’s Airavateshwara Temple of Darasuram, Tamil Nadu, vividly depicts giving birth in a standing position with the help of a group of five women. Here the mother has swollen belly, and she is supported by two midwives on her both side (Goyal, 2012). There is a piece of cloth placed on her thigh for the secure delivery of the baby (Figure 13).
Several representations of pregnant women giving birth in standing positions with the help of midwives are found in temple art of Tamil Nadu from the nineth century onwards. For example, the Pungampadi Shiva temple of Tamil Nadu is noticeable. Giving birth in a squatting position with the help of midwives is also available in early medieval temple art but is limited in number. For example, in the Sun temple of Modhera, Gujrat, a visually pregnant woman giving birth to a child in a squatting position, is supported by two midwives on both sides. The child is shown halfway out (Figure 14).
But for Bengal, maybe the most popular birthing position was kneeling. Two plaques from a small temple of Shalban Bihar, Mainamati, Comilla, have the depiction of birthing in a kneeling position with the help of a midwife. The plaques are part of series depicting the childhood adventures of Lord Krishna. The first plaque shows a pregnant woman sitting in a kneeling position, another woman sitting behind her. Though both of her hands are broken, it is quite clear that she was presented with an approach to help the birthing process. The next plaque shows the baby is born and placed on the floor (Uddin & Rezowana, 2015). The mother is resting her head on her left hand, with the right hand she is grabbing the midwife’s shoulder in a gesture to enduring the labour pain (Figure 15).
This birthing position with a little upgrade may be continued in Bengal till the eighteenth century because some Hindu temples with terracotta ornamenting have the depiction of birthing in kneeling forward position. Later, an inverted large bowl has been used for leaning over (Figure 16).
Conclusion
This study illustrates that researching traditional rituals, especially childbirth ceremonies, can play a significant role in the modern medical system, rather than dismissing all kinds of traditional or indigenous notions as superstitious or unscientific. Since indigenous knowledge still exists in society, gaining an idea can help provide influential and prolific insights for health professionals. Simultaneously, the result reported in this study is based on qualitative research that focuses on the concept of traditional childbirth as it is the most significant human experience, beliefs and practices associated with pregnancy. Significantly, the traditional childbirth practice has not entirely disappeared from Bangladesh. Many ethnic communities follow the traditional childbirth method; some of this knowledge can be helpful in modern childbirth practice remarkably. However, this study revealed that the method has been practiced for a long time and effectively. Therefore, to gain an in-depth knowledge of these notions, the exigency is to conduct a comprehensive study on childbirth and TBA in Bangladesh.
Footnotes
Acknowledgements
We are immensely grateful to respected Swapna Mahato, a senior nurse at Panchbibi Upazila Health Complex, Joypurhat district in Bangladesh, who assisted us tremendously while conducting this study. We are also grateful to the ten women who took part in the interview and one birth attendant for their incredible support and cooperation. Besides, four women deserve special thanks for giving us the idea of four birth positions through modelling. Therefore, we would like to express our gratitude to all of them.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.