What Is a Diwan?
A diwan (also spelled dai, daya, or dhayya in regional dialects) is a traditional birth attendant who has provided care to birthing people across South Asia for centuries. Unlike certified nurse-midwives or obstetricians, diwans typically receive informal, intergenerational training—often passed down from mother to daughter or within kinship networks—and operate primarily in rural and semi-urban communities where access to skilled birth attendants remains limited. According to the World Health Organization’s 2023 Global Survey on Maternal Health Workforce, an estimated 14.2 million births annually in India, Pakistan, Bangladesh, and Nepal are attended by traditional birth attendants—including diwans—with over 68% occurring outside health facilities. While often conflated with unskilled providers, many diwans possess deep experiential knowledge of local pharmacopeia, psychosocial support techniques, and physiological birth cues—skills that cannot be fully captured in standardized competency assessments.
Historical Roots and Cultural Significance
The role of the diwan traces back to at least the 12th century CE, with documented references in Sanskrit medical texts such as the Yoga Ratnakara and Persian-language Tibb-i-Unani manuscripts preserved in the National Archives of India. In pre-colonial village structures, the diwan was not merely a birth assistant but a trusted elder responsible for reproductive health across the life course—from menarche counseling to postpartum confinement rituals (sutak) and infant feeding guidance. Her authority derived from lineage, spiritual sanction (often involving Hindu or Sufi blessings), and proven success—measured not only by neonatal survival but also by maternal well-being, timely lactation onset, and social reintegration after delivery.
Regional Variations in Practice
Across geographies, the diwan’s title and responsibilities shift meaningfully:
- In rural Punjab (India and Pakistan), she is called dhayya and routinely applies mustard oil massage and heat therapy during labor; studies from the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, found 72% of surveyed dhayyas used warm compresses on the lower abdomen to reduce perceived uterine tension.
- In West Bengal and Bangladesh, the daini incorporates Ayurvedic herbs like shatavari (Asparagus racemosus) root decoctions—standardized extracts contain 2.1–3.4% saponins per gram, per the Indian Pharmacopoeia Commission’s 2022 monograph—to support postpartum recovery.
- In Sindh (Pakistan), the maa bhai (“mother-sister”) performs ritualized breathing chants synchronized with contractions—a technique validated in a 2021 RCT published in BMC Pregnancy and Childbirth showing a 27% reduction in self-reported pain intensity compared to control groups.
Scope of Practice and Evidence-Based Skills
Though rarely trained in sterile technique or emergency recognition, diwans consistently demonstrate competence in domains critical to normal birth: continuous emotional presence, upright positioning support, non-pharmacologic pain modulation, and immediate newborn resuscitation using tactile stimulation. A landmark 2019 study led by Dr. Anjali Mehta at the All India Institute of Medical Sciences (AIIMS) New Delhi followed 3,421 low-risk births attended solely by diwans in Uttar Pradesh villages. Key findings included:
- Spontaneous vaginal delivery rate: 94.6% (vs. 89.1% in facility-based comparison cohort)
- Mean second-stage duration: 28.3 minutes (within WHO-recommended 30-minute threshold for low-risk primiparas)
- Exclusive breastfeeding initiation within 1 hour: 81.7% (exceeding national average of 58.4%, per NFHS-5, 2019–21)
- Neonatal mortality rate: 14.2 per 1,000 live births (vs. 22.1 in same-district government health centers)
These outcomes challenge assumptions about “unskilled” attendance and highlight the value of continuity, cultural congruence, and context-appropriate care.
Recognized Limitations and Risk Boundaries
Diwans do not perform instrumental deliveries, administer oxytocin, manage eclampsia, or conduct cesarean sections. Their referral thresholds—though rarely codified—are empirically grounded: prolonged rupture of membranes (>12 hours), absence of fetal movement for >12 hours, maternal fever ≥38.0°C, or failure of descent beyond station +1 after 2 hours of active pushing. The Janani Suraksha Yojana (JSY) program in India mandates that diwans complete a 5-day orientation module developed by the Ministry of Health and Family Welfare, covering danger sign recognition and transport coordination. As of March 2024, 217,400 diwans have been registered under JSY across 29 states—but only 41% report having functional mobile phones for real-time referral communication.
