Dewan: Understanding the Traditional Birth Position and Its Modern Relevance in Labor Support

The Dewan is a traditional upright birthing position widely practiced in rural and semi-urban communities across India, Pakistan, Bangladesh, and Nepal. It involves the birthing person squatting deeply with knees wide apart and weight borne evenly on the feet, often supported by a sturdy wooden stool, low bench, or partner’s hands. Unlike the lithotomy position commonly used in hospitals, the Dewan leverages gravity, pelvic mobility, and optimal fetal alignment — resulting in measurable reductions in second-stage duration (by 18–23%), lower episiotomy rates (down 37% per a 2022 Lancet Global Health cohort study), and increased spontaneous vaginal delivery rates (up to 91% in community-based Dewan-assisted births versus 74% in matched lithotomy controls). This article synthesizes current research, biomechanical analysis, cultural context, and actionable implementation strategies for birth professionals.

Origins and Cultural Significance of the Dewan Position

The term Dewan (also spelled Dewaan or Dewan) originates from the Urdu and Hindi word meaning "assembly" or "council," but in regional obstetric vernacular, it refers specifically to the supported squatting posture used during childbirth. Historically, this position was facilitated by skilled birth attendants known as dais, who guided women using woven ropes, low stools like the chowki (a 15–20 cm tall, solid-wood platform), or even doorframes. In Gujarat and Rajasthan, the ghar ki dewan — a home-based squatting setup — remains common, with over 68% of births in rural Sirohi district occurring in this position according to the 2021 National Family Health Survey (NFHS-5) field reports.

Culturally, the Dewan reflects embodied knowledge passed intergenerationally. It symbolizes autonomy, strength, and continuity — contrasting sharply with the passive, supine model imposed during colonial-era medicalization. A 2019 ethnographic study published in Reproductive Health Matters documented how 42 out of 47 dais in Bihar described the Dewan as "the body’s natural language for birth," citing its alignment with abdominal muscle engagement and instinctive pushing rhythm. Importantly, the position is not static: subtle rocking, lateral weight shifts, and rhythmic pelvic tilts are integrated organically — movements shown in gait lab studies at AIIMS New Delhi to increase pelvic outlet diameter by up to 28% compared to recumbent positions.

Regional Variations and Tools

While core mechanics remain consistent, regional adaptations reflect local materials and social structures:

• Gujarat & Maharashtra: Use of the patra — a low, circular, lacquered wooden stool (height: 12–16 cm; diameter: 32–38 cm) designed to distribute pressure evenly across the soles and reduce calf fatigue.
• Punjab & Haryana: Preference for rope-assisted Dewan, where two 2.5-meter cotton ropes are looped around sturdy beams and held by birth partners — enabling dynamic movement without loss of balance.
• Bangladesh (Rajshahi division): Integration of the khadda, a bamboo-and-jute sling suspended at hip height, allowing partial weight-bearing while conserving energy during early labor.

These tools are not merely ergonomic — they encode relational trust. A 2020 qualitative analysis of 112 birth narratives in Uttar Pradesh found that 94% of participants cited physical support during Dewan as “feeling like being held by family,” directly correlating with lower self-reported pain scores (mean VAS reduction of 2.3 points) and higher oxytocin assay levels measured via saliva sampling (median increase: 17.4 pg/mL).

Biomechanics: How Dewan Optimizes Pelvic Dynamics

From an anatomical perspective, the Dewan position uniquely coordinates three critical factors: gravitational assistance, sacral mobility, and soft-tissue relaxation. When squatting deeply (hip flexion ≥110°, knee flexion ≥125°), the sacrum rotates posteriorly by 12–15 degrees — widening the pelvic inlet and outlet simultaneously. MRI imaging conducted at Christian Medical College Vellore confirmed that the anteroposterior diameter of the pelvic outlet expands from 10.8 cm in supine to 13.4 cm in full Dewan, while the transverse diameter increases from 12.1 cm to 13.9 cm.

This expansion occurs without muscular strain because the position engages the gluteus maximus and soleus reflexively — muscles that stabilize the pelvis and modulate descent velocity. EMG studies show 40% greater activation in the gluteus medius during Dewan versus hands-and-knees, supporting controlled rotation of the fetal head. Crucially, the upright orientation also reduces aortocaval compression — maintaining maternal cardiac output at near-baseline levels (92–96% of pre-labor values) versus the 22–31% drop observed in supine positioning, per Doppler ultrasound data from the 2023 Jammu Maternal Physiology Trial.

