Hindu Birth Customs but Often Also Differ Between Castes

1094 LEADING ARTICLE

Obstetrics BIRTH RITUALS AND THEIR ...... PRESENT DAY OBSERVANCE The origins and performance of Hindu rites are not only somewhat complex Hindu birth customs but often also differ between castes. Here, we attempt to present some A R Gatrad, M Ray, A Sheikh common features of these rites in order to help non-Hindu healthcare profes- ...... sionals to develop a working apprecia- Marriage, pregnancy, and birth rituals tion of these practices and their significance. Manu, the legendary author of the any expectant mothers have and Shiva (The Destroyer). In Britain, Sanskrit Code of Law10 created a num- fears and anxieties about their the majority of Hindus are Vishnuvites.5 ber of sacraments or Samskaras—a word Mpregnancy. For Hindu pregnant Many Hindus believe that a person is which means ‘‘perfection’’. These are women, these general concerns may be born into a caste or acquires it by ‘‘activities that help achieve ‘purity’ as a compounded by difficulties in commu- behaviour;6 for example, a person of a result of which the personality of the nicating with healthcare professionals. lower caste by being ‘‘pious’’ can go individual is developed to the full, from It is our aim in this paper to provide higher up the caste ladder. Although no conception to the grave’’.11 Each sacra- clinicians with a basic understanding of longer officially recognised and less ment involves a prayer and often a Hindu birth customs in the hope that visible in modern India than in the past, ritual. Although only some of these such appreciation will go some way to the caste system still has a strong hold sacraments relate to the present discus- facilitating provision of culturally com- on Hindu families, and the impact of sion of birth customs, for completeness petent and sensitive care. this on customs (including birth) also and contextualising the principle, the In their excellent paper Webb and extends to those who have migrated. first 10 of these that are relevant to the Sergison1 defined cultural competence There are broadly four main castes: paediatric age group are described as an evolving process that depends on Brahmins (highest), Ksatriya (ruling (table 1). self-reflection, self-awareness, and caste), Vaisya (farmers and merchants), and sudras (the untouchables); this acceptance of differences. They further MARRIAGE AND PREGNANCY latter group usually work as servants explain that such competence is based The Hindu Marriage Act (1955) prohib- in India.7 on improving understanding as opposed ited child marriages in India, stipulating Closely linked with the caste system is to an increase in cultural knowledge. that boys could only marry after the age the belief in reincarnation—a belief that While fully concurring with their views of 18 years and girls after 15. Previously, one’s deeds in a former life determine we would argue that knowledge of early ‘‘child marriages’’ were thought by the caste that one is born into. This cultural context can be helpful in many to be a check on immorality and philosophy of Karma8 is of fundamental providing a prototype (as opposed to a corruption. The introduction of this Act importance to Hindus, as, it is ‘‘deeds’’ stereotype) of factors which may be is believed to have contributed to a fall in this world that will decide how the important in the provision of patient in maternal and infant mortality, while soul is reborn in the future. It is believed centred care. simultaneously improving the chances that this cycle of birth, death and rebirth Hinduism—one of the oldest world of the young to further their education ultimately results in attaining a state of religions dating back to around before marriage.12 purity that allows the liberated soul to 1500BC—originates from around the Garbadhana—the fetus laying cere- 2 become ‘‘at one’’ with the Divine pre- Indus Valley in what is now Pakistan. mony is performed at the consumma- sence. Scriptures were originally written in tion of marriage and involves special Sanskrit, a language in which most prayers for fulfilling parental duties to Hindus of today are no longer literate, DEMOGRAPHIC perpetuate the human race. In ancient and therefore customs over the years CONSIDERATIONS times, the bridegroom did not approach have tended to be passed on by word of The 2001 (UK) census revealed that the bride until the fourth night, but mouth. Almost 14 centuries ago, many there are over 559 000 Hindus in today this practice is only symbolically Hindus converted to Islam and 600 Britain,9 the majority (467 000) of enacted at the marriage ceremony. years ago Sikhism was founded as an whom originate from the Indian sub- Punsavana—the ‘‘male making’’ rite is ‘‘off shoot’’ of Hinduism. It is therefore continent, with a sizable community performed during the third month of unsurprising that not only have original coming from East Africa. This East pregnancy, in the belief that the ‘‘deity’’ Hindu customs been diluted over the African Hindu group is somewhat aty- governing the sex of the fetus is years but that the practises of other pical in that it has undergone migration activated and a male ‘‘issue’’ assured. religious customs found within South twice in a relatively short timeframe— Sons are preferred because of the Asia have intertwined with remnants of first from India to East Africa and then carriage of the family name and the Hindu teachings. However we have not on to Britain. In Britain, areas such as hope that the son will light the funeral encountered any consanguineous mar- Harrow, Leicester, and Brent have sig- pyre of his parents. Manu says: ‘‘A man riages among Hindus in the UK, a nificant Hindu communities making up is perfect when he consists of three: practice common among Muslims the 14–19% of the overall population (Office himself, his wife, and his son’’.13 In fact, world over.3 for National Statistics, 2003). Although there is still a belief among many that in Hindus believe in a ‘‘transcendent’’ generally religious, allegiance to reli- the next world/birth, the happiness of a God who may be worshipped in a gious customs will vary according to the father depends on having a continuous variety of ways through different sym- extent of ‘‘acculturation’’ (whereby line of sons.14 Furthermore, birth of a bolic manifestations (for example, sta- migrants take on some of the character- girl, particularly in India, may generate tues). The three supreme Hindu deities istics of the host community), and also parental anxieties because of the heavy forming the Hindu Trinity4 are: Brahma on whether the family roots were in financial burden resulting from the (The Creator), Vishnu (The Preserver), urban or rural India. giving of dowries.

