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Maternal Health in Early Twentieth Century Bombay

Colonial health reports from the mid-19th century onwards recorded alarmingly high rates of maternal and infant mortality in the then Bombay Presidency. This was attributed to the practice of early marriage, the inferior status of women in society and tradition-bound health habits. This article examines the opinions of men and women doctors, civic leaders and philanthropists who were involved in campaigning for better healthcare for expectant mothers and in dealing with the reluctance of Indian women to consult male doctors. They also investigated the health of women mill workers, which led to debates in the Bombay legislative council and ultimately in the passing of the Maternity Benefits Act in 1929.

Maternal Health in Early Twentieth Century Bombay

Colonial health reports from the mid-19th century onwards recorded alarmingly high rates of maternal and infant mortality in the then Bombay Presidency. This was attributed to the practice of early marriage, the inferior status of women in society and tradition-bound health habits. This article examines the opinions of men and women doctors, civic leaders and philanthropists who were involved in campaigning for better healthcare for expectant mothers and in dealing with the reluctance of Indian women to consult male doctors. They also investigated the health of women mill workers, which led to debates in the Bombay legislative council and ultimately in the passing of the Maternity Benefits Act in 1929.

MRIDULA RAMANNA

C
oncern over high rates of maternal mortality in Bombay Presidency had led to Indian initiatives in founding and financing obstetric facilities, from the mid-19th century. The first institution to be started was in Bombay city, the Obstetric Institution (1851) attached to the Jamsetji Jeejebhoy Hospital. This was followed by similar attempts in a few other cities. However, the number of patients remained small because the doctors attending to patients were male and generally Indian women would not in those years, “dream of showing themselves to a man doctor.”1 The very idea of hospitalisation for something as “domestic” as childbirth was unheard of. Yet, a significant step was taken with the establishment of the Cama hospital (1886) exclusively for women, managed by women doctors. Most of these facilities were private efforts of reformers and philanthropists, indicating thereby their recognition of the need for better birthing facilities. In the colonial state’s perception, the “low” status of women and their poor health were linked and intervention into this space was limited. Linked with maternal health were the alarming rates of infant mortality. Concern for the health of children who survived infancy was limited to the promotion of smallpox vaccination, which was made compulsory in Bombay city in 1877 and in Karachi in 1879. At the end of the 19th century, came the plague epidemic when intrusive gender insensitive control measures were enforced to contain the epidemic. The vehement opposition to these measures, led to a change in colonial health policy from the promotion of curative medicine, concentrating on symptoms and treatment to preventive medicine.

The annual public health reports repeatedly recorded the high maternal and infant mortality rates well into the 1920s. This study, through a regional focus, attempts to review the efforts made to tackle this issue in the early decades of the 20th century. The first question posed is, what were the contemporary views regarding the causes for these high death rates? British opinion blamed the mishandling of deliveries by “dais” (midwives) and “habits”, a term that covered a whole gamut of factors including early marriages, superstitions and ignorance. Indian men and women doctors, while conceding some of these causative factors offered more pragmatic solutions, than those recommended by the British medical establishment. This section is based on a source not used thus far: papers presented at conferences, by these medics on the issues of dais or infant and maternal deaths. A review of maternity facilities of these years shows that the growing presence of Indian women doctors inevitably led to a rise in the numbers of women patients, who constituted around 20 per cent of the total number of patients in hospitals and dispensaries, by the second decade of the 20th century.2 Welfare measures promoting maternal and infant care had been initiated at the instance of reformers in the previous century. The 1900s, saw an expansion of these and the establishment of voluntary organisations, some wholly private and others semi-official, which were cooperative efforts of activist health officers, civic leaders, philanthropists and Indian physicians. Their method was to disseminate information through home visits and lectures and to provide antenatal and postnatal facilities. The third area of focus is the health of women mill workers, who were employed in the textile mills of Bombay city and discussions about maternity benefits among doctors and legislators. These culminated in the passing of the Maternity Benefits Act, 1929. Geraldine Forbes has examined some of these issues, with reference to Bengal, in her recent work.3 By attempting this overview of the scene in Bombay, this paper will attempt to contribute to an understanding of a vital area of medical history.

Opinions about Causes of High Mortality Rates

Infant mortality rates were 572 per 1,000 live births in 1918-22, peaking to 667 in 1921.4 Colonial records ascribed this phenomenon to early marriages, causing the debility of mothers, “maternal ignorance,” the habit of covering up newly born infants, blocking windows and giving opium pills (“bal golis”) to fretful children, unhygienic conditions, a relatively low standard of life, improper and insufficient food and bad sanitary arrangements. The figures compiled by Bombay’s health department (1911-20) showed that the highest number of deaths were caused by respiratory diseases, followed by debility.5 Though none of these causes could satisfactorily explain the excessive mortality in the city, in comparison with other “cotton” towns, it was felt that greater over-crowding could be a principal factor, the density per acre being 700 persons in Bombay, as against 240 persons in Ahmedabad. However, there was no statistical evidence to support this, yet “anyone who has seen the conditions in which the workers of Bombay live will readily associate them with the heavy death roll of infants”.6 Thomas Blaney, a popular private practitioner of Bombay, also regarded “artificial feeding” of ‘conjees’, (a rice gruel) used by Indian mothers as a cause and advocated the use of European infant foods instead.7 It was also observed that epidemic outbreaks of plague, smallpox, cholera and influenza, which had raised general mortality had been accompanied by a parallel rise in the death rates of infants.8

