Birth on the Threshold: Childbirth and Modernity in South India (review)

Birth on the Threshold traces out the relationships among reproductive practices, gender, biomedicine, and modernity in contemporary Chennai (formerly Madras), India. Although scholarship on the politics of home versus hospital birth has generally been forged in the Euro-American context, Cecilia Van Hollen takes a relatively familiar set of debates and demands that we consider them in a global view. Examining the anthropology of childbirth, she compellingly demonstrates that while urban and semiurban Tamil women are happy to consume—and indeed, regularly insist upon—a host of obstetric "interventions," questions of safety and equity of access to quality health care remain unresolved.

Each chapter in the book addresses a different modernizing process affecting poor women's experiences during childbirth in the southern Indian state of Tamil Nadu. These include the professionalization and institutionalization of obstetrics in colonial and postcolonial India, transformations in the relationship between consumption patterns and reproductive rituals, the emergence of new technologies for managing the pain of birth, the international mandate to reduce population in India, and development agencies' agenda to spread biomedical conceptions of reproductive health for mothers and children.

While Van Hollen is at pains to make clear that she is not simply engaging in a debate about the merit of hospital births, her interest is a related one: "demonstrating the historical and cultural specificity of the transformations in the experience of childbirth for working-class women of Tamil Nadu in the late twentieth century" (p. 15). She goes on to argue that "resistance to biomedical birth in Tamil Nadu is not counterhegemonic; it is based on a critique of the discriminatory ways in which allopathic services are (or are not) provided rather than on a critique of allopathy itself" (p. 16). In short, she argues that women's reproductive bodies have embodied formations of modernity (be these colonial, postcolonial, or development formations), but that women are ambivalent about that embodiment.

Within Van Hollen's broad canvas of what is at stake in how women choose from among different reproductive practices, a number of elements stand out as particularly praiseworthy. Her discussion of Shahida, an interstitial figure administering a particularly south Indian version of modern medicalized home births, artfully brings local ethnographic detail to bear on the macroprocesses of global biomedicine. As for the anthropology of medicine and gender, Van Hollen makes a necessary intervention into a major trope—that of sakthi—in which Tamil women have been seen to derive power through their own suffering: in a robust retort to this analysis, she uses her informants' voices to argue that rather than deriving power through suffering, they actively critique their gender-, caste-, and class-based subordination even as they are aware of their complicity in its perpetuation. Finally, those already familiar with Van Hollen's fine work on targets, pain relief, and development discourse will not be disappointed in her elaboration of those themes within the book.

However, as Van Hollen informs us, "the book does not make one, overarching point about the transformation of ideas and practices relating to childbirth in Tamil Nadu at the end of the millennium. . . . Instead . . . the book loops and swirls around several key points of reference, each of which is given equal valence" (p. 5). Because parts of the book were so thoughtful, this self-conscious distancing of herself from a larger argument left me at times wishing that she had, perhaps more ambitiously, attempted to suture together her points in a more integrated way. Nevertheless, Birth on the Threshold is a fine addition to the anthropology of childbirth, to the anthropology of development (which has for the most part puzzlingly neglected the field of health), and to ethnographies of south India.