Many expectant mothers have fears and anxieties about their pregnancy. For Hindu pregnant women, these general concerns may be compounded by difficulties in communicating with healthcare professionals. It is our aim in this paper to provide clinicians with a basic understanding of Hindu birth customs in the hope that such appreciation will go some way to facilitating provision of culturally competent and sensitive care.

In their excellent paper Webb and Sergison¹ defined cultural competence as an evolving process that depends on self-reflection, self-awareness, and acceptance of differences. They further explain that such competence is based on improving understanding as opposed to an increase in cultural knowledge. While fully concurring with their views we would argue that knowledge of cultural context can be helpful in providing a prototype (as opposed to a stereotype) of factors which may be important in the provision of patient centred care.

Hinduism—one of the oldest world religions dating back to around 1500BC—originates from around the Indus Valley² in what is now Pakistan. Scriptures were originally written in Sanskrit, a language in which most Hindus of today are no longer literate, and therefore customs over the years have tended to be passed on by word of mouth. Almost 14 centuries ago, many Hindus converted to Islam and 600 years ago Sikhism was founded as an “off shoot” of Hinduism. It is therefore unsurprising that not only have original Hindu customs been diluted over the years but that the practises of other religious customs found within South Asia have intertwined with remnants of Hindu teachings. However we have not encountered any consanguineous marriages among Hindus in the UK, a practice common among Muslims the world over.³

Hindus believe in a “transcendent” God who may be worshipped in a variety of ways through different symbolic manifestations (for example, statues). The three supreme Hindu deities forming the Hindu Trinity⁴ are: Brahma (The Creator), Vishnu (The Preserver), and Shiva (The Destroyer). In Britain, the majority of Hindus are Vishnuvites.⁵

Many Hindus believe that a person is born into a caste or acquires it by behaviour;⁶ for example, a person of a lower caste by being “pious” can go higher up the caste ladder. Although no longer officially recognised and less visible in modern India than in the past, the caste system still has a strong hold on Hindu families, and the impact of this on customs (including birth) also extends to those who have migrated. There are broadly four main castes: Brahmins (highest), Ksatriya (ruling caste), Vaisya (farmers and merchants), and sudras (the untouchables); this latter group usually work as servants in India.⁷

Closely linked with the caste system is the belief in reincarnation—a belief that one’s deeds in a former life determine the caste that one is born into. This philosophy of Karma⁸ is of fundamental importance to Hindus, as, it is “deeds” in this world that will decide how the soul is reborn in the future. It is believed that this cycle of birth, death and rebirth ultimately results in attaining a state of purity that allows the liberated soul to become “at one” with the Divine presence.

DEMOGRAPHIC CONSIDERATIONS

The 2001 (UK) census revealed that there are over 559 000 Hindus in Britain,⁹ the majority (467 000) of whom originate from the Indian subcontinent, with a sizable community coming from East Africa. This East African Hindu group is somewhat atypical in that it has undergone migration twice in a relatively short timeframe—first from India to East Africa and then on to Britain. In Britain, areas such as Harrow, Leicester, and Brent have significant Hindu communities making up 14–19% of the overall population (Office for National Statistics, 2003). Although generally religious, allegiance to religious customs will vary according to the extent of “acculturation” (whereby migrants take on some of the characteristics of the host community), and also on whether the family roots were in urban or rural India.

BIRTH RITUALS AND THEIR PRESENT DAY OBSERVANCE

The origins and performance of Hindu rites are not only somewhat complex but often also differ between castes. Here, we attempt to present some common features of these rites in order to help non-Hindu healthcare professionals to develop a working appreciation of these practices and their significance.

Manu, the legendary author of the Sanskrit Code of Law¹⁰ created a number of sacraments or Samskaras—a word which means “perfection”. These are “activities that help achieve ‘purity’ as a result of which the personality of the individual is developed to the full, from conception to the grave”.¹¹ Each sacrament involves a prayer and often a ritual. Although only some of these sacraments relate to the present discussion of birth customs, for completeness and contextualising the principle, the first 10 of these that are relevant to the paediatric age group are described (table 1).