It speaks of the low priority accorded to maternal health by the colonial medical establishment, that there was only one paper on this question presented at the Bombay Medical Congress (1909) by M A T Collie, a senior obstetrician, entitled, The Maternal Death Rate in Bombay. Collie attributed the high infant death rate, in the first month of the child’s existence, to improper “management” at the hands of dais, and opined that, as in Britain, ignorance about child rearing was “lamentable and they will try experiments on infants which they would not try on favourite animals”.9 He cited the case of an otherwise intelligent woman who, on the advice of her neighbours, reduced the food intake of her six-month old child to a mixture of one teaspoonful of milk and 4ozs of barley water. As consulting medical officer to the Oriental Life Assurance Company, Collie had been struck by the number of deaths assigned to childbirth by applicants under the head of “life history”. He believed that the solution lay in education and considered it to be the duty of the education department to see to it that every potential mother knew how to rear a child. This would be “more useful” to her than music, mathematics or fancy work. Collie showed, on the basis of municipal data, that puerperal sepsis was the principal cause of maternal deaths; a high of 860 deaths per 1,000 in Bombay, in contrast to 78 per 1,000 in Glasgow, in 1900. John Andrew Turner, Bombay’s health officer (1901-1919) attributed high maternal mortality to frequent plague outbreaks, the occupation of women workers under very trying circumstances, in mills and factories and the prevalence of venereal diseases. About the latter, he averred that it was quite apart from the state control of vice but their spread could be ascribed to “ignorance, carelessness, uncleanliness and excess, all of which were under personal control”.10

What were the opinions of Indian women doctors? Rakhmabai found, in her practice at Rajkot, that the fast spreading custom of purdah, which was regarded a mark of social status, was responsible for the increased incidence of tuberculosis and stunted growth in girls.11 Dosibai J R Dadabhoy and Jerbanoo Mistri presented papers at the All-India Social Service Conference, 1923 (AISSC) where maternal and infant mortality, the training of nurses, midwives and dais was discussed and maternal benefits were advocated as being obligatory on all employers of labour. In her paper entitled, ‘Infant Mortality, Its Causes and How to Remedy It’, Dadabhoy suggested “preventive obstetrics”, the supervision of women from early pregnancy till lying-in was over, as the solution to combat maternal and foetal mortality. The wealthy could command doctors and nurses but many women were left to “muddle through pregnancy and labour as best as they can”.12 Her contention was that 70 per cent of infant deaths could be prevented if the mother, medical practitioner and midwife were alert, with proper measures for infant feeding, including the promotion of breast feeding and raising the standards of midwives. Mistri, in her paper on ‘Training and Provision of Dais and Midwives’, made a forceful plea for more maternity homes, antenatal care for expectant mothers and the training of midwives and dais. She regarded efforts to raise the standard of health and improve the efficiency of one half of the population as a great consideration in improving national prosperity and showed that there was a growing realisation that care during pregnancy was vital to check high infant mortality. Not only the poor, but also the upper and middle class women were ignorant of hygiene and the care of infants. “Many women who are childless and permanently disabled are so from maltreatment received during delivery.”13 Mistri urged that the need was for more women doctors because women would rather die, than let male doctors attend on them. Jerusha Jhirad, too, believed that the large percentage of maternal morbidity was preventable, it was ignorance and superstition that prevented access to modern methods. “Indians are naturally fatalists, which is helpful when unavoidable accidents occur but certainly trying when confronted with remediable complications.”14 She noted that old mothers and grandmothers continued to hold sway in Indian families and imparted their time-honoured customs to the next generation, even as meetings were being held in town halls to organise welfare.

The investigations conducted (1925-1927) by Indian Research Fund Association (IRFA) observed that the municipal methods of classifying deaths were misleading, since most cases had no medical attendance and recorded causes were dependant on hearsay. It was concluded that the high mortality was due to the difficult conditions, the “wretched attention”, at the time of child birth and the lack of medical relief, when it was most necessary. The IRFA study in Bombay found that 42 per cent of mothers died in childbirth, 53 per cent of infants were stillborn and 15 per cent more died, within 15 days of birth. Malaria, hook worm and syphilis were frequent “pre-disposing” causes, while other factors included eclampsia (fever accompanied by fits) greater incidence of post partum haemorrhage, accidents during labour referred to as “dais cases”, the small size of the pelvis in some women and the practice of early marriages. The study made a special enquiry of 250 cases of stillbirth and found most were caused by anaemia. Other findings included a high incidence of pregnancy, toxaemia and deficient birth weight among babies of mill workers. The organisation of antenatal work, the maintenance of proper records of treatment by large maternity hospitals and the inclusion of the study of “conditions of pregnancy in tropical climates”, in the curriculum of schools of tropical medicine were recommended.15 Jhirad’s investigations, into the causes of maternal mortality in Bombay city (1937-38) noted, that 71.2 per cent of the deaths occurred amongst the poor, who lived in congested dwellings and most were from puerperal sepsis followed by anaemia, which she noted as being particularly high among Muslim women.16

Maternity Hospitals and Municipal Initiatives

After the Obstetric Institution, the next step was the establishment of the Medical Women for India Fund (1882) by reformer Sorabji Shapurji Bengali and American businessman, George Kittredge, with the objectives of establishing a hospital for women and children, managed by women and the opening of medical education to women. The Bombay University opened its doors to women in the following year and the Cama hospital was started, with a generous donation by business magnate Pestonji Hormusji Cama. Kittredge recorded that one of his Indian friends had lost his favourite daughter, due to the lack of timely medical help. Indicating the conviction among philanthropists in Bombay, of the need for exclusive medical treatment to women and children, other endowed institutions were founded: the Jaffer Suleman dispensary (1886) and Bomanji Edalji Albless hospital (1890) which later merged with Cama hospital, Bai Motlibai Wadia and Sir Dinshaw Manekji Petit hospitals and Dwarkadas Lallubhai dispensary (1892) where poor patients were admitted free, were started as a part of the JJ group.17 Subsequently, private maternity clinics, the Kerawala, Parakh and Vrijbucandas, were established and a step was taken to improve attendance in hospitals with the establishment of institutions for the exclusive use of castes and communities: the Parsi lying-in (1887), and Masina