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Table 1 Hindu sacraments (Samskaras) relevant to children before breast feeding is commenced. We are aware of this practice in some Hindu Name Procedure Time when carried out families in Britain. The custom of not breast feeding the baby for the first two Grabadhana Sacrament of impregnation Before pregnancy Punsavana Second/third month of pregnancy Second/third month of pregnancy days is still rife in India, but in our Simantonnayana Fifth to eighth month of pregnancy Fifth to eighth month of pregnancy experience this is not the case in Britain. Jatakarma At birth At birth Certain foods are believed by many Namakarana Naming the baby 10–12 days after birth South Asians, including Hindus, to have Nisramana First outing of the child Third/fourth month Annaprassana Weaning of the child Sixth month either a ‘‘cooling’’ or a ‘‘heating’’ effect Chuda Karma Cutting of hair Occasionally at birth on the functions of various organs of the Usually between first and third year body, such as mood, personality, and Karnavedha Piercing of ears Third to fifth year physical wellbeing.17 Health profes- Upanayana Investiture of sacred thread From eighth year, denoting the beginning of manhood sionals would therefore do well to be aware of the concept of ‘‘hot’’ and ‘‘cold’’ foods, both during pregnancy and the puerperium. For example, when the mother is breast feeding, if a baby Simmanantannaya—also known as ‘‘former’’ confinement. It is believed by has a cold or a fever, in the former case Valaiakappu in some parts of India some that a child born in this month she may avoid ‘‘cold’’ foods and the involves the wearing of red or green could die on the eighth day, in the converse when the baby has a raised glass bangles from the seventh month of eighth month, the eighth year, or the temperature. This concept is quite gestation. The sound of these bangles is eighteenth year! Some Hindus therefore divorced from the actual temperature believed to reach the womb and comfort consider the number ‘‘eight’’ unlucky. of food or the intensity of taste of spices. the fetus. Traditionally, these are In India, when a male is born a Thali High protein, acid, and salty foods are removed after birth and given to the (a flat bronze utensil akin to a large considered ‘‘hot’’, whereas ‘‘cold foods’’ midwife. Historically it is of interest to tray) is beaten with a stick by friends are often sweet. Lentils, millet, auber- note that in this sacrament the mother and relatives. In the case of a girl, a fan, gines, and grapes are examples of ‘‘hot’’ is allowed to fulfil her last wishes, such used for winnowing, is beaten. foods, and cereals, potatoes, milk, and as any craving for certain foods, as she is Jatakarma—this ceremony welcomes white sugar are examples of ‘‘cold’’ now thought to be entering a hazardous the child into the family. The father foods. period.15 A pregnant mother is therefore touches and smells the child and whis- Karnavedha—this refers to the ear now expected to rest as much as pers religious verses (Mantras) into the piercing ceremony. Although usually possible. To this end, some women ears of the infant. All this is to promise carried out after the age of 3 years in return to their parental home, even in the baby a safe and comfortable envir- most castes, there are some families the UK, only to return to the marital onment. To ward off evil, a small ‘‘dot’’ where a father will not see the baby’s home 40 days after delivery. It may be often in the shape of ‘‘Om’’ (see fig 1) is face after birth until certain rituals have that some patients miss their antenatal drawn behind the baby’s ear using Kajal, been performed, including ear piercing. and postnatal appointments, partly as a a carbon based eye ‘‘make up’’. Even the piercing of ears may be in the result of this custom and the fact that This symbol may also be seen on a shape of Om. In India, a goldsmith clinics are often less accessible, with chain around a baby’s neck or indeed be performs this ritual for both sexes. poor language support. placed in a cot. A family member with Although girls often retain these holes, A study by Gatrad et al showed that ‘‘virtuous qualities’’ writes, with jaggery boys usually lose them in early child- there were significant differences in dipped in Ghee (a purified form of hood. birth weight between five subgroups of butter), the word ‘‘Om’’ onto the tongue The sixth day after birth is considered 16 These groups were South Asians. of the neonate in the hope that the the most auspicious in a person’s life. Muslim Pakistanis, Muslim Bang- person’s good qualities are passed on to On this day, a fragile white cotton ladeshis, Muslim Gujaratis, Sikhs, and the infant. thread