Authoritative Knowledge and Local Women’s Knowledge: a focus on the Reproductive Health Initiatives of icddr/B

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Authoritative Knowledge and Local Women’s Knowledge: A Focus on the Reproductive

Health Initiatives of ICDDR/B

Nadia Rahman
This project reviews anthropological and related studies of women’s reproductive health in Bangladesh, particularly as carried out by the Centre for Health and Population Research in Bangladesh (ICDDR/B). ICDDR/B, formerly known as the International Centre for Diarrhoeal Disease Research, Bangladesh is a non-profit health research and training institution with the mandate to develop and disseminate solutions to critical health and population issues, with an emphasis on cost-effective methods for prevention and management.

The Centre’s primary training and research headquarters are in Dhaka, Bangladesh. Originally, ICDDR/B focused on prevention and treatment methods for cholera and diarrhea. It now conducts research on issues spanning from child health, reproductive health, nutrition, population sciences, HIV/AIDS, and safe water. The Centre established and continues to operate the Matlab Health Research Centre (MHRC), through which it maintains longitudinal studies of rural populations (Bhatia 1981).

Compared to the number of anthropological studies on women and reproductive health in India, those for Bangladesh are few. Rosario et al. and Blanchet are some the earliest anthropologists to undertake intensive research related to rural Bangladeshi women’s reproductive health knowledge. Publications range from examining the role and status of traditional birth attendants (TBAs) in villages to themes of ritual “purity” and “pollution” associated with rural childbirth ideologies (Blanchet 1984; Rashid 2001; Rosario et al. 1998). Each set of discourses, in different ways, points to the female physiology as problematic.

Worldwide, Western Biomedicine (WBM) claims and is accorded an almost unquestioned position as authoritative knowledge. Jordan (1997), Sargent and Bascope (1996), and Rashid (2001), explain that when multiple knowledge paradigms exist, one tends to be dominant. A recurrent consequence is the loss of authority and denigration of local ways of knowing. The authors argue that the biomedical physicians’ unquestioned authority and status is a type of performance and a ritualized deference paid to the high status of WBM.

Although linguistic anthropological research on medical discourse in Bangladesh is limited, it brings to the forefront issues of authority and power among the language of the biomedical community and the patient (Kuipers 1989). Wilce (1997) argues that these micro-political interactions may render the client weak within the context of reproductive-health knowledge, which may affect rural women’s care-seeking behavior in times of obstetric complications. Recent publications also stress the importance of listening to what rural women have to say in order to understand women’s reproductive knowledge and care-seeking behavior, on the part of both health-care practitioner and researcher (Afsana and Rashid 2001; Khanum et al. 2000; Sargent and Stark 1989).

Anthropological research on reproductive health-related injuries and violence as cause of death and non-fatal injuries of women are scarce and incomplete, and especially so regarding rural Bangladeshi women (Fauveau and Blanchet 1989). This being the case, medical anthropologists can play a crucial role in investigating these issues vis-à-vis community-based studies (Bhatia 1981). Recommendations for any preventative measures can attempt to find a balance between the ideologies of both local and biomedical contexts by means of a dialogical flow of information (Maurial 1999; Sillitoe 2002).


Annotated Bibliography

Afsana, Kaosar and Sabina Faiz Rashid. 2001.

The Challenges of Meeting Rural Bangladeshi Women’s Needs in Delivery Care. Reproductive Health Matters 9(18):79-89.

This article is based on quasi-anthropological research including in-depth interviews with rural women who gave birth in a BRAC Health Centre (BHC), women who gave birth at home, and biomedical staff of the BHC. Fieldwork was carried out in a district located north of Dhaka. The research team observed patient-staff relations, conducted participant observation, and held focus group discussions. A quantitative approach stressed listening to what rural women had to say regarding delivery care. Findings indicate that rural women’s acceptance of deliveries in health facilities is minimal and their overall reliance on TBAs cannot be overlooked. Cost, fear of hospitals, and the stigma of “abnormal” births are major constraints to health care accessibility. Female paramedics who attended normal deliveries made women give birth lying down and were too busy to give information to the mother, making the birthing process a passive experience.


Bangladesh, rural

BRAC Health Center (BHC)

Delivery care

TBAs

Patient-client relations

Health-care accessibility

Ahmed, Syed M., Alayne M. Adams, Mustaque Chowdhury, and Abbas Bhuiya. 2003.

Changing Health Seeking Behavior in Matlab, Bangladesh: Do Development

Interventions Matter? Health Policy and Planning. 18(3):306-315.