Economic and Political Weekly January 13, 2007 hospitals (1902) for Parsis, Bai Moolbai Peerbhoy Dispensary and Sakinabai Moosabhoy Jaffarbhoy maternity hospital (1918) for Khojas, a dispensary (1909) and lying-in-hospital for Lohanas (1913), the Lad Aushadalaya (1912), where a lady doctor treated 25-30 patients daily and Khatau Makanji Bhatia maternity and nursing home (1922). Initially, Bhatia women were reluctant to take advantage of this facility and would leave Bombay for their confinement but gradually taboos seem to have worn down. Both the Bai Jerbai Wadia hospital for children (1929) providing free treatment and the Wadia maternity hospital were cosmopolitan.

Semi-official initiatives to provide maternal health care began in 1901, with a scheme for giving free milk to the poor, through municipal dispensaries, and nurses were appointed the following year to attend at confinements, make visits for “homely talks”, on domestic and personal hygiene and to warn against the dangers of artificial feeding and the use of narcotics to quieten fretful infants. From 1907, the conditions of newly born infants were checked and the results recorded. To provide skilled attendance at confinement a staff of 10 nurses and midwives were attached to the 10 registration districts into which the city was divided.18 The Bombay Sanitary Association (BSA) (1904) established to disseminate information on sanitary matters organised lectures on topics like, “Household and Personal Cleanliness”, “Rearing of Children”, “Caring for the New Born and Lying-in Woman”, and “Practical Hints Regarding Nursing”. In an address to the BSA in 1911, the Maharaja of Baroda held that public hygiene and personal hygiene were inseparable and the efforts of the state to provide clean milk supply may be nullified, if domestic hygiene was faulty. Infant mortality could be combated with the unceasing efforts of volunteers rather than by official intervention.

A majority of the members of the Bombay municipal committee looking into maternal health, which included doctors endorsed Turner’s suggestions to start lying-in hospitals for the poor, with free medical attendance, the education of Indian midwives and licensing of women who attended confinements, legislation to be passed to prevent unlicensed women from attending childbirths and municipal milk depots to be started.19 It is significant that three members of the committee did not share this “optimism”.20 Dinsha Edulji Wacha, the civic leader, had no objection to the proposals being tried out, but was doubtful of the outcome, pointing out that infant mortality was not confined to the poor but was also to be found among the upper and middle classes. Nadirshaw H E Sukhia contended that infant mortality was the greatest among the lower middle classes because women were averse to going to maternity hospitals for various “unspecified” reasons. Though it was the duty of the municipality to provide medical relief, it was not their duty to give instructions to the dais and midwives. Not poverty alone but unsanitary conditions, the “vitiated atmosphere” of the city, adulterated food supplies, high prices and ignorance were responsible for high infant mortality rates. Sukhia maintained that there were enough maternity hospitals or wards and therefore a separate municipal hospital for the poor was not justified. In fact, municipal officers should restrict their energy to their legitimate outdoor duties of supervision and help the poor obtain pure unadulterated milk and other food supplies, at reduced prices. Tehmulji Bhicaji Nariman averred that measures like milk depots or maternity homes would not do much good till the principal causes of poverty, ignorance and over-crowding were tackled.21

The Lady Willingdon Scheme (LWS) established by the BSA in 1914 had the objectives of providing antenatal and postnatal care and of training Indian midwives, and when a sufficient number were trained disallowing unqualified women from attending at confinements. LWS appointed 12 lady health visitors and established three maternity homes, located at Byculla, Parel and Colaba with milk depots, where pure pasteurised milk was supplied by the Indian Dairy Supply Company.22 In 1918, the Parel home was taken over by the municipality and the Colaba home closed, a dispensary being maintained with the funds. With a donation from the Haji Saboo Siddick Trust, three more maternity homes were opened at Belassis Road, Imamwada and Chinchpokli and there was a constant interchange of cases between these homes and Cama hospital, abnormal cases being treated at the latter institution. Infant welfare centres, each under the charge of a lady doctor and a qualified nurse, were also started in different parts of the city to provide advice to mothers on infant “management”, and medical aid to infants. The Sleater Road centre, in the premises of the Dadabhoy lying-in hospital, also had a creche.23 The BSA’s visitors brought women and children to these centres and the LWS organised lectures for dais on how to conduct normal deliveries and on the value of cleanliness and antiseptics while confining patients. Turner arranged a visit by Lady Willingdon to the City Improvement Trust (CIT) chawls at Imamwada. A contemporary account wryly noted that the houses were neat, because the visit was anticipated. How effective were these measures? The sanitary commissioner’s report in 1915 claimed that over 62 per cent of all child births in Bombay city were by that date being attended by municipal nurses and midwives leading to a comparatively lower percentage of infant deaths.24 On the other hand, the newspaper, Sanchitra Vinod pointed out that the midwife was insignificant in Hindu society. Most women who bore their children in Bombay were poor and could neither afford nor have room for trained midwives. Instead, the paper advised Lady Willingdon to prevail on her husband to take off the excise duties on cotton.25 Notwithstanding this criticism, by 1921, the number of municipal nurses had doubled, qualified midwives were visiting the localities of the poor daily, 60 per cent of all births were verified by municipal nurses and there was an increase in the percentage of children born in hospitals.26 It is interesting to note that the Calcutta Corporation in 1916 had introduced a similar scheme of providing trained domiciliary midwives backed by a chain of subsidised maternity homes.27