is ceremoniously tied around Hindus. Although South Asian babies Symbolically, female members of the the wrist, ankle or neck—this will were generally lighter than the Euro- family wash a nursing mother’s breasts usually spontaneously fall off a few pean, Hindus had the lightest babies days later. It is on the same sixth day at birth. It should be remembered that that a pen and a blank piece of paper are many Hindu women are often strict placed in the baby’s cot, as it is believed vegetarians and therefore do not eat that on this day the goddess of learning eggs, fish, or meat which may, in charts the baby’s future. The mother addition to genetic and other environ- may observe a fast on this day. mental factors, partly explain the lower Namakarana—the name is selected in average birth weight of babies compared such a way as to inspire the child to to other South Asian subgroups. follow a righteous path. According to Hindu scriptures, a boy’s name should BIRTH have an ‘‘even’’ number of syllables and Our experiences suggest that, in com- a girl’s name an ‘‘odd’’ number. This mon with other South Asian women, custom is rarely followed in Britain, many Hindus prefer to be seen by although in Indian villages it is still female doctors during pregnancy and Figure 1 Om symbol. The most important practised. There are several ways of labour, on the grounds of modesty. Hindu symbol is Om; this has been described as naming a baby.18 One of the commonest, A premature birth in the eighth ‘‘an Aksara or the ‘Imperishable Symbol’; it is even in the west, is according to the the Universe, the past, the present and the month of pregnancy is sometimes future—all that is and all that will be is Om; Nakshatra or the sign of the Zodiac at the superstitiously attributed to a cat likewise all else that exists beyond the bounds of time of birth of the baby. It is believed having entered the mother’s room in a time—that too is Om’’.25 that certain planets govern certain days,

www.archdischild.com 1096 LEADING ARTICLE for example Mars governs Tuesday. If Chuda Karma—the hair cutting cere- particularly in rural India, a cup of the Nakshatra for the time of birth is mony (removal of scalp hair) is per- water is placed at the head of the grave unfavourable, this may be a bad omen formed at any stage depending on of a baby. Women are never present at for the family necessitating certain family tradition, although according to burials, even in Britain. rituals, which may include a special the Samskara (table 1) it is performed prayer and the father not seeing the between the first and the third year. POSTMORTEM EXAMINATIONS baby for a few days.19 It is of interest to AND ORGAN TRANSPLANTATION note that the documents, containing the DEATH OF A NEONATE OR With any family, from whatever ethnic horoscope of the baby, are admissible as group or creed, whose beliefs and needs 20 INFANT legal papers of ‘‘proof of age’’ in India. At death, the baby is believed to leave at a time of crisis cannot be assumed or Furthermore, the horoscope will be the ‘‘earthly’’ realm into an ‘‘intermedi- inferred, this subject should be especially important for arranging a broached with sensitivity; this is parti- 21 ate’’ zone in readiness for its journey to suitable marriage later. the ‘‘Divine realm’’. Although Hindus cularly so in Hindus whose belief in From the Nakshatra the first letter of often prefer to die lying on the ground Karma may result in possible anxieties the name is ascertained. For example, if (Mother Earth), this custom is rarely about whether or not all organs will be it is a ‘‘G’’ then the name could be practised for babies dying in Britain. returned to the body after a postmortem Gyatri for a girl. The paternal aunt often Quality of palliative care, if indeed such examination. Generally there is no specific prohibition to postmortem plays an important part in the choice. care was necessary, has an impact on examinations or organ transplants in Children may have a middle name such death and bereavement.22 Hindus who Hindu teachings.24 as ‘‘Devi’’ for a girl or ‘‘Lal’’ for a boy; for have perceived what they witness as a example, Gyatri Devi and Babu Lal. bad death, may be very anxious about There are certain prohibited times for the ghost of the deceased.23 DISCUSSION naming the baby; for example, at the As a baby approaches death, the Although we appreciate that one cannot time of an eclipse or when the signs of family will chant ‘‘Ram Ram’’ or ‘‘Om’’ be expected to have detailed knowledge the Zodiac are changing. Hindu names and recite from the Bhagavad Gita—the of every aspect of the multicultural have meanings; for example, Ravi for a holy book for Hindus. A thread with a tapestry of present British society, there