MARRIAGE AND PREGNANCY

The Hindu Marriage Act (1955) prohibited child marriages in India, stipulating that boys could only marry after the age of 18 years and girls after 15. Previously, early “child marriages” were thought by many to be a check on immorality and corruption. The introduction of this Act is believed to have contributed to a fall in maternal and infant mortality, while simultaneously improving the chances of the young to further their education before marriage.¹²

Garbadhana—the fetus laying ceremony is performed at the consummation of marriage and involves special prayers for fulfilling parental duties to perpetuate the human race. In ancient times, the bridegroom did not approach the bride until the fourth night, but today this practice is only symbolically enacted at the marriage ceremony.

Punsavana—the “male making” rite is performed during the third month of pregnancy, in the belief that the “deity” governing the sex of the fetus is activated and a male “issue” assured. Sons are preferred because of the carriage of the family name and the hope that the son will light the funeral pyre of his parents. Manu says: “A man is perfect when he consists of three: himself, his wife, and his son”.¹³ In fact, there is still a belief among many that in the next world/birth, the happiness of a father depends on having a continuous line of sons.¹⁴ Furthermore, birth of a girl, particularly in India, may generate parental anxieties because of the heavy financial burden resulting from the giving of dowries.

Simmanantannaya—also known as Valaiakappu in some parts of India involves the wearing of red or green glass bangles from the seventh month of gestation. The sound of these bangles is believed to reach the womb and comfort the fetus. Traditionally, these are removed after birth and given to the midwife. Historically it is of interest to note that in this sacrament the mother is allowed to fulfil her last wishes, such as any craving for certain foods, as she is now thought to be entering a hazardous period.¹⁵ A pregnant mother is therefore now expected to rest as much as possible. To this end, some women return to their parental home, even in the UK, only to return to the marital home 40 days after delivery. It may be that some patients miss their antenatal and postnatal appointments, partly as a result of this custom and the fact that clinics are often less accessible, with poor language support.

A study by Gatrad et al showed that there were significant differences in birth weight between five subgroups of South Asians.¹⁶ These groups were Muslim Pakistanis, Muslim Bangladeshis, Muslim Gujaratis, Sikhs, and Hindus. Although South Asian babies were generally lighter than the European, Hindus had the lightest babies at birth. It should be remembered that many Hindu women are often strict vegetarians and therefore do not eat eggs, fish, or meat which may, in addition to genetic and other environmental factors, partly explain the lower average birth weight of babies compared to other South Asian subgroups.

BIRTH

Our experiences suggest that, in common with other South Asian women, many Hindus prefer to be seen by female doctors during pregnancy and labour, on the grounds of modesty.

A premature birth in the eighth month of pregnancy is sometimes superstitiously attributed to a cat having entered the mother’s room in a “former” confinement. It is believed by some that a child born in this month could die on the eighth day, in the eighth month, the eighth year, or the eighteenth year! Some Hindus therefore consider the number “eight” unlucky.

In India, when a male is born a Thali (a flat bronze utensil akin to a large tray) is beaten with a stick by friends and relatives. In the case of a girl, a fan, used for winnowing, is beaten.

Jatakarma—this ceremony welcomes the child into the family. The father touches and smells the child and whispers religious verses (Mantras) into the ears of the infant. All this is to promise the baby a safe and comfortable environment. To ward off evil, a small “dot” often in the shape of “Om” (see fig 1) is drawn behind the baby’s ear using Kajal, a carbon based eye “make up”.