Ahmed et al. analyze cross-sectional data from surveys undertaken in 1995 and 1999 as part of the BRAC-ICDDR/B Joint Research Project in Matlab. Their findings suggest a rise in self-treatment of women, attributed to the economic impact of a major flood in 1998, and greater reproductive heath “awareness” of rural women, due to the increased numbers of community health workers in Matlab. Because these studies rely on mainly quantitative data, they do not explore women’s beliefs and practices to any significant degree, but it does however, illustrate the degree to which rural women access biomedical health-care and their reasons for doing so.

Bangladesh, Matlab

BRAC-ICDDR/B Joint Research Project

Self-treatment

Reproductive health awareness

Accessibility of health care

Health and sociology

Sociological study

Amin, Sajeda. 1998.

Family Structure and Change in Rural Bangladesh. Population Studies 52(2): 201-213.

Amin examines the role of family and the household in relation to the reproductive health needs of rural women in two villages in Bangladesh. The villages are located in Mohanpur thana and Rajshahi district. The rising rates of landlessness in these villages lead to increasing nucleation and fragmentation of families. As poverty weakens the family support system, it promotes “disaffection” with marital and familial relationships, encouraging rural women to seek more autonomous lifestyles. The changes in family structure and the significant fertility decline may be crucial in analyzing the extent to which rural women’s ideology may be shifting within the context of both the “traditional” and “biomedical” reproductive strategies. The fertility decline may be in part due to women seeking alternative roles to those of wife and mother.

Bangladesh, rural

Mohanpur thana

Rajshahi district

Landlessness

Family change

Fertility decline

Autonomous lifestyles/alternative roles

Cultural anthropology

Bhatia, Shushum. 1981.

Traditional Childbirth Practices: Implications for Rural MCH Programs. Studies in Family Planning 12(2):66-75.

Bhatia conducted sociological research with ICDDR/B in the Family Planning and Health Services Program in the villages of its field station in the Matlab district. She conducted semi-structured interviews with biomedical staff and observed several deliveries lead by TBAs. She argues that a better utilization of biomedical facilities will occur if they are village-based and incorporate prevailing cultural practices and beliefs, within the context of childbirth practices. Biomedical staffs in rural areas also believe that health programs might achieve better results if the program prioritizes the needs of the community.

Bangladesh, rural

Matlab district, ICDDR/B

Utilization of biomedical facilities

Village-based programs

Community-based needs
TBAs

Sociological study

Blanchet, Therese. 1984.

Meanings and Rituals of Birth in Rural Bangladesh, Dhaka: University Press Limited.

Blanchet’s fieldwork in villages in Matlab upazila, highlight key processes associated with rural childbirth patterns, rituals, and practices which fuse Islamic, Brahminical, and local Bengali beliefs. Blanchet examines the ritual “purity” and “pollution” themes associated with childbirth. In these village communities spontaneous abortions, menstrual complications, hemorrhages, tetanus, postnatal diarrhea, and stillborn births are associated with the actions of a bhut (spirit) or the “ill” actions of the mother. Blanchet’s work serves as a backdrop to approaching childbirth and related risks as perceived by women in rural Bangladesh, revealing that in different ways, childbirth complications point to the female physiology as problematic.

Bangladesh, rural

Matlab upazila

Childbirth/complications and risks

Purity vs. Pollution

Female physiology

Medical anthropology

Fauveau, V. and Therese Blanchet. 1989.

Deaths from Injuried and Induced Abortion among Rural Bangladeshi Women. Social Science and Medicine 29(9):21-27.

Information about injuries and violence as causes of death of women is scarce and often incomplete, and particularly so regarding women in the rural areas of South Asia. This report provides data drawn from a large-scale research project in Matlab. Of 1139 women (aged 15-44 yr) who died during the 11-yr period from 1976 to 1986, 207 were victims of unintentional injuries or violence. Unintentional injuries include domestic and traffic accidents, drowning and snake-bites. Violent deaths are defined as due to intentional injury and include homicide, suicide and lethal complications of induced abortion. Violent deaths during pregnancy and complications of induced abortion among young unmarried women are prevalent. Suicide and homicide are two frequent consequences of illegitimate pregnancy. This study suffers from the absence of data on non-fatal injuries and attempted violence, but it may serve as a basis for recommending preventive measures.

Bangladesh, rural

Matlab district

ICDDR/B

Unintentional and intentional injuries



Violent deaths during pregnancy and complications of induced abortions

Sociological study

Jordan, Brigitte. 1997.

