Professional competition amidst intractable maternal mortality: Midwifery in rural Pakistan during the COVID-19 pandemic

https://doi.org/10.1016/j.socscimed.2022.115426Get rights and content

Highlights

  • Overt disparagement of Dais by LHWs treats traditional midwives as dangerous competitors.

  • Local cultural and religious values related to izzat and purdah are strongly held value systems.

  • The importance of biomedical or governmental advice pales compared to local gender norms.

  • COVID-related fear of hospitals stressed the inadequate maternal health care infrastructure.

  • COVID-related conditions highlighted the advantages of Dais for meeting women's needs.

Abstract

Low-income countries with intransigent maternal mortality rates often follow WHO guidelines that prioritize access to skilled, or professionalized, prenatal and birthing care. Yet the impact of these initiatives in areas still suffering high maternal mortality is opaque. Despite heavy and long investments, the professionalization of midwifery in Pakistan is incomplete, and declines in maternal mortality have plateaued. Traditional midwives have lost status, but they continue to see clients and have influence in their rural communities. We conducted a rapid ethnography among traditional midwives (Dais) and trained Lady Health Workers (LHWs) in two communities of Attock, Pakistan from May to July of 2020. Our findings underscore the importance of long-term presence and trust to maternal care, especially in conditions of resource scarcity or fear (e.g., fear of COVID). We provide evidence of overt disparagement of Dais by LHWs; (2) illustration of the conflicts between gender norms and biomedical priorities of hospitalized births; and (3) exacerbated fear of hospitals during COVID, which served to highlight the advantages of Dai care. Professionalization programs for midwifery must include structures and training to ensure collaborative communications across the country's midwives. Failure to respect the rational decisions of traditional midwives and their patients in circumstances of scarcity, high stress, and isolation only ignores the material and cultural conditions of these vulnerable communities.

Keywords

Midwifery
Competition
Pakistan
Professionalization
Lady health workers

Data availability

Data will be made available on request.

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