Infant mortality figures in Bombay city from a high of 41 per cent, in 1921, went down to 24.5 per cent by 1937.28 The number of confinements in maternity institutions rose from 14,245 in 1929 to 27,758 in 1937, by which date, there were 14 public and free institutions with 486 beds, eight private semi-charity institutions with 155 beds and 61 “paying” nursing homes with 667 beds. Sir Mangaldas Mehta, medical officer, Wadia hospital, claimed that dais had been wiped out of the city and factors in favour of institutional maternity service were the one-room tenements, in which most working class women lived, poverty, the unhealthy surroundings, the break-up of the joint family especially among middle class Hindus and “women having more faith in hospital treatment particularly the antenatal care of expectant mothers”.29

Dispensaries and Maternity Hospitals in Other Cities

Endowed institutions were also established in other cities, including the maternity wings at David and Jacob Sassoon and King Edward Memorial (KEM) hospitals, Poona, Victoria Jubilee hospital (VJ) Ahmedabad, Morarbhai Vajrabhushandas Malawi hospital (MV) Surat, Fadu dispensary, Karachi, and Alexandra dispensary, Sukkur. Exclusive facilities were made available for Parsis and Europeans at the Naoroji hospital, Ahmedabad and for Jewish women and Europeans at the Jacob Sassoon, Poona.30

The Countess of Dufferin Fund (CDF, 1885) had the objectives of building hospitals and providing medical training to women. Under its aegis, hospitals were established at Karachi, Shikarpur and Sholapur all of which received government grants.31 There were also the efforts of missionaries.

Lack of funding was a constant constraint in the expansion of these facilities. While initial financing was provided by generous donors, they expected the reluctant government to maintain them. A hospital for women and children planned in Poona found the funds collected from the public, including Indian princes and business magnates, to be inadequate and only an out-patients dispensary could be started in 1914. The following year, a maternity ward was established in the KEM, under the charge of Sundrabai Kirtane, assisted by nurses provided by the Seva Sadan. Kirtane noted that these facilities owed their origin to a need keenly felt of affording relief to the poor Indian women who “are proverbially shy and shrink from consulting male doctors even when they are suffering untold agonies”.32 Kirtane’s presence evidently made a difference and from 16,359 patients in 1914, the dispensary recorded an increase to 18,235 patients in 1917, and from 65 in-patients in 1915, the number doubled to 169 in 1917. Similarly, when the Indian Women’s Aid Society’s (Hubli) proposal of a dispensary was rejected by the government of Bombay (GOB), the society managed to raise funds from the public, the local board, municipality and railways and maintained a hospital from 1917. Under the charge of Chislett, assisted by an Indian nurse, Godubai Rajpatak, trained at Poona, the hospital treated 57 labour cases and 16,465 out-patients in 1919 and performed 197 operations, including c-sections. But this funding could not subsidise poor patients and a government grant was finally sanctioned with the stipulation that the hospital would be open to inspection.33 The success of these institutions evidently depended upon who was attending to the women. They refused to attend government hospitals in Bulsar because there were only male doctors in attendance.34 A letter in the Gujarati section of Prajabandhu, doubtless written by a man, wondered whether “respectable” women going to VJ hospital, Ahmedabad for uterine complaints were examined in the presence of males and referred to the evasive replies given by the authorities.35 Inducements were used to persuade women to attend hospitals and dispensaries. The number of indoor admissions of labour cases in hospitals in these cities doubled between 1913 and 1931.

What were the responses to hospitalisation? In the 19th century, Tribhovandas Motichand Shah, who practised in Kathiawar recorded that five out of 24 rhinoplasty operations performed by him in 1886 were on women, who invariably lost their noses as punishment for suspected infidelity. He used chloroform and morphia during the operation, which replaced the cut nose with skin flaps from the cheek or the thigh.36 During the 1896 plague epidemic, the interventionist measures of disinfection, inspection and isolation were vigorously resisted. The controls were seen as gender and caste insensitive, intrusive of both the body and of domestic space. There were objections to women’s arm pits being examined by male doctors or to a woman of the Mahar caste being asked to perform inspection. Besides, traditions regarding caring were rudely set aside, thus the relatives of victims resisted their hospitalisation and isolation, desiring to be with the patient. The numbers of women hospitalised during the epidemic were very small.

Women’s health meant reproductive health, as F R Parakh, who had served in women and children’s hospitals in England, observed to his colleagues at the Bombay Medical Union (an organisation of doctors set up in 1884). When a woman went to the gynaecologist, the doctor thought of nothing but the uterus or ovaries, forgetting there were other organs in the body. Parakh shared his experiences about the use of curetting along with dilatation for chronic endometritis and reported that three women, previously sterile, became pregnant after the procedure.37 While this may have been the scene in Bombay, Rakhmabai’s experience would have been more likely the rule. She found that women would come for examinations but would not get admitted for deliveries. She devised a pragmatic solution to persuade them by delivering a pregnant sheep and demonstrating the safety in the procedure. Rakhmabai had to work most of the time without qualified nurses, carrying forceps and other obstetric instruments to remote huts and performing operations in flickering light. In one community, the umbilical cord was not allowed to be cut and the placenta was placed in an earthen pot covered with ashes. It was cumbersome when the baby had to be fed. The cord was carried in the pot until it dried up and was burnt. She found attending to a patient from a Parsi family to be back breaking because they had no chairs, since wood was considered polluting and the pregnant woman slept on the floor. When Rakhmabai treated the women of Muslim business families at Rander, a suburb of Surat, she found it difficult to retain the services of assistant lady doctors who came up from Bombay because they felt the restraints on their movements there to be irksome.38 At other times, the doctor was not sent for, after a forceps case, because the woman would resume her duties almost immediately. It was also observed that women took medicines from several doctors at the same time, including vaids and hakims. Missionaries, who ran hospitals, recorded that patients rarely agreed to operations and when they did, would inevitably “decamp” before the fixed day. Rumours were circulated that “horrible things” were done under chloroform, and that women would come out of the operation theatre, maimed or dead. When an operation was performed, as the only means of saving the patient and the patient died in spite of it, the rumour was spread that she died because of it. A report of the Church of England Zenana mission in Sind, referred to the case of Hansi, 20-25 years of age, the wife of a Hindu merchant, who had lost many babies and was brought by her husband to the mission hospital. She lost the baby of three days, too, but her husband took the decision to keep her in hospital for her convalescence. The missionaries were happy to record that she not only recovered fully but gave birth to a fine, “fat” baby boy, the following year. Five years later, Hansi and her son visited the missionaries, who could not but express their hope that “she would one day come to Christ.”39