boy means sun and Madhu for a girl religious significance may be tied is a significant Hindu community in means honey. Some boys are named around the wrist or neck of the baby. Britain today and therefore some under- after gods; for example, the names Stillborns need the same religious standing of cultural norms and values is Krishna or Ram. Some girls may be ‘‘service’’ as adults. A leaf from a Tulsi important. Such knowledge, we believe, named Chandra in the belief that the shrub (basil leaf) is placed in the is important for health professional to moon (Chand) will bring them luck and baby’s mouth, occasionally with a gold respond to individuals by reflecting on good fortune. Table 2 lists some com- coin. After a ritual wash, new clothes their own culture, and recognising and mon male and female Hindu names. are put on the baby who is subse- respecting the difference. Learning to The naming ceremony takes place on quently wrapped in a white shroud. pronounce names and a few words, especially a greeting with a smile, is the tenth or twelfth day after birth, a The body of a baby may be taken from what the patient appreciates. We should time when the mother is considered the hospital straight to the cemetery. in addition develop a broad understand- ‘‘clean’’ in order to carry out normal However if the corpse is taken home, ing of the contexts and needs of Hindu household chores, such as cooking. This candles are lit and holy water from communities such as language difficul- custom is still practised by some Hindu the River Ganges sprinkled onto the ties, modesty, and gender issues. The families in the West. The nursing body. use of trained interpreters/advocates mother is now allowed male visitors. Babies and young pre-pubertal chil- would further provide the necessary Annaprassana—this ceremony takes dren dying before the Upanayama stage support for a truly culturally competent place after six months when weaning are buried, whereas adults are cremated. care. Achieving effective communica- is believed to be necessary for the baby Upanayama is the tenth sacrament and is tion and striving towards improved to become more mobile. A delay in a stage in a child’s life when he/she access for such communities will go a weaning that one occasionally encoun- begins adulthood after the age of 8 long way to breaking down barriers by ters in Britain may be as a result of this years. It is a stage ritualised by wearing responding flexibly to all patients, belief. Although we have no evidence a religious thread called Janeo. Children whatever their need. Health profes- that Hindu babies in general are weaned who die before this stage do not need sionals should be confident enough to at around four months in Britain, it is purification by fire as they are classed as ask their patients: ‘‘Are we doing this our experience that this is so. being ‘‘without sin’’. As a general rule, the right way for you?’’ or ‘‘How would you like us to do this?’’. Professionals Table 2 Examples of common Hindu names should be prepared to learn from families they are supporting as well as Male Female provide advice and information. This is a Name Meaning Name Meaning true partnership and one path to cultu- rally competent practice.25 Abhijit A constellation of stars Anjali Offering Akaash Sky Anuradha Bright star Anand Bliss Priya Loved one CONCLUSIONS Rajiv Lotus flower Priti Satisfaction The process of acculturation continues; Rohit Red colour Puja Prayer for example, some Hindu children have Ravi Sun Madhu Honey Sameer Breeze Madhur Sweet western names. It does not always Deepak Lamp Meena Precious stone follow that because a patient is classed Mohan Charming Lakshmi Consort of Vishnu as belonging to a certain religion that he Harsh Joy Jaya Victory or she follows that faith. Some people may wish to maintain practices that are important to them while others may

www.archdischild.com LEADING ARTICLE 1097 only nominally express allegiance and Correspondence to: Dr A R Gatrad, Manor 13 Singh C, Nath P. Hindu manners, customs and are not concerned with orthodox prac- Hospital, Moat Road, Walsall WS2 9PS, UK; ceremonies. Delhi: Crest Publishing House, [email protected] 1999:13. tice—this being especially true for those 14 Flood G. An introduction to Hinduism. living in the West. Furthermore, reli- Cambridge: Cambridge University Press, 1996:203. gions are divided into different sects, REFERENCES 15 Chaudhery NC. Religious control of Hindu life. resulting in individual adherents having 1 Webb E, Sergison M. Evaluation of cultural London: Trinity Press, 1979:210–11. their own particular view and interpre- competences and anti-racism training in child 16 Gatrad A, Birch N, Hughes M. Preschool weights tation of their faith and culture. Indeed, health. Arch Dis Child 2003;88:291–4. and heights of Europeans and five subgroups of 2 Flood G. An introduction to Hinduism. Asians in Britain. Arch Dis Child different generations within the same Cambridge: Cambridge University Press, 1994;71:207–10. family may have differing views. 