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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.

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

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.

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

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 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

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

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