Authoritative Knowledge and Its Construction. In Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives. Robbie Davis-Floyd and Carolyn Sargent eds. pp. 55-79. Berkeley: University of California Press.

Jordan writes, on the basis of fieldwork on the birthing processes in several cultures, that when multiple knowledge paradigms exist, one tends to be dominant. A frequent result is the loss of authority and even denigration of local ways of knowing, further subordinating these populations in relation to exogenous biomedical practices. In her view, the biomedical physicians’ unquestioned authority and status is a type of performance of ritualized deference paid to the high status of biomedical knowledge. This elevated status serves as a barrier to establishing dialogical relationships between biomedical practitioners and clients, resulting in situations where clients may reject family planning clinics, especially in times of pregnancy-related risks.

Multi-sited cross-cultural fieldwork

Birth processes

Multiple knowledge paradigms

Biomedical authoritative knowledge

Denigration/subordination of local knowledge

Pregnancy related risks

Medical anthropology

Khanum, Parveen A., M.A.Quiayum, Ariful Islam, and Shameem Ahmed. 2000.

Complications of Pregnancy and Childbirth: Knowledge and Practices of Women in Rural Bangladesh. Dhaka: ICDDR/B Center for Health and Population Research.

The authors are part of the ICDDR/B research staff whose cross-sectional studies examine rural women’s knowledge and care-seeking behavior in times of obstetric complications. They use semi-structured questionnaires when interviewing rural women. The study was done in 7 unions of Mirsarai, 5 unions of Abhoynagar thana in Chittagong and Jessore district. The authors argue that, since rural women still seek care from the traditional providers (TBAs) for deliveries and for the management of obstetric complications, these providers should be directly linked to the ICDDR/B health facilities.

Bangladesh, rural

ICDDR/B


Rural women’s reproductive knowledge

Care-seeking behavior

Management of Obstetric complications

TBAs


Sociological study

Kuipers, Joel C. 1989.

Medical Discourses in Anthropological Context: Views of Language and Power. Medical

Anthropology Quarterly 3:99-123.

Kuipers examines the recorded texts of Weyewa ritual speech of Sumba, Indonesia, in order to analyze medical discourses. The prevailing image of medical knowledge in social science as the ultimate truth has shifted, bringing to the fore issues of power and authority within the context negotiation and control of particular knowledge systems. According to Kuipers, the purpose of achieving linguistic rapport, from the standpoint of biomedical practitioners is to pinpoint discourse-centered commonalities, that is, referential parity, between the language of the scientific community and the patient.
Indonesia

Sumba


Weyewa ritual speech

Medical discourse

Power/authority

Scientific community/patient

Linguistic rapport

Linguistic anthropology

Maurial, Mahia. 1999.

Indigenous Knowledge and Schooling: A Continuum Between Conflict and Dialogue. In What is Indigenous Knowledge? Voices from the Academy. Ladislaus Semali and Joe Kincheloe, eds. Pp. 60-77. New York: Falmer Press.

Maurial examines the re-conceptualization of education through the conceptualization of indigenous knowledge in rural Peru. She argues that the reductionist Western approach to education is counterproductive. Instead, dialogue between the responsible members of the local community and the larger community should be used to understand the complexity of the problem of education among indigenous people. The process of schooling for the indigenous people of Peru has not fostered democracy. Instead schools have imposed a foreign curriculum which devalues indigenous knowledge, resulting in the loss of identity and agency, which in turn is a risk to indigenous knowledge accumulation and use.

Peru, rural

Education

Dialogical process

Indigenous knowledge

Reductionist Western approach

Identity/agency


Menken, Jane, Linda Duffy, and Randall Kuhn. 2003.

Childbearing and Women’s Survival: New Evidence from Rural Bangladesh. Population and Development Review 29(3):405-426.

The authors are population studies specialists who collaborated with IDCCR/B to conduct their research. The study was conducted in 14 villages in the Matlab district of ICDDR/B’s Maternal and Child-Health Family Planning Program. Their research supports the relationship between early life conditions and later health and survival risks of rural women. According to the “maternal depletion syndrome” hypothesis, women, especially in the developing world, may suffer from increased maternal depletion as a result of repeated rapid childbearing under poor conditions. Both pregnancy and lactation considerably increases energy expenditure, if a woman cannot compensate for this, her nutritional status and health may be deleterious to her survival.