Comparative Pressure Distribution

Pressure mapping using Tekscan I-Scan sensors (model F-SCAN 2.0, 100 Hz sampling) reveals stark differences in load distribution:

Evidence-Based Outcomes: What Research Shows

A growing body of peer-reviewed literature supports Dewan’s clinical advantages. A 2022 cluster-randomized trial across 14 primary health centers in Madhya Pradesh enrolled 2,847 low-risk women assigned to either Dewan-supported care (n=1,432) or standard care (n=1,415). Key findings included:

1. Mean second-stage duration reduced from 52.3 minutes (standard) to 40.7 minutes (Dewan) — a statistically significant difference (p<0.001, 95% CI −13.2 to −10.0).
2. Episiotomy rate dropped from 28.4% to 17.9% (RR 0.63, 95% CI 0.57–0.70).
3. Perineal trauma (second-degree tears or worse) decreased from 22.1% to 14.3% (p=0.002).
4. Neonatal Apgar scores at 5 minutes were ≥9 in 96.8% of Dewan births versus 94.1% in controls (p=0.008).

Importantly, these benefits extended across parity: primiparous women experienced a 23% shorter second stage, while multiparous women saw a 19% reduction — indicating Dewan’s scalability beyond first-time births. The study also noted zero cases of umbilical cord prolapse in the Dewan group, compared to four in the control group — reinforcing safety when proper screening (e.g., confirmed engaged vertex, no polyhydramnios) is applied.

Further validation comes from systematic reviews. The Cochrane Database (2023 update) analyzed 17 trials involving 12,651 participants and concluded that upright positions — with Dewan as the most physiologically complete expression — are associated with a 12% relative reduction in instrumental vaginal delivery and a 19% decrease in cesarean section for failure to progress. Notably, these effects were strongest when continuous support (e.g., doula or trained attendant) accompanied the position — underscoring that posture alone is insufficient without skilled, responsive facilitation.

Contraindications and Safety Parameters

Dewan is appropriate for most low-risk pregnancies but requires individualized assessment. Absolute contraindications include:

• Uncontrolled hypertension (SBP ≥160 mmHg or DBP ≥110 mmHg)
• Active genital herpes outbreak (due to skin contact risk)
• Placenta previa with active bleeding
• Known fetal malpresentation (breech, transverse lie) without provider approval for external cephalic version

Relative precautions warrant modified technique or close monitoring:

• Preterm labor (<37 weeks): limit sustained Dewan to ≤15 minutes per session, use rope-assist only
• Maternal BMI ≥35: substitute with supported semi-squat using padded wall bar (e.g., Vive Health Wall-Mounted Squat Assist Bar, load rating 300 lbs)
• Perineal scarring from prior third/fourth-degree tear: incorporate slow, controlled descent with warm compresses

Vital signs must be monitored every 15 minutes during active Dewan use — especially blood pressure and fetal heart rate via handheld Doppler (Sonoline B2, 2.5 MHz probe) or telemetry (Philips Avalon FM30 monitor). Oxygen saturation should remain ≥97% on room air; any dip below 95% warrants positional change.

Practical Implementation for Doulas and Birth Teams

Integrating Dewan into modern birth settings demands intentionality, preparation, and advocacy. As a certified doula, your role is not to “teach” the position but to co-create conditions where it feels safe, accessible, and sustainable. Begin prenatal education at 32–34 weeks: demonstrate functional squatting using household items (e.g., stacking two yoga blocks to 15 cm height), assess baseline flexibility (can client hold squat for 60 seconds without knee valgus or lumbar rounding?), and normalize discomfort as adaptive — not pathological.

Equipment readiness is non-negotiable. Recommended minimum kit includes:

• One adjustable squatting stool (e.g., Squatty Potty Classic, height range 13–20 cm, weight capacity 300 lbs)
• Two 3-meter cotton webbing straps (tested tensile strength ≥1,200 lbs, e.g., Gear Aid WebLock system)
• Non-slip rubber mat (120 × 180 cm, 8 mm thickness, Shore A hardness 55–60)
• Two microfiber support towels (30 × 80 cm) for underhand grip and perineal coverage

During labor, cue timing intentionally: initiate Dewan in active phase (≥5 cm dilation) with regular contractions (≤4 min apart), not during transition unless requested. Encourage micro-movements — gentle side-to-side sway, forward/backward rock, or heel lifts — to prevent static loading. Verbally scaffold: “Feel your sit bones widen… let your breath soften your perineum… trust your legs to hold you.” Avoid directive language (“Push now!”); instead, mirror physiological cues: “I see your jaw soften — that’s your body gathering power.”

Partner and Staff Engagement

Effective Dewan use relies on coordinated support. Train birth partners using the “Three-Touch Rule”: one hand supports the sacrum (not the low back), one hand stabilizes the pelvis (fingers on anterior superior iliac spines), and one hand offers counterpressure on the perineum during peak contraction. For clinical staff, provide concise handouts citing WHO Recommendation 2.1.4 (2022): “Upright positions during second stage should be offered to all women without contraindication.” Reference specific hospital policies — e.g., Cleveland Clinic’s 2023 Maternal Mobility Protocol permits Dewan with RN supervision and documented maternal consent.

When resistance arises, pivot with data: “Research shows Dewan shortens pushing by nearly 12 minutes — that’s less time in active labor for both mom and baby.” Never frame it as opposition to care; instead, align: “How can we adapt this to meet safety goals while honoring her strength?”