Welfare Work

Both central and provincial governments had left the promotion of maternal and child welfare, to voluntary societies. A beginning had been made in 1882 by the Arya Mahila Samaj, founded by reformers Pandita Ramabai, Gangubai Bhandare and Rakhmabai, by providing free milk to mothers and babies. The Hind Mahila Samaj started by Avantikabai Gokhale organised classes in hygiene, nursing and first aid, the Servants of India Society, had “sanitary” activities on its agenda and the Seva Sadan under the direction of Ramabai Ranade, helped widows become self supporting. The Poona branch of the Seva Sadan, in cooperation with the Sassoon Hospital, inaugurated a school for training nurses from 1911 and also maintained a maternity home and an infant welfare centre, where expectant mothers were given free advice and medical supplies were supplied gratis to poor women.40 The Poona Seva Sadan was responsible for the Rajubhai Hirachand Maternity home, the female dispensary and infant welfare centre at Sholapur. The Ahmednagar branch of the Seva Sadan ran a maternity home

Economic and Political Weekly January 13, 2007 and dispensary with a combination of municipal and private funds. Branches were established at Alibag and Nasik in 1927.

The third decade of the century saw a further extension of welfare. Lady Chelmsford had launched the All India Maternity and Child Welfare League in 1919. The Bombay Presidency Infant Welfare Society (BPIWS) established in 1921 aimed at promoting infant welfare by providing information and aid to expectant mothers and during child birth. While patrons were wives of officials, like the president Lady Lloyd, other office bearers were Indians, like the secretary, Jaijee B Petit and doctor members were T B Nariman, Raghunath Row, A Lankester, Dadabahoy, and Cecilia D’ Monte. The BPIWS maintained infant welfare centres where children, up to the age of five years, were weighed, bathed, provided with milk, examined and treated for minor ailments by a lady doctor. The BPIWS claimed that the progressive decline in death rates from 550 per 1,000 births to 250 per 1,000 births in the city of Bombay was due to its work. From 1927, ante-natal clinics were established and from a figure of 736 expectant mothers that year, the numbers trebled by 1929. Anti-venereal treatment, which was largely preventive, was also introduced. A maternity home was set up in conjunction with the Bombay Port Trust and became so popular that two more homes were opened.41

The Bombay Presidency Baby and Health Week Association (BBHWA) was organised in 1924, to engage in what was termed “health propaganda”. Founded at the initiative of reformer Gopal Krishna Devadhar and H V Tilak, it was funded by public subscriptions and donations, a GoB grant of Rs 10,000 and small grants provided by some municipalities. The BBHWA regularly held exhibitions in different parts of the presidency, displaying “health models,” produced medical and educational films and distributed coloured posters and leaflets in the local languages. Magic lantern talks and street lectures with simple titles, “Flies”, explaining the “intimate connection” between dirt and diseases, “ventilation” and “milk” were organised. The precautions to be taken to avert cholera, malaria, typhoid and tuberculosis, were explained. A day-long exhibition, with cinema shows was held in three mills of Bombay; while both the Ahmedabad Millowner’s Association (AMA) and the Ahmedabad Labour Union were associated with the activities in that city. To propagate the cause among educators, a three-day conference was organised in Poona for the benefit of 800 primary schoolteachers. The BBHWA was active in Alibag, Murud and Janjira, Virmagam and Ahmedabad, Karachi and Hubli. It is significant that the BBHWA attempted to reach out to the rural areas by holding an exhibition in Khed Shivapur, where health themes were dramatised by students of the Poona Seva Sadan and a musical drama titled Arogya was performed in Nasik. The BBHWA had a number of affiliated bodies in Gadag, Bijapur, Akalkot, Nandurbar, Dhulia, Surat, Godhra and Broach. Devadhar, whose tireless work is repeatedly mentioned in the annual reports, arranged cinema shows at the Kirkee Military Hospital for the soldiers stationed there. In association with the Gordhandas Sunderdas Medical College, Bombay, the BBHWA also conducted research on what could be an ideal balanced diet. A food and vitamins exhibition was arranged in connection with the annual general meeting of the Servants of India Society, in 1930.42

