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Sarah Pinto, Where There Is No Midwife: Birth and Loss in Rural India.

Sarah Pinto, Where There Is No Midwife: Birth and Loss in Rural India. New York: Berghahn Books, 2008. xi + 330 pages.

In Where There Is No Midwife: Birth and Loss in Rural India, anthropologist Sarah Pinto (Tufts University) has written a rich ethnography that examines rural Indian women's experiences with reproduction and biomedical interventions across different social classes and castes. Based on the author's fieldwork in the north Indian state of Uttar Pradesh, the research situates women at the center of global processes of development, showing why and how rural women accept, reject, or transform discourses that aim at reproductive "uplift." Pinto lived with an upper-caste family but worked among all social strata in a rural village she calls Lalpur; and this ethnography draws a compelling, nuanced portrait of the suffering that women experience in everyday life. In the process, the author explores the tensions of caste and women's complex responses to state and NGO interventions into their reproductive lives. It will be a welcome read for scholars interested in gender, caste, development, and the deployment of health-focused discourses on the subcontinent.

The book is organized into seven chapters, each of which is thematically structured. Chapter 1, "Work: Where There Is No Midwife," describes Pinto's entry into the field, when she set out to study dais (traditional midwives). Finding they did not exist, she describes the work of birth attendants, which is divided along caste lines, with Dalit (formerly untouchable) women responsible for postpartum care and disposal of the placenta. The second chapter delves into the abject social meanings the placenta takes on in Lalpur. In this chapter, Pinto uncovers the multiple levels of significance involved in who handles the placenta, and she explains how it is disposed of according to complex schemes that highlight local notions of gender and kinship. She also shows how the placenta remains a fraught object for health workers, who are scandalized by the "primitive" practices of local birth workers even as they themselves maintain divisions of caste in their own treatment and training of traditional birth attendants. Chapter 3, entitled "Medicine: Development without Institutions," explores how local, uncertified practitioners of medicine create authority in those spaces where biomedicine has not quite extended its reach. This chapter is among the strongest parts of the book and could be read independently as a study of local interactions with the discourse of "development." Pinto compellingly describes how those ersatz local efforts to forge medical authority take shape along lines of class and caste, or how "socialities that resemble 'untouchability' are woven into ethoses of improvement" (p. 27).

In chapter 4, Pinto shares rural women's responses to her own pregnancy, which gave her insight into local beliefs concerning visuality, the evil eye, and concealment, particularly where often devastating health outcomes are at stake. Chapter 5, "Dying: In the Big, Big Hands of God," is devastating: a description of how rural women in both lower and upper castes deal with the horrible, yet still all too common, experience of infant death. This chapter shows how rural women seek biomedical interventions only to find that, at the moment those interventions are needed most, they are unavailable. Despite their efforts to adhere to what they believe the "experts" require of them in seeking medical care, they still experience tragic losses and failures. Pinto questions the extent to which these failures are those of the "individual" (as in popular development belief), arguing that women's access to adequate pre- and post-natal healthcare is uneven, with a government still largely concerned with population "control" rather than with a genuine improvement in the health of rural women.

In chapter 6, Pinto offers a detailed historical analysis of Indian medical interventions and programs that aim to improve women's health. She does an excellent job showing how medical discourses have both changed and remained the same over time, whether under colonialism or as a part of global health initiatives, always targeting traditional birth attendants as figures of either blame or uplift. Pinto shows how condescending efforts on the part of NGOs to give voice to the participatory knowledge and experience of traditional birth attendants are really just so much developmental window dressing. In reality, "no one listens when you use the voice you are told you are supposed to have" (pp. 241-42). Finally, the seventh chapter concludes with an examination of where the rural fits into national and global efforts at intervention, showing why refusals of biomedical care are actually so much more complex than they may seem.

Drawing on the theoretical literature of medical anthropology as well as that of psychoanalysis, this is a complex, multilayered work. Pinto is a fine writer, and throughout the book her ethnography beautifully illuminates her theoretical arguments. There were a few moments, particularly toward the end, where the fit between ethnography and theory was not as strong, and where I would have liked to see more analysis of the ethnography. For example, Pinto's moving portrayal of the slightly unhinged Dalit woman Pushpadevi, who is distressed by her life, her abusive husband (now in prison for murder), and her inability to control her family size, leaves the reader longing for more closure in considering what so much suffering means for this particular individual, and not just for Dalit and Muslim ambivalence toward medical interventions. However, this is a minor criticism, and in general the ethnography holds together brilliantly.

Where There Is No Midwife makes a significant contribution to the literature on reproduction, globalization, and development in India. It will be of interest to social scientists, feminist scholars, and Asianists concerned with issues of caste, development, and globalization on the Indian subcontinent, and it should be required reading for anyone working in development or reproductive health.

RACHEL NEWCOMB

Rollins College
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Author:Newcomb, Rachel
Publication:Southeast Review of Asian Studies
Article Type:Book review
Date:Jan 1, 2009
Words:958
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