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Figure 1

 Om symbol. The most important Hindu symbol is Om; this has been described as “an Aksara or the ‘Imperishable Symbol’; it is the Universe, the past, the present and the future—all that is and all that will be is Om; likewise all else that exists beyond the bounds of time—that too is Om”.²⁵

This symbol may also be seen on a chain around a baby’s neck or indeed be placed in a cot. A family member with “virtuous qualities” writes, with jaggery dipped in Ghee (a purified form of butter), the word “Om” onto the tongue of the neonate in the hope that the person’s good qualities are passed on to the infant.

Symbolically, female members of the family wash a nursing mother’s breasts before breast feeding is commenced. We are aware of this practice in some Hindu families in Britain. The custom of not breast feeding the baby for the first two days is still rife in India, but in our experience this is not the case in Britain.

Certain foods are believed by many South Asians, including Hindus, to have either a “cooling” or a “heating” effect on the functions of various organs of the body, such as mood, personality, and physical wellbeing.¹⁷ Health professionals 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 has a cold or a fever, in the former case she may avoid “cold” foods and the converse when the baby has a raised temperature. This concept is quite divorced from the actual temperature of food or the intensity of taste of spices. High protein, acid, and salty foods are considered “hot”, whereas “cold foods” are often sweet. Lentils, millet, aubergines, and grapes are examples of “hot” foods, and cereals, potatoes, milk, and white sugar are examples of “cold” foods.

Karnavedha—this refers to the ear piercing ceremony. Although usually carried out after the age of 3 years in most castes, there are some families where a father will not see the baby’s face after birth until certain rituals have been performed, including ear piercing. Even the piercing of ears may be in the shape of Om. In India, a goldsmith performs this ritual for both sexes. Although girls often retain these holes, boys usually lose them in early childhood.

The sixth day after birth is considered the most auspicious in a person’s life. On this day, a fragile white cotton thread is ceremoniously tied around the wrist, ankle or neck—this will usually spontaneously fall off a few days later. It is on the same sixth day that a pen and a blank piece of paper are placed in the baby’s cot, as it is believed that on this day the goddess of learning charts the baby’s future. The mother may observe a fast on this day.

Namakarana—the name is selected in such a way as to inspire the child to follow a righteous path. According to Hindu scriptures, a boy’s name should have an “even” number of syllables and a girl’s name an “odd” number. This custom is rarely followed in Britain, although in Indian villages it is still practised. There are several ways of naming a baby.¹⁸ One of the commonest, even in the west, is according to the Nakshatra or the sign of the Zodiac at the time of birth of the baby. It is believed that certain planets govern certain days, for example Mars governs Tuesday. If the Nakshatra for the time of birth is unfavourable, this may be a bad omen for the family necessitating certain rituals, which may include a special prayer and the father not seeing the baby for a few days.¹⁹ It is of interest to note that the documents, containing the horoscope of the baby, are admissible as legal papers of “proof of age” in India.²⁰ Furthermore, the horoscope will be especially important for arranging a suitable marriage later.²¹

From the Nakshatra the first letter of the name is ascertained. For example, if it is a “G” then the name could be Gyatri for a girl. The paternal aunt often plays an important part in the choice. Children may have a middle name such as “Devi” for a girl or “Lal” for a boy; for example, Gyatri Devi and Babu Lal. There are certain prohibited times for naming the baby; for example, at the time of an eclipse or when the signs of the Zodiac are changing. Hindu names have meanings; for example, Ravi for a boy means sun and Madhu for a girl means honey. Some boys are named after gods; for example, the names Krishna or Ram. Some girls may be named Chandra in the belief that the moon (Chand) will bring them luck and good fortune. Table 2 lists some common male and female Hindu names.

The naming ceremony takes place on the tenth or twelfth day after birth, a time when the mother is considered “clean” in order to carry out normal household chores, such as cooking. This custom is still practised by some Hindu families in the West. The nursing mother is now allowed male visitors.

Annaprassana—this ceremony takes place after six months when weaning is believed to be necessary for the baby to become more mobile. A delay in weaning that one occasionally encounters in Britain may be as a result of this belief. Although we have no evidence that Hindu babies in general are weaned at around four months in Britain, it is our experience that this is so.

