Where There is No Midwife: Birth and Loss in Rural India (Fertility, Reproduction and Sexuality)
Berghahn Books, Oxford
In her book Where there is no midwife Pinto reports on her ethnographic study of childbirth in the north Indian state of Utter Pradesh. While Pinto conducted her anthropological fieldwork in a rural village in northern India, she fell pregnant herself which added an interesting dimension to her fieldwork. One message in the book is that there are many different ways of 'being involved in childbirth' and that the World Health Organization's notion of a TBA (Traditional Birth Attendant) does not easily fit everybody involved in childbirth in India.
India is fairly rapidly developing country, with a huge difference in the rate of development between rural and urban areas. It has a rapidly growing private health care system for those who can afford it (mainly urban middle-class elites) and underfunded government health care system for the rest of its enormous population. Pinto remarks upon the failures of publicly funded health care in India, as well as the temporary nature of the Non-Governmental Organisations (NGOs) in the health field. She comments that, in this climate "people create medical roles for themselves, while others are more officially linked with ever-changing development projects" (p17).
Pinto observes the limitations of the formal health care system in India, a system which fails its rural poor. Pinto has a critical view of the World Bank's Safe Motherhood Initiative, an initiative which included creating demand for maternal health services. She considers there too much emphasis on the 'demanders (rather than suppliers) of care and on the psychological source of desire' (p. 191). She continues "The promise of cure effaces the ability to provide it" (p. 205), which politicians, policy-makers, and many others know is not the case in rural India, moreover local people are very well aware that "babies die in hospital too" (p. 205). In fact Pinto (p. 220) concludes that the state in rural India in many ways acts like a NGO with often one-off and short-term intervention "rather than a source of long-term, dependable services", taking this to a more theoretical level in her discussion on modernity and tradition.
I read most of the book on my way to Nawalparasi in the south of Nepal, an area which borders the Indian states of Utter Pradesh and Bihar. As we were conducting fieldwork in Nepal to select an intervention site for a largely maternity-care based study, a lot of what Pinto wrote about resonates with my impression of this part of Nepal which has open borders with India. Interestingly, Pinto (p. 226) mentions that some of her insights in development spring from the work of Stacey Pigg (1992) on Nepal.
The book constantly changes between the micro level of the village with good, long quotes or stories from the field to the geopolitics and theories of development. The former really brings the topic to life for the reader, whilst the latter sets the book in the wider socio-economic and political context of India today.
Religion plays a large part in the analysis, in this largely Hindu country; religion with a sentence of things being out of an individual's control. Many of the more personal stories in the book cover both birth and death, for example. Pinot links beliefs with cultural rationality and experience. Something she expresses eloquently: "… because God can be interlocutor as well as distant omnipotence, to say 'Everything is in the hands of God' situates causality in a balance between engagement and overwhelming causation of which human action is only one part" (p.205).
Pinto tells a lovely story of applied research ethics, which many who have conducted research in developing countries and/or with marginalised people have experienced. On arrival in a village with her local contact this man summons a child to fetch her grandmother who helps in childbirth. When this woman arrives he commands her "You must help her … answer her questions" (page 239). Pinto reflects on her textbooks on research ethics and the production of knowledge which she see "turning to white cremation ash" (p.239).
There are a few typos in the book for example on page 220 'heath' instead of 'health' and page 189 'greif' instead of 'grief'. It's a pity as there appeared to have been plenty of time for the publisher to correct typos between the publication of the hardback version (Pinto 2008) and this paperback version.
Where there is no midwife is an exciting and useful book for those interested in 'Development Studies'; 'Reproductive Health'; 'Women's Studies', the 'Sociology of Health & Illness' as well as, of course 'Medical Anthropology'.
Edwin van Teijlingen
University of Bournemouth
ReferencesPIGG, S. (1992) Inventing social categories through place: Social representation and development in Nepal. Society for the Comparative Study of Society & History 34(3):491-513.
PINTO, S. (2008) Where There is No Midwife: Birth and Loss in Rural India. New York: Berghahn Books.