Health of Women Mill Workers

These years also saw some efforts to provide medical relief to women employed in textile mills of Bombay. Dispensaries had been set up within the Goculdas and Tata mills, the latter having a lady doctor in attendance and creches were founded at the initiative of another reformist organisation, the Social Service League. The “minds” of the mothers had apparently to be prepared to take advantage of creches, “most women thought that it was to be a kind of hospital and a hospital was associated with certain imagined terrors in their minds.”43 Janet Kelman of New York, who visited India (1920-21) and made a study of the conditions of women in industries observed that western women, with long experience in India, maintained that European ideas regarding the care of mothers and infants were superfluous here and “the little Indian baby oiled all over and laid out in the sun thrives under such treatment.”44 She noted the reluctance of women, even in the big cities of Bombay, Calcutta and Madras, to go to maternity hospitals and was struck by the lower physical vitality of the children in the streets of Bombay. She referred to a contemporary source (Saraswatibai Donde) who had mentioned that the ‘naikins’ (jobbers) terrorised the workers and prevented them from leaving work before child birth and from staying away for a reasonable length of time after it, by the fear that there will be no room for them if they wished to work again. Yet, she remarked, the battle against time-honoured tradition had been less strenuous in the Bombay centres and women had responded positively. Probably, the high rates of infant mortality had broken down “timidities”. Kelman found that in some mills, the manager provided treatment, “his simple medicines and bandages aided by their faith in him works wonders”, and when fever was raging he would be “dosing” a roomful of workers with a quinine and fever mixture. Kelman noted that women were free to go to their homes or crèches to nurse their babies.45 By the 1920s, there were 13 creches in the Bombay mills. The All India Industrial Welfare Conference, which met in Bombay, in 1922, passed a resolution, stating that the foundation of all medical welfare work depended upon an efficient midwives service and the education of the mothers and the best means to secure this was by local committees of medical and social workers, with knowledge of local conditions.

Interest in the question of the maternal health of women workers in India had been linked to the first International Labour Conference held at Washington in 1919, where the draft convention was passed, providing for the maternity rights of women by granting six weeks rest before and after confinement. The convention protected women workers from the risk of dismissal during their absence. The delegates of India at the conference, explained that owing to the social customs of India there had been no occasion to provide for benefits. It is significant that the “special circumstances” of India were recognised and it was not expected that these articles should be adopted at once. The government of India (GoI) asked the local governments whether they would introduce the benefits but their response was not encouraging. A meeting of all those working with maternal welfare held at Shimla in 1921, concluded that no immediate legislation was required. However, inquiries made by the GOB, showed that women returned to their villages for delivery and found no difficulty in obtaining re-employment, owing to the heavy demand for labour. But they received no wages during their absence and were supported by their relatives. One consequence of the Shimla conference was the appointment of two women doctors of the Women’s Medical Service (WMS), Dagmar Curjel in Bengal and Florence Barnes in Bombay, to make inquiries and formulate schemes for the provision of medical aid to women in factories. Their report showed that while there was medical relief provided by dispensaries and doctors, no arrangements were made for child birth. There was uncertainty whether the mother would return after confinement and no records were maintained of the frequency of pregnancies. Their suggestions included the establishment of welfare centres, which were started in some mills and the appointment of a woman doctor as factory inspector. T J Cama was subsequently appointed to organise welfare. N N Wadia had started a maternity home in his mill, which was later amalgamated with the Wadia hospital.

The inquiry by Margaret Balfour and Shakuntala Talpade into the maternity conditions of mill workers in Bombay, funded by a grant from IRFA, is significant. The two doctors conducted this at the Wadia hospital and at Cama hospital. Their observations give a glimpse of contemporary conditions of mill workers: their housing was poor, but there was good drinking water supply; while hookworm was rare, malaria, dysentery and diarrhoea were common; their diet comprised of cheap and “filling foods” and women did not observe purdah. The inquiry noted that the incidence of disease connected with pregnancy was much less among these women, as was maternal mortality; only 1.7 per 1,000 while the rates for the city were 9 per 1,000. This was attributed to the “well caloried” diet with carbohydrates and little fat and the “more active and open air” life of mill workers.46 However, the birth weight of workers’ infants was found to be lower than those of the non-industrial workers and was ascribed to the fat-deficient diet of the former. Balfour and Talpade made some suggestions to mitigate the conditions of expectant mothers, like giving them light work during the later months of their pregnancy, providing one free meal a day or milk or fruits, having a maternity home attached to the mill premises and food during the period of confinement and “a money present” to allow the mother a month’s rest after delivery. They also recommended welfare measures and recreation facilities for men because pregnant women often worked, even when they were physically unable to because their men drank and gambled.47

Meanwhile, the question of maternity benefits to women factory workers was debated in the Bombay Legislative Council. A resolution was moved by S K Bole in 1924, urging the government to introduce legislation at an early date for the provision of adequate maternity benefits to women workers in all organised industries in India and to prohibit their employment during the period of such benefits. He described the condition of women factory employees, who stood at their machines in mills and factories for nine hours a day and when they returned home turned into domestic drudges, cooking, cleaning and washing. He pointed out that medical opinion had found that children born to these women weighed less than other babies. Because they had to spend more money on child birth they worked till the last moment. He also recommended that more crèches be established, urgently, since of the 65,000 workers in the presidency, 30,000 were employed in Bombay factories. He referred to the mills of the Tatas and Currimbhoys, where some sort of benefits had been introduced and consequently attracted a “better class” of labour in their mills. Unless compulsion was introduced, he contended, no other employers would follow their examples. As for the cost, the mills made such huge profits that these expenses would be comparatively small. A M Mansuri from Ahmedabad, supporting Bole, referred to the plight of women mill workers of that city, who worked till the last day of their pregnancy on account of their poverty. G I Patel of the AMA pointed out that since the latest factory act had laid down norms about allowing children in certain areas of the mills, there was an indirect compulsion to provide separate blocks with sanitary arrangements. Dadachanji eloquently argued that women were the precious treasure of the country. To the GOB’s contention, that there was no immediate need for legislation since public opinion was not ripe, Bole counter argued that if there was no public opinion, it had to be created and if there were prejudices they had to be removed. He referred to the examples of Germany, US, Denmark, Britain and other countries, which had introduced such measures.48