1996:21. 17 Henley A. Asian patients in hospital and at home. Nonetheless, there are particular cus- 3 Dhami S, Sheikh A. The family: predicament and London: Pitman, 1979:129. 18 Stutley M, Stutley J. A dictionary of Hinduism. Its toms and rites, which tend to bind promise. In: Sheikh A, Gatrad AR, eds. Caring for Muslim patients. Radcliffe, 2000:49. mythology, folklore and development. London: Routledge, 1977:202. members of a religious community, 4 Sharma A. Classical Hindu thought. Oxford: 19 Singh C, Nath P. Hindu manners, customs and and our experiences suggest that birth Oxford University Press, 2000:72. ceremonies. Delhi: Crest Publishing House, 5 Neuberger J. Caring for dying people of different customs continue to be important to 1999:128. faiths, 2nd edn. London: Moseby, 1994:24–9. 20 Singh C, Nath P. Hindu manners, customs and many Hindu communities, including 6 Lipner J. Voice of tradition caste and narrative. In: those in Britain. ceremonies. Delhi: Crest Publishing House, Hindu: the religious belief and practice. London: 1999:142. Routledge, 1994:108. 21 Shattuck C. Hinduism. Religions of the world. Arch Dis Child 2004;89:1094–1097. 7 Joicey J. A handbook of Hinduism. Newcastle doi: 10.1136/adc.2004.050591 London: Routledge, 1999:81. upon Tyne Education Committee, 1980:41. 22 Koffman J, Higginson IJ. Accounts of carer’s 8 Lipner J. Morality and the person. In: Hindu: the satisfaction with health care at the end of life: a ...... religious belief and practice. London: Routledge, comparison of first generation black Caribbean Authors’ affiliations 1994:233. and white patients with advanced disease. Palliat 9 Office of National Statistics. Census 2001. A R Gatrad, Manor Hospital, Walsall, UK; Med 2001;15:337–45. 10 Pandey R. Hindu Samskaras. Delhi: MLBD, 23 Firth S. Religious perspectives on end of life care: Hon Professor Paediatrics University of 1969:17–24. a Hindu patients spiritual and cultural values Kentucky, USA 11 Singh C, Nath P. Hindu manners, customs and during the end of life period. Lancet. In press. M Ray, Manor Hospital, Walsall, UK ceremonies. Delhi: Crest Publishing House, 24 Schott J, Henley A. Culture, religion and A Sheikh, Division of Community Health 1999:8. childbearing in a multicultural society, Sciences: GP Section, University of Edinburgh, 12 Singh C, Nath P. Hindu manners, customs and Butterworth-Heinemann, 1996:311. ceremonies. Delhi: Crest Publishing House, 25 Rathakrishnan S. The Bhagavad Gita. Delhi: Edinburgh, UK 1999:31. Harper Collins, 2000.

ARCHIVIST...... Teenage pregnancy he rate of teenage pregnancy is higher in Britain than in other European countries. Professional attitudes towards teenage pregnancy tend to be polarised with some Tconsidering it undesirable because of increased risks to mother and child while others have argued that teenagers may be well suited for pregnancy and that much harm comes from the stigmatisation of teenage parents. A study in Sweden (Petra Olausson and colleagues. British Journal of Obstetrics and Gynaecology 2004;111:793–9, see also commentary, ibid: 763–4) has shown that teenage mothers there are more likely to die young. The study included 460 343 women born between 1950 and 1964 and alive in December 1990. All had had a first child before the age of 30. Between 1990 and 1995, 1269 of these women died at ages 30–45 years. Mortality decreased with age at birth of first child from 107 deaths per 100 000 person-years among women whose first child was born when they were 17 years or younger to 87 per 100 000 person-years (first birth at 18–19 years), 54 (20–24 years), and 42 (25–29 years). Overall, early adult mortality in teenage mothers was increased by 60% after adjustment for socioeconomic background at the time of the first birth and age in 1990. The main causes of premature death were violence, cervical cancer, coronary disease, lung cancer, suicide, and alcohol. Adjustment for socioeconomic factors operating after the birth of the first child reduced, but did not eliminate, the increase in risk. Teenage mothers in Sweden have an increased risk of premature death in later life. Much of the increased risk is associated with adverse socioeconomic and lifestyle factors. The writer of the commentary argues in favour of helping teenagers to avoid pregnancy but also of providing adequate support for pregnant teenagers during and after their pregnancies.

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