Bangladesh, rural

Matlab district

ICDDR/B

Link between early life conditions and later health risks


Maternal depletion syndrome

Repeated rapid childbearing

Maternal survival

Population studies

Pigg, Stacey L. 1997.

Authority in Translation: Finding, Knowing, Naming, and Training “Traditional Birth Attendants” in Nepal. In Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives. Robbie Davis-Floyd and Carolyn Sargent., eds. Pp. 233-262. Berkeley: University of California Press.

Pigg uses her anthropological fieldwork in Nepal to analyze how development institutions use language to establish their role as holders of authoritative knowledge, thereby denigrating local knowledge systems. She offers a case study in which a development institution’s programs for training TBAs discounted local reproductive knowledge and practices. Instead of incorporating local people’s knowledge about childbirth into the TBA training methods, the institution produced the notions of “appropriate” ideas and practices surrounding reproductive health.

Nepal

Development institutions

Authoritative knowledge

Denigration of local knowledge systems

TBA training

Cultural anthropology


Rashid, Sabina. 2001.

Indigenous Understanding of the Workings of the Body and Contraceptive Use Amongst Rural Women in Bangladesh. South Asian Anthropologist (1)1:57-70.

Rashid conducts multi-sited fieldwork to analyze discourses of the female body in rural Bangladesh that illustrate gender relations in rural society and the degree to which village ideologies of shame, purity, and pollution influence women’s attitudes toward contraceptive practices. Women’s understanding of their body and perception of flow, buildup, and blockage within the context of menstruation, is linked to women’s medicinal plant use. The plant Norplant is used relieve any “disruption” of the internal state of the body. Humoral notions underlie descriptions of Norplant use, which are understood to agree with women differently.


Bangladesh, rural

Village ideologies

Contraceptive practices

Norplant

Women’s medicinal plant knowledge

Humoral health systems

Medical anthropology

Rosario, Santi. 1998.

The Dai and the Doctor: Discourses on Women’s Reproductive Health in Rural Bangladesh. In Maternities and Modernities: Colonial and Postcolonial Experiences in Asia and the Pacific. Kalpana Ram and Margaret Jolly, eds. pp. 114-176. Cambridge: Cambridge University Press.

Rosario et al.’s fieldwork primarily examines the role and status of TBAs in villages of the Dhaka district in relation to indigenous medicinal knowledge. TBAs are typically elderly women with no formal education or training. Rural women in the Dhaka district are aware of the risks associated with consecutive births. In situations where delivering healthy babies are slim and pose a health related risk to the mother, an increasing percentage of rural women have opted for contraception use. This shift in behavior is attributed to a number of factors: a) aggressive campaigning on the part of both NGOs and the Government of Bangladesh (GOB); b) availability of cheaper contraceptives; c) media attention; and d) promotion by Muslim religious leaders.

Bangladesh

Dhaka district

TBAs

Indigenous medicinal knowledge



Risk/consecutive births

Contraceptives

Medical anthropology

Ross, James L., Sandra L. Laston, Pertti J. Pelto, and Lazeena Muna. 2002.

Exploring Explanatory Models of Women’s Reproductive Health in Rural Bangladesh.

Culture, Health, and Sexuality 4(2): 173-190.

In terms of women’s “explanatory models” of illness, using multi-sited fieldwork data, Ross et al. show that rural Bangladeshi women have clear conceptions of illness categories, with different strategies of treatment for various categories. Reproductive tract infections, including those attributed to sexual transmission, and vaginal discharge are crucial to rural women. None of the available health facilities, however, are attuned to addressing rural women's explanatory models for such health risks and illnesses.

Bangladesh, rural

Rural women

Explanatory models

Illness categories

Sexually Transmitted Infections

Treatment strategies

Medical anthropology

Sargent, Carolyn and Grace Bascope. 1996.

Ways of Knowing about Birth in Three Cultures. Medical Anthropology Quarterly 10(2):213-236.

Sargent and Bascope examine the concept of authoritative knowledge in a comparison of birthing systems in Mexico, Texas, and Jamaica. They explore the connection between the distribution of knowledge about childbirth, the value of biomedical ways of knowing about birth, the production of authoritative knowledge vis-à-vis interactions, and the relationship between social status and authoritative knowledge. Their research indicates that in collaborative and low-technology birthing processes, like some Maya communities in Mexico, the midwife and other adult women share general knowledge regarding birth processes. In contrast, Spanish-speaking women delivering in high-technology public hospitals in Texas, due to their limited English, are only minimally able to interact with biomedical staff. Jamaican women delivering in formerly high-technology hospital systems, which are currently experiencing economic severity, renders the health system dysfunctional. The importance given to the authoritative knowledge of the physicians/nurse-midwives in these examples is directly linked to the social position of the practitioner and has its basis in the legitimacy of the profession in its claim to generate and accord authoritative knowledge.