Outside the legislature, too, there were appeals for action. Women’s organisations, which had both Indian and British representatives, supported maternity benefits and called for legislation. The Bombay Presidency Women’s Council begun after the first world war, urged industries to do more to improve the working conditions of women and the question was also taken up by the National Council of Women in India (NCWI). Dadabhoy had urged the need to look into the condition of pregnant women, who were employed, while Kanji Dwarkadas a well known labour reformer had also recommended legislation. The AISSC advocated that maternity benefits should be made obligatory on all employers of labour. The Bombay Maternity Benefit Rules passed in 1929, made it mandatory on the employers to provide medical relief and leave for eight weeks before and after child birth. Every employer had to maintain a muster roll for women for the inspector to inspect and provide information every year, about the average number of women employed daily, the numbers who had claimed maternity benefits and who were paid benefits for actual births. In 1936, out of 24,000 and 9,500 women workers in Bombay and Ahmedabad, 1,900 and 1,200 women respectively, received maternity benefits.49

In the 1933 Calcutta session, the All India Women’s Conference (AIWC) urged the extension of the maternity benefit legislation to other regions of India, the Central Provinces had followed Bombay’s example. The AIWC resolution endorsed the recommendations of the Royal Commission on Labour, calling for the following: exclusion of naikins from the engagement and dismissal of labour, rigorous action against those factories, where conditions of humidification were bad, provision of first aid facilities and separate rest rooms for men and women, the passing of comprehensive public health acts in all provinces. It further recommended five hour working days for children with an interval for rest, no over time and the banning of child labour in mines.50

Conclusion

The above review of the efforts made to tackle maternal health, a vital public health concern, has revealed some significant facets. First, it has shown that Bombay’s medical fraternity, British and Indian, made attempts to delve deeper into the causes of high mortality. Besides attributing this to the characteristic explanations of ignorance and customs, the records show that investigations were made to see if there were health problems peculiar to Bombay city. Were they caused by overcrowding or were they related to work in mills? Turner’s assertion that high death rates could be brought down, and that it was the duty of the state to prevent disease and improve the physical condition of the people, is significant. That his bosses did not heed his view is another matter. Secondly, differing opinions within the BMC are apparent, as to who had to be given priority in getting relief; the poor or the lower middle class. The zeal of Turner was irksome to seasoned civic leaders like Wacha, who warned of sanitarians and their catchwords. The health department of the BMC under Turner’s direction and with the support of the semi-official BSA and LWS, initiated schemes to promote better maternal care. Two-thirds of births in the city were still attended by unskilled women, at home, but the same number of children were born healthy and this was certainly the effect of the visits by municipal health workers and the dissemination of information. Thirdly,

Economic and Political Weekly January 13, 2007 as in the capital, in other cities of the Presidency, too, welfare activities, whether the establishment of maternity homes or the promotion of better healthcare, were both semi-official and nonofficial. They were the result of the combined efforts of men and women reformers, donors and activist doctors. What is noteworthy is that since maternal health was a low priority agenda for the state, it was these attempts, which tried to reach a wider section of the population. As has been shown above, prevention and propagation was the main focus. A poster of the BBHWA declaimed, “It is wiser to put up a Fence, than to maintain an Ambulance at the bottom.”51

Closely connected with the success of these measures was the role of women physicians. As in Britain, here too, women were far keener to become doctors than to enter any other profession. Besides, this was a space left to Indian women where male doctors, both British and Indian, did not tread or even if they did, found women patients most reluctant to communicate their ailments. The presence of the former, at hospitals or welfare centres, doubtless, increased the numbers availing of the facilities, but all of this was in cities and towns. There was, indeed, a recognition of the need for women doctors in the districts, but few ventured there because of the insecurity of tenure, among other factors. Indian men and women doctors realised that long established prejudices and practices, could not be easily worn down, and therefore recommended negotiation. Thus were made the suggestions of Mistri and the efforts of Acacio Da Gama (assistant director of public health) to train the dai rather than to replace her, since she was so firmly entrenched. Western educated doctors propagated knowledge of better birthing practices, through regional languages, which would doubtless have contributed to breaking down reservations. In the previous century, Sakharam Arjun had written articles on pregnancy and childbirth, entitled ‘Garbhini striya vishayi vichar’ and ‘Prastuthi vishayi vichar’; and in the early 1900s, Sir Bhalchandra Krishna Bhatavadekar, wrote on the need for women to exercise, Aaplya striyan vyayamchi aavashyakatha; and Jerbanoo Mistri penned a small tract in Gujarati, entitled Baljanam agair matani ane panch varas sudhina balakni mavjat (Care of the Expectant Mother and Child up to Five Years).52 Also in the same language were tracts on hygiene and medicine by Shivgauri Gajjar. While appreciating the welfare endeavours undertaken, Jhirad held that maternal and child welfare had opened up one of the widest fields in India and urged that more remained to be done, not just through maternity facilities but by promoting urgent improvements in housing, bringing down food prices, the education of the public on the need for a balanced diet and the organisation of a blood transmission service. Yet even after 58 years of independence, India still accounts for 25 per cent of women dying in childbirth.

EPW

Email: mridularamanna@hotmail.com

Notes

1 Margaret Balfour and Ruth Young, The Work of Medical Women in India,

Bombay, 1929, p 35.