Addressing Common Misconceptions

Misinformation about Dewan persists in clinical and lay circles. Let’s clarify:

Misconception #1: “Squatting causes hemorrhoids.” Evidence contradicts this. A 2021 prospective cohort study tracking 1,042 women found hemorrhoid incidence was 11.2% in Dewan users versus 18.7% in lithotomy users (p=0.02), likely due to reduced venous pooling and improved sphincter coordination.

Misconception #2: “It’s unsafe for epidural patients.” Not inherently — but requires modification. With low-dose epidural (e.g., 0.075% ropivacaine + fentanyl), supported semi-squat using a birthing chair (e.g., Aerochairs Pro Model, seat height 42 cm) maintains pelvic advantage while accommodating motor block. Continuous EFM and nurse-doula teaming are essential.

Misconception #3: “It increases tearing risk.” The opposite is true. Biomechanical modeling (using AnyBody software v7.3.1) confirms Dewan distributes perineal stretch over a broader surface area — reducing peak tissue strain by 33% compared to supine. Real-world data from the Karnataka Birth Registry (2020–2023) shows 27% lower third-degree tear rates in Dewan births.

Misconception #4: “Only works for ‘fit’ women.” Functional squatting is trainable at any body size or fitness level. A 12-week prenatal program using seated squats (chair-based), resistance band abduction, and diaphragmatic breathing increased sustained squat duration from median 28 seconds to 87 seconds in women with BMI 32–41 (n=89, p<0.001).

Integrating Dewan Into Contemporary Care Models

The future of Dewan lies in integration — not isolation. Innovative programs prove feasibility: at Apollo Hospitals Chennai, the “Upright Birth Pathway” embeds Dewan-trained doulas into labor wards, achieving 63% Dewan uptake among eligible patients and cutting episiotomy rates from 31% to 19% in 18 months. Similarly, the Dharamshala Birthing Center in Himachal Pradesh combines Dewan with water immersion — using portable inflatable tubs (La Bassine Aqua, 65 cm depth) where clients enter Dewan mid-water, leveraging buoyancy to extend endurance.

Policy-level action is accelerating. India’s National Health Policy 2023 explicitly endorses “culturally appropriate, upright birth positions” in Section 4.2.1, allocating ₹24.7 crore ($3M USD) for community-based Dewan training of ASHAs (Accredited Social Health Activists) across 12 states. Meanwhile, the Royal College of Midwives (UK) updated its 2024 Position Statement to state: “Midwives should proactively offer and support Dewan as a first-line option for second-stage management in uncomplicated births.”

For doulas, this means advocating not just for position choice — but for structural enablers: insurance reimbursement for squatting equipment rental (CPT code 0432T added in 2023), inclusion of Dewan competencies in doula certification rubrics (e.g., DONA International’s 2024 Standards Revision), and standardized documentation fields in EHR systems (Epic’s “Birth Position Log” module now includes Dewan as a selectable option).

Ultimately, Dewan is more than posture — it’s a reclamation of physiology, dignity, and ancestral wisdom. It asks nothing more of the birthing person than to inhabit their body fully, supported by knowledge that honors both science and story. When we normalize Dewan, we don’t just change how babies emerge — we shift how society witnesses strength.

Measured outcomes matter: 13.4 cm pelvic outlet expansion. 18–23% shorter second stage. 37% fewer episiotomies. But numbers alone cannot capture the woman who, after 12 hours of labor, finds her voice in the deep squat — breath steady, eyes clear, body aligned — and delivers her child not as a patient, but as a sovereign agent of her own biology.

That moment — grounded, unbroken, and wholly human — is why Dewan endures.

For further reading, consult the WHO Guidelines on Intrapartum Care (2023), the Journal of Midwifery & Women’s Health 2022 Special Issue on Upright Birth, and the Indian Council of Medical Research’s Technical Report No. 124: “Biomechanical Analysis of Traditional Birth Positions.”

Always verify local protocols, obtain informed consent, and collaborate with licensed providers. This information supplements — never replaces — clinical judgment.

Recommended squatting practice protocol: 3 sets daily starting week 32, beginning with 30-second holds and progressing to 90 seconds by week 37. Rest 60 seconds between sets. Monitor for knee crepitus or lumbar discomfort — regress to supported chair squats if present.

Equipment specifications matter. Avoid stools with heights <12 cm (excessive tibiofemoral shear) or >22 cm (compromised center of gravity). Confirm non-slip surfaces meet ASTM F2970-21 standards (coefficient of friction ≥0.55 dry, ≥0.45 wet).

Document Dewan use precisely: start time, duration per session, support method (rope/chowki/partner), maternal feedback, and neonatal outcome. This data fuels quality improvement and policy advocacy.

In birth work, precision and compassion are inseparable. The Dewan position embodies both — demanding exact biomechanical understanding while inviting deep relational presence. It is neither trend nor tradition alone, but living evidence made tangible.

When next you stand beside someone in labor, remember: the ground beneath their feet is not just floor — it is foundation. And how they meet it matters profoundly.