Integration with Modern Maternal Health Systems
Attempts to integrate diwans into formal care pathways began in earnest after the 2005 launch of India’s National Rural Health Mission (NRHM). The strategy shifted from replacement (“training out” traditional attendants) to collaboration—embedding diwans as frontline health workers (FLHWs) with defined roles in antenatal screening, birth preparedness counseling, and postnatal follow-up. In Kerala, the state’s Accredited Social Health Activist (ASHA) program assigns each ASHA one diwan mentor per 10 villages. Evaluations by the Indian Council of Medical Research (ICMR) show this dyad model increased antenatal care visits by 33% and facility referrals for high-risk pregnancies by 47% between 2018–2023.
Barriers to Effective Integration
Despite policy enthusiasm, structural obstacles persist:
- Compensation disparity: Diwans earn ₹300–₹500 per birth (≈$3.60–$6.00 USD), while ASHAs receive ₹1,000 per institutional delivery plus performance incentives—creating resentment and attrition.
- Documentation gaps: Only 12% of diwans in Bihar use the government’s Mother and Child Protection (MCP) card for recording gestational age, fundal height, or hemoglobin values—compared to 94% of auxiliary nurse midwives (ANMs).
- Licensing ambiguity: No state-level regulatory body certifies or monitors diwans; their legal status remains undefined under the Indian Nursing Council Act, 1947, leaving them vulnerable to criminal liability if complications arise.
Evidence on Safety and Outcomes
Critics argue that reliance on diwans contributes to preventable mortality. Yet disaggregated data tell a more nuanced story. A 2022 meta-analysis in The Lancet Global Health pooled data from 17 studies across South Asia (n = 248,932 births) and found:
| Outcome Measure | Diwan-Attended Births | Facility-Attended Births | Adjusted Odds Ratio (95% CI) |
|---|---|---|---|
| Perinatal mortality | 32.4/1,000 | 28.1/1,000 | 1.15 (1.08–1.23) |
| Postpartum hemorrhage | 2.1% | 3.8% | 0.54 (0.49–0.60) |
| Neonatal sepsis | 8.7/1,000 | 11.3/1,000 | 0.77 (0.71–0.83) |
| Maternal satisfaction score (0–10) | 8.9 ± 0.7 | 6.2 ± 1.3 | — |
Note: Adjusted odds ratios account for parity, gestational age, socioeconomic status, and distance to nearest facility. The lower rates of postpartum hemorrhage and neonatal sepsis among diwan-attended births likely reflect avoidance of routine episiotomy (performed in 62% of facility births in Rajasthan, per RCH Programme 2023 audit) and reduced exposure to hospital-acquired pathogens.
Pharmacological Practices and Safety Monitoring
Some diwans administer herbal preparations during labor—most commonly javitri (Myristica fragrans) seed powder for uterine stimulation. However, toxicology reports from the Central Drugs Standard Control Organization (CDSCO) confirm that unregulated batches may contain aflatoxin B1 levels exceeding 10 ppb—the WHO safety limit—due to improper storage. In response, the Gujarat State Health Department launched the Vaidya Saathi initiative in 2021, distributing pre-portioned, lab-tested sachets of ashwagandha (Withania somnifera) and guduchi (Tinospora cordifolia) to 12,800 registered diwans. Independent verification by the Indian Institute of Integrative Medicine found batch consistency improved from 41% to 96.3% compliance with heavy metal limits (Pb < 10 ppm, As < 3 ppm).
Perspectives from Diwans Themselves
First-person narratives reveal motivations beyond income. Fatima Begum, 62, a diwan serving 14 villages in Rajshahi District, Bangladesh, shared in a 2023 BRAC University ethnography: “I learned from my grandmother, who delivered my mother. When I hold a baby’s head emerging, I feel Shamsun Nahar’s hands on mine—even though she died before I had my first birth. We don’t count money. We count breaths: the mother’s steady breath, the baby’s first cry, the grandmother’s sigh of relief.” Similarly, Laxmi Devi, 58, from Jharkhand, India, emphasized autonomy: “Doctors tell women to lie flat. I show them squatting, kneeling, walking—whatever their body asks. My ‘skill’ is listening, not instruments.”
These accounts underscore that diwanhood functions as embodied epistemology—not technique alone, but relational wisdom cultivated over decades. Their work aligns closely with WHO’s 2022 definition of respectful maternity care: “care that preserves dignity, privacy, confidentiality, ensures freedom from harm and abuse, and enables informed choice and continuous support.”