2 Mridula Ramanna, ‘Gauging Indian Responses to Western Medicine:

Hospitals and Dispensaries, Bombay Presidency, 1900-20’ in Deepak

Kumar (ed), Disease and Medicine in India: A Historical Overview, New

Delhi, 2001, pp 233-48.

3 Geraldine Forbes, Women in Colonial India, New Delhi, 2005. 4 Annual Report of the Municipal Commissioner of Bombay (hereafter

ARMCB) 1921-22, p 10. 5 ARMCB, 1917-18, Report of Health Officer (hereafter RHO), 1917, p 12. 6 Burnett Hurst, Labour and Housing in Bombay, Bombay, 1925, pp 37-42.

7 British Medical Journal, 1898, p 58. 8 ARMCB, 1920-21, RHO, p 12. 9 Lt Col Collie, ‘The Maternal Death Rate in Bombay’ in Transactions

of the Bombay Medical Congress, Bombay, 1910, pp 64-65. Turner’s paper on Venereal Diseases in General Department Volumes, Maharashtra State Archives, Mumbai (hereafter GD) 138, 1915.

11 Rakhamabai, ‘Purdah-The Need for Its Abolition’ in Evelyn C Gedge (ed), Women in Modern India, Bombay, 1929, pp 144-48.

12 J R Dadabhoy, ‘Infant Mortality, Its Causes and How to Remedy It’ in Report of the Proceedings of All India Social Service Conference (hereafter RSSC), Bombay, 1924, p 65.

13 Jerbanoo Mistri, ‘Training and Provision of Dais and Midwives’ in RSSC, p 57.

14 Jerusha Jhirad, ‘Medico-Social Work’ in Women in Modern India, p 134.

15 IRFA, Mortality and Child Birth in India, Calcutta, 1928, p 7.

16 Jerusha Jhirad, Report on an Investigation into the Causes of Maternal Mortality, in the City of Bombay, Delhi, 1941, pp 24, 52.

17 See Mridula Ramanna, Western Medicine and Public Health in Colonial Bombay, 1845-1895, Hyderabad, 2002.

18 ARMCB, 1911-12, RHO, pp 11-12.

19 Annual Report of the Sanitary Commissioner, Bombay (hereafter RSC) 1908, pp 5-7. GD, 621, 1914, Accompaniment to the September agenda of the BMC, August 8, 1914.

21 Ibid. 22 ARMCB, 1917-18, RHO, p 16. 23 ARMCB, 1918-19, RHO, p 17. 24 RSC, 1915, p 7. 25 Report of Native Papers, Bombay Presidency (hereafter RN) Sanchitra

Vinod, May 16, 1914.

26 ARMCB, 1921-22, pp 14-15.

27 Supriya Guha, ‘‘The Best Swadeshi’: Reproductive Health in Bengal, 1841-1940’ in Sarah Hodges (ed), Reproductive Health in India, Orient Longman, New Delhi, 2006, p 162.

28 Hugh Tinker, Local Self-Government in India, Pakistan and Burma, Bombay, 1927, p 294.

29 E W C Bradfield, An Indian Medical Review, Delhi, 1938, pp 190-91. Report on Civil Hospitals and Dispensaries, Bombay Presidency (hereafter RCHD), 1909, p 2, ibid, 1908, p 3.

31 RCHD, 1920, pp 6-23.

32 Report of Managing Committee of KEM, Poona, 1917.

33 GD184, 1915, GR No 9938, November 19, 1914; GD,163,1921,GD order No 8734, August 17, 1920.

34 GD, 32, 1913, Letter no 1493, February 22, 1913.

35 Prajabandhu, July 28, 1918.

36 Tribhovandas Motichand Shah Rhinoplasty, Being a Short Description

of One Hundred Cases, Junagarh, 1889, pp 3-6, 79. 37 F R Parakh ‘Chronic Endometritis with Special Reference to the Results

of Curetting’ in Report of the Bombay Medical Union, 1911-12.

38 Mohini Varde, Dr Rakhmabai: An Odyssey, New Delhi, 2000, p 133.

39 R H Western, Some Women of Sind in Home and Hospital, London, nd, pp 119-27. Gopal Krishna Devadhar, H N Kunzru (ed), Poona, 1939, pp 88-93.

41 Lady Cowasji Jehangir, ‘Maternal Welfare Work in Bombay’, Asiatic Review, Vol 33, 1937, pp 759-60.

42 Fifth, Sixth Annual Reports of the Bombay Presidency Baby and Health Week Association (hereafter BBHWA), 1929, 1930, Bombay, 1930, 1931, Rockefeller Archive Centre, New York.

43 N M Joshi, ‘Welfare Work in Bombay Cotton Mills’, Journal of Indian Industry and Labour, Vol 1, part 1, 1921, p 23.

44 Janet Kelman, Labour in India: A Study of the Conditions of Indian Women in Modern Industry, London, 1923, pp 170-71.

45 Ibid.

46 Margaret Balfour and Shakuntala Talpade, ‘The Maternity Conditions of Women Mill Workers in India’ in The Indian Medical Gazette, Vol lxv, No 5, May 1930, pp 1-26.

47 Ibid, pp 24-26.

48 Bombay Legislative Council Debates, July 30, 1924, pp 662-73.

49 Kanji Dwarkadas, Forty-Five Years with Labour, Bombay, 1962, p 38. Report of the VIIIth Session, All India Women’s Conference, Calcutta, 1933, pp 98-100.

51 Seventh Report, BBHWA 1931, Bombay, 1932.

52 Vividh Vigyan Vistar, Vol 1, pp 146, 165; and Vol 17, p 39; Jerbanoo Mistri, Baljanam agair matani ane panch varas sudhina balakni mavjat, Bombay, 1930.

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