Review of Birth on the Threshold: Childbirth and Modernity in South India by Cecilia Van Hollen. Berkeley, CA. University of California Press, 2003.

 

Kathryn Coffey

SUNY College at Cortland

           

In her book Birth on the Threshold, Cecilia Van Hollen describes the modernization of childbirth among poor women of Southern India. The author begins the book with the birth story of Mumtaz, a Tamil Nadu woman who delivered her baby “right in the doorway (vācal) of the house.” The author elucidates the importance of the doorway as the threshold between the private (home) and public (the world) space as a metaphor “for a shift from one institutional site (i.e., the family and the midwife) to another institutional site (i.e., the public hospital as a site of both the state and biomedicine)” and “a shift in systems of knowledge about the body in general and women’s reproductive bodies in particular” (p. 3).  In the book’s Introduction, Van Hollen describes Tamil women adorning this sacred space with intricate geometric designs made of rice flour called kōlams which bring blessing to all who pass through the threshold. She artistically uses the metaphor of kōlams to describe the individual processes of change that “loop and swirl” to pull together the transformation and modernization of childbirth in Southern India (p. 6).

Although Van Hollen rarely compares the Southern Indian cultural experiences to those of Western cultures, in Chapter 1, The Professionalization of Obstetrics, she enlightens the reader on the colonial history of obstetrics in India via cultural and gender variations. Obstetrics had long been a female dominated field in India due to cultural taboos that did not allow women to be seen by male doctors. This push also came from a disdain for midwives (dais) who had always been responsible for non-institutionalized births. Van Hollen describes the hierarchy of midwives and reveals the low class status of the profession and how they are thought to clean the pollution of birth.

In Chapter 2, Maternal and Child Health Services in the Postcolonial Era, Van Hollen thoroughly describes the postcolonial structures of maternal and child health (MCH) services in both rural and urban Tamil Nadu from a social, familial and institutional perspective. She found that in urban Madras, most women give birth in a hospital setting whereas in the rural Kaanathur-Reddikappam region, about half of the women chose to give birth at home.

Throughout the book, Van Hollen skillfully interweaves Tamil women’s stories together to describe the childbirth experience from pregnancy through the postpartum period. In Chapter 3, Bangles of Neem, Bangles of Gold, she beautifully describes cīmantam (the ritual celebration of first pregnancy) and pregnant women as “auspicious burdens” (p.77). She describes the reinvention of the cīmantam tradition from a ritual of preparation for a woman’s first birth, to a more consumer centered celebration where the mother-in-law is portrayed as materialistic and greedy. It is in this section of the book that the author meticulously describes the concepts of ācai (“a combination of food cravings, an increase in ‘heat,’ the demands of the fetus (cūl), and a desire to return to the maternal home to be cared for” (p.87)) and sakti (“divine female power associated with actions and the generative force of the universe” (p. 240)”. In relation to pregnancy, when a woman’s ācai, is met (she is given gifts of bangles or gold), this gives her sakti.  If she has sakti, she will have a positive delivery experience and healthy baby.

In Chapter 4, Invoking Vali, the author describes how rather than decreasing the pain of childbirth by use of analgesic drugs as in western cultures, women of Tamil Nadu have come to expect an acceleration of the experience using oxytocin drugs such as pitocin. To Tamil women, a prolonged labor connotes danger to the mother and the baby. In addition, Van Hollen describes the concept of invoking vali: pain or suffering. The more a woman suffers during childbirth, the more sakti or power she has. Van Hollen describes how the discourse of modernity has thus changed the way of thinking about vali. 

In Chapter 5, Moving Targets, while discussing “The Emergency,” or the campaign of forced sterilization in the mid 1970’s, Van Hollen invokes the neo-Malthusian theory of economic development to describe overpopulation and poverty; “fertility must be controlled to ensure greater economic prosperity for the families of the poor, for their nations, and for the world as awhile” (p.143). Van Hollen remains professionally non-judgmental while describing critiques of this theory and the existing family planning tactics of the Tamil government where women are persuaded into an abortion or have an IUD inserted without their knowledge.

In Chapter 6, “Baby Friendly” Hospitals and Bad Mothers, the author describes cultural traditions in Tamil Nadu that have women fast for the first three days postpartum so that food would not have a negative affect on the mother or baby.  The author describes how allopathic practitioners would view these women as ignorant “victims” of tradition, or even immoral criminals endangering their newborns. She also describes a similar clash of ideals between cultural and biomedical views of breastfeeding.

Throughout the book, Van Hollen describes with great depth, the concepts of childbirth and modernity from cultural, social and individual perspectives.  Although the chapters describing colonial and postcolonial childbirth policy and practices in India were somewhat extensive and loquacious, they include important historic details regarding Indian traditions and how Tamil Nadu culture has changed.  Although Birthing the Nation could benefit undergraduate students, it seems most appropriate for graduate students due to its theoretical nature. Though the author is a medical anthropologist, the contents of the book would benefit readers from the fields of anthropology, sociology, international health, and of course gender studies.

Although broad in scope, the book left this reader curious about two separate issues: How does modern childbirth relate to the caste system, and how unmarried women traverse this process of childbirth. Although an in depth explanation of the caste systems is unfeasible, a brief description may be helpful to the reader. Van Hollen briefly mentions access to abortion but does not suggest that all unmarried women choose abortion over giving birth to a child outside of marriage. Incorporating this information could be helpful to having a full understanding of childbirth in Tamil Nadu.

Returning to the idea of the interconnected geometric patterns of the kōlams that decorate the thresholds in Tamil Nadu, Van Hollen skillfully exposed the international, national and local processes of transformation of childbirth in Tamil Nadu. In the Conclusion of the book, Van Hollen discusses how the discourse of modernity suggested that poor women’s cultural traditions were unclean, dangerous and put both mother and child at risk. In order to become modern, they were told to use allopathic medicine and give birth in a modern health care facility. However, once they complied, they were treated with disdain and disrespect because of their “backward” cultural practices.  Van Hollen  reveals that “the connection between maternity and modernity was thus riddled with contractions” and although “institutional and noninstitutional options were available, discourses of modernity simultaneously both compelled and repelled poor women from seeking maternal health care in allopathic institutions” (p.211). Van Hollen suggests an inextricable link between the structures (both global and local) of poverty and the struggle for women’s reproductive rights, and class and gender discrimination.