The guidelines for pregnant women released recently by the the department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy, or AYUSH Ministry, have garnered a lot of media attention. Titled Mother and Child Care through Yoga and Naturopathy, the booklet of guidelines purportedly draws on the principles of these alternative systems of medicine to help “manage all the motherhood problems”. Media reports have focused on the “unscientific recommendations” in the booklet. However, a closer look at the ten-page bilingual booklet reveals several additional areas for concern.
Any advisory/guideline for pregnant women needs to keep in mind the larger realities under which women go through pregnancy and childbirth in this country. India continues to have the largest number of maternal deaths in the world. WHO reports that five women die of pregnancy-related causes every hour in the country, a total of 45,000 maternal deaths every year. Pregnant women, especially those from marginalised communities like Dalits and adivasis, as well as those in geographically remote locations, continue to face great challenges in accessing healthcare especially during emergencies. The nutritional status of pregnant women remains very poor with very high levels of anemia among them – the recently concluded National Family Health Survey (NFHS 4) reports that half of all pregnant women in this country are anaemic, a figure that has seen only marginal improvement in the last decade since NFHS 3. It is well known that anaemia is perhaps the most important contributor to women’s ill-health and deaths during pregnancy – over a third of all maternal deaths are due to excessive bleeding, a condition in which death is hastened by concomitant anaemia and another 20% of these deaths are due to anaemia itself. Maternal anaemia also has adverse consequences for the foetus, including preterm birth and low birth weight.
It is in this larger context that the ministry’s booklet needs to be viewed. The booklet recommends that pregnant women consume a “sattvic diet” and specifically advises that eggs and meat should be avoided. The guideline also specifies a daily diet plan that advises whole wheat roti twice a day. With the heavily fluctuating prices of dals, eggs remain the cheapest and most wholesome protein source accessible to many women. It is a well-known scientific fact that proteins, an essential component of haemoglobin, are essential along with iron and vitamins, to correct anaemia. In 2009, an expert group of the Indian Council of Medical Research had said that eggs are an excellent source of high quality protein for pregnant women and that addition of non-vegetarian food to the diet can increase protein intake in pregnancy. Thus, this ban on eggs and meat in the face of widespread malnutrition, and contrary to existing recommendations from governmental bodies themselves, makes one wonder if this is a push from the culturally hegemonic vegetarianism lobby rather than any advice based on sound scientific principles.
There are great variations in traditional diets among regions and communities in different parts of India, along with different cultural beliefs and taboos around diets in pregnancy. In such a scenario, to prescribe a one-size-fits-all diet is naive and simplistic, to say the least. For example, there is no mention of rice, the staple food of several communities, in the recommended daily diet plan. Moreover, traditional forms of medicine have been known to tailor advice to individual constitutions and contexts and such generic advice as in the booklet goes against the grain of such systems. There is also no reference mentioned in the booklet to where these recommendations are drawn from, thus leading to questions on credibility of the recommendations.
Quite apart from these nutritional concerns, it is also important to look at the guidelines from a woman-centred view point. The guidelines prescribe what women should and should not do in pregnancy. In addition to the dietary advice, they also ask pregnant women to “have spiritual thoughts”, “keep themselves in peace”, “detach themselves from desire, anger, attachment, hateredness (sic) and lust”, “avoid bad company and be with good people in stable and peaceful conditions always”. In the patriarchal culture that most women live in in the country, they have very little say and decision-making power in everyday household matters, let alone on whom they associate with, the emotional conditions they live in, or over their desires, sexual or otherwise. As per NFHS 4, over a quarter of ever-married women report having faced spousal violence. Studies show that domestic violence often escalates in pregnancy and denial of sexual demands is a well-known trigger for domestic violence. In the author’s own experience of working with Dalit women in a rural community in northern Tamil Nadu, even women who were otherwise considered empowered in terms of their leadership in local communities or in their financial participation in microcredit groups, often faced physical and sexual violence at the hands of their spouses. In a situation where they had no control over their sex lives, and where their spouses took very little responsibility for contraception, pregnancies were often not the joyous events they are made out to be for these women. There are several studies from across different regions in India that substantiate these observations and document widespread violence in women’s lives. In addition, women often go through pregnancy in several challenging circumstances – drought, financial crisis, conflict. The guidelines do not seem to take any of these realities of women’s lives into account while giving generic prescriptions of good behaviour. What is even more disappointing is that while all of this advice is directed to the pregnant woman, there is no mention of what support she would require from her family and society to enable her to follow these, thus placing the onus completely on the woman to adhere to such good behaviour.
In the patriarchal discourse, the woman has been seen as merely an instrument to produce progeny and heirs to sustain the traditional family structure. These guidelines also essentialise the woman to merely be a vessel for a healthy child. For instance, the guideline says malnutrition in pregnancy can lead to anaemia, rickets and bow knee in the child. While maternal nutrition is indeed an important determinant of health outcomes of the infant, it is ironic that the ministry seems to forget the woman at the centre of it all, and that malnutrition in the form of anaemia is the biggest contributor to the large number of women themselves dying during pregnancy. The guidelines also equate pregnancy with motherhood, failing to acknowledge the needs of a whole group of women for whom pregnancy may not result in motherhood, when the pregnancy may not be wanted or may not result in a live baby.
Given that these guidelines are based on a questionable interpretation of science and are completely devoid of the context of pregnancies in India, one wonders if they will indeed be of any use to the women they are addressed to, or whether they are a tool to further control women by invoking, through a lens of patriarchy, principles from traditional medical systems.
What then would be more useful recommendations for women in pregnancy? Without going into specifics, something that would allow for adaptation to different contexts and realities, would spell out the support systems needed from partner, family, society and health systems, and would help women negotiate the power structures that control them. Let us hope the ministry learns from the responses these guidelines have generated and makes future guidelines more women-centred.
Subha Sri B is an obstetrician working with Rural Women’s Social Education Centre, a dalit women’s organization in Tamil Nadu. She is also the Chairperson of CommonHealth, Coalition for Maternal-Neonatal Health and Safe abortion.