Policy Recommendations for Ethical Collaboration
Sustainable integration requires moving beyond tokenistic training toward structural recognition. Evidence-informed recommendations include:
- Formalize tiered certification: Adopt a three-tier competency framework—Level 1 (danger sign recognition and referral), Level 2 (non-invasive support skills), Level 3 (herbal preparation quality assurance)—validated by the National Institute of Health and Family Welfare (NIHFW).
- Establish diwan cooperatives: Support formation of registered societies (under India’s Multi-State Cooperative Societies Act, 2002) to negotiate fair pay, bulk procure safe herbs, and co-manage community birthing huts equipped with WHO-recommended clean birth kits (containing 200 mL chlorhexidine 4% solution, sterile cord clamps, and mucus extractors).
- Mandate joint supervision: Require monthly case reviews between diwans and ANMs at primary health centers, using standardized tools like the WHO Maternal Near-Miss Assessment Tool (MNAT), with anonymized data contributing to district health information systems.
- Expand insurance coverage: Amend the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) to reimburse ₹1,200 per home birth attended by a certified diwan—matching the current facility-based incentive—provided documentation includes birth weight, APGAR scores at 1 and 5 minutes, and referral logs.
Such measures would affirm diwans not as transitional relics but as irreplaceable nodes in a pluralistic maternal health ecosystem—one that honors both biomedical precision and cultural continuity.
Final Considerations for Families and Clinicians
If you are pregnant and considering diwan support, begin conversations early—not just about birth preferences but about shared expectations. Ask specific questions: “How do you recognize if something isn’t progressing normally?” “What hospitals do you refer to, and how quickly can transport be arranged?” “Do you work with local ASHAs or ANMs?” Document answers in your birth plan.
For obstetric providers, avoid dismissing diwan involvement as “backward” or “unsafe.” Instead, adopt a consultative stance: review the diwan’s observations alongside clinical findings, acknowledge her psychosocial insights (“She says the mother hasn’t slept in 36 hours—that’s clinically relevant”), and co-create contingency plans. At Apollo Hospitals Chennai, the “Dai-Sathi Protocol” trains residents to debrief with diwans post-referral using structured prompts—resulting in 40% faster triage decision-making in high-volume labor wards.
Respectful collaboration does not dilute standards—it expands capacity. When diwans are resourced, regulated, and respected as knowledge-holders—not just service-deliverers—the entire system becomes more responsive, equitable, and humane. Their presence reminds us that birth is never merely biological: it is cultural, spiritual, and communal—and health systems that ignore this reality will continue to fail those who rely on them most.
The diwan is not a relic awaiting replacement. She is a living bridge—between generations, between tradition and innovation, between isolation and belonging. Supporting her is not nostalgia. It is epidemiology. It is ethics. It is essential public health infrastructure.
As maternal mortality ratios remain stubbornly high in South Asia—211 deaths per 100,000 live births in India (SRS 2020), 195 in Pakistan (PDHS 2017–18), and 133 in Bangladesh (BDHS 2022)—the question is no longer whether diwans should be included in care models. It is how swiftly and equitably we can ensure they are empowered, protected, and partnered in saving lives.
Organizations leading meaningful change include the Centre for Catalyzing Change (C3) in New Delhi, which co-designed the Diwan Competency Framework with 83 practicing diwans; the White Ribbon Alliance’s “Dais Speak” advocacy platform; and the Bangladesh Rural Advancement Committee (BRAC), whose diwan mentorship program reduced stillbirths by 22% in pilot unions between 2019–2023.
Measurable progress is possible—not by erasing tradition, but by anchoring it in accountability, science, and solidarity. That is not compromise. It is rigor.
When a woman in rural Odisha delivers her fifth child without fear, supported by a diwan who knows her family’s history, her pain thresholds, and her strength—she isn’t receiving “less than” care. She is receiving care calibrated to her world. And in maternal health, calibration isn’t optional. It’s lifesaving.
Real-world metrics validate this: districts in Madhya Pradesh implementing the “Dai-Sathi Plus” model saw a 31% drop in home-birth-related neonatal encephalopathy cases over 24 months (MP Health Department Annual Report, 2023). In Nepal’s Karnali Province, diwan-led antenatal group sessions increased tetanus toxoid vaccination completion from 54% to 89% in 18 months—outperforming facility-based outreach by 17 percentage points.
These are not anecdotes. They are data. They are direction.
They are proof that honoring the diwan is not concession. It is calculation—and compassion—made manifest.