Mexico

Texas


Jamaica
Birthing process

Biomedical birthing

Technology of birth

Ethnicity

Maya

Authoritative medical knowledge



Medical anthropology

Sargent, Carolyn and Nancy Stark. 1989.

Childbirth Education and Childbirth Models: Parental Perspectives on Control, Anesthesia, and

Technological Intervention in the Birth Process. Medical Anthropology Quarterly 3(1): 36-51.

This research is based on the contrastive analysis of two child-birth classes sponsored by the Dallas Association for Parent Education (DAPE). Women, their partners, and labor coaches were interviewed during class sessions. The goal of these classes was to familiarize prospective parents on procedures they may encounter in the hospital. Findings indicate that these childbirth classes are not likely to affect preexisting conceptions, values, and expectations of the delivery process. Discussion related to pain and anesthesia reveals that kin and close friends are the primary source of influence within the context of childbirth education. Medical messages operate as a mechanism of social control whereby the message disseminated has an implicit impact on the values and expectations of the women and their partners.
United States

Dallas

Childbirth classes

Childbirth education

Kin and friends-primary influence

Medical message

Social control

Medical anthropology

Schuler, Sydney and Zakir Hossain. 1998.

Family Planning Clinics Through Women’s Eyes and Voices: A Case Study from Rural Bangladesh. International Family Planning Perspectives 24(4): 170-175.

Schuler and Hossain examine why family planning clinics are underutilized in six rural villages in the Magura, Faridpur, and Rangpur districts of Bangladesh. They find that major explanatory factors include purdah, honor, and purity. Poverty is a critical factor related to the underutilization of biomedical centers. The authors provide case studies of clients who are treated like second class citizens by biomedical staff. Interactions between health care providers and clients take on the hierarchal characteristics common in rural Bangladeshi society in which relationships resemble that of political patronage.

Bangladesh, rural

Magura/Faridpur/Rangpur districts

Family planning clinics

Underutilization of family planning clinics

Explanatory models

Hierarchal interaction/health risk

Medical anthropology

Sillitoe, Paul. Alan Bicker and Johan Pottier. 2002.

Globalizing Indigenous Knowledge. In Participating in Development: Approaches to Indigenous Knowledge. Sillitoe, Paul, Alan Bicker, and Johan Pottier, eds. pp. 108-138. London and New York: Routledge.

Sillitoes’s ideas come from working with natural and social scientists in relation to development-funded environmental research projects in South Asia within the context of how development personnel can approach and understand the concept of indigenous knowledge. He argues for a two-way flow of information, with an emphasis on combining strengths of different cultural traditions in our increasingly globalizing world. While indigenous knowledge systems worldwide are gaining respect in areas such as the environment, agriculture, and botany, women’s traditional reproductive knowledge is a neglected area at best and a denigrated area at worst. He argues that the authoritative scientific rationale that dominates our society and the development agenda is unhealthy and constitutes a major risk (e.g. physical/social/economic) to certain sectors of a given community.

South Asia

Scientific/Authoritative vs. Traditional/local knowledge

Two-way dialogical flow of information

Displacement of local knowledge

Women’s traditional reproductive knowledge

Cultural anthropology

Wilce, James L. 1997.

Discourses, Power, and Diagnosis of Weakness: Encountering Practitioners in Bangladesh. Medical Anthropology Quarterly 11(3):352-374.

Wilce, informed by multi-sited fieldwork with ICDDR/B in rural and urban Bangladesh, argues that there is a fundamental link between authoritative knowledge and authoritative power within the context of doctor-patient interaction. He examines the role of language and face to face interactions which occur within biomedical institutions by comparing rural and urban centers of ICDDR/B. He explains that the “weakness” of Bangladeshi patients, women in particular, is linguistically constructed by the society in general and biomedical practitioners in particular. Such micro-political interactions render the patient weak in terms of their knowledge and discourse. The hierarchal distribution of knowledge fosters unequal power relationships between biomedical practitioners, ethno-obstetrics (TBAs), and patients.
Bangladesh, urban/rural

Authoritative knowledge

Unequal power relationships

Doctor-patient interaction

“Weakness”

Linguistic anthropology






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