Chuda Karma—the hair cutting ceremony (removal of scalp hair) is performed at any stage depending on family tradition, although according to the Samskara (table 1) it is performed between the first and the third year.

DEATH OF A NEONATE OR INFANT

At death, the baby is believed to leave the “earthly” realm into an “intermediate” zone in readiness for its journey to the “Divine realm”. Although Hindus often prefer to die lying on the ground (Mother Earth), this custom is rarely practised for babies dying in Britain. Quality of palliative care, if indeed such care was necessary, has an impact on death and bereavement.²² Hindus who have perceived what they witness as a bad death, may be very anxious about the ghost of the deceased.²³

As a baby approaches death, the family will chant “Ram Ram” or “Om” and recite from the Bhagavad Gita—the holy book for Hindus. A thread with a religious significance may be tied around the wrist or neck of the baby. Stillborns need the same religious “service” as adults. A leaf from a Tulsi shrub (basil leaf) is placed in the baby’s mouth, occasionally with a gold coin. After a ritual wash, new clothes are put on the baby who is subsequently wrapped in a white shroud. The body of a baby may be taken from the hospital straight to the cemetery. However if the corpse is taken home, candles are lit and holy water from the River Ganges sprinkled onto the body.

Babies and young pre-pubertal children dying before the Upanayama stage are buried, whereas adults are cremated. Upanayama is the tenth sacrament and is a stage in a child’s life when he/she begins adulthood after the age of 8 years. It is a stage ritualised by wearing a religious thread called Janeo. Children who die before this stage do not need purification by fire as they are classed as being “without sin”. As a general rule, particularly in rural India, a cup of water is placed at the head of the grave of a baby. Women are never present at burials, even in Britain.

POSTMORTEM EXAMINATIONS AND ORGAN TRANSPLANTATION

With any family, from whatever ethnic group or creed, whose beliefs and needs at a time of crisis cannot be assumed or inferred, this subject should be broached with sensitivity; this is particularly so in Hindus whose belief in Karma may result in possible anxieties about whether or not all organs will be returned to the body after a postmortem examination. Generally there is no specific prohibition to postmortem examinations or organ transplants in Hindu teachings.²⁴

DISCUSSION

Although we appreciate that one cannot be expected to have detailed knowledge of every aspect of the multicultural tapestry of present British society, there is a significant Hindu community in Britain today and therefore some understanding of cultural norms and values is important. Such knowledge, we believe, is important for health professional to respond to individuals by reflecting on their own culture, and recognising and respecting the difference. Learning to pronounce names and a few words, especially a greeting with a smile, is what the patient appreciates. We should in addition develop a broad understanding of the contexts and needs of Hindu communities such as language difficulties, modesty, and gender issues. The use of trained interpreters/advocates would further provide the necessary support for a truly culturally competent care. Achieving effective communication and striving towards improved access for such communities will go a long way to breaking down barriers by responding flexibly to all patients, whatever their need. Health professionals should be confident enough to ask their patients: “Are we doing this the right way for you?” or “How would you like us to do this?”. Professionals should be prepared to learn from families they are supporting as well as provide advice and information. This is a true partnership and one path to culturally competent practice.²⁵

CONCLUSIONS

The process of acculturation continues; for example, some Hindu children have western names. It does not always follow that because a patient is classed as belonging to a certain religion that he or she follows that faith. Some people may wish to maintain practices that are important to them while others may only nominally express allegiance and are not concerned with orthodox practice—this being especially true for those living in the West. Furthermore, religions are divided into different sects, resulting in individual adherents having their own particular view and interpretation of their faith and culture. Indeed, different generations within the same family may have differing views. Nonetheless, there are particular customs and rites, which tend to bind members of a religious community, and our experiences suggest that birth customs continue to be important to many Hindu communities, including those in Britain.