Three days past her due date, Ruth Malik’s gynaecologist ordered a sonography to check on the baby. The report came with a cryptic diagnosis: cord around the neck. Preparations began for a caesarean section.
Malik had grasped more than ever during her pregnancy that questions are unacceptable in the healthcare system. But something of her doughtiness returned as she realised that things were swiftly being taken out of her hands. “Is it putting the baby at risk?” she asked.
It didn’t go down well. Her doctor “terrified her”, telling her that she was endangering the life of her baby. “It is the last thing a woman giving birth wants to be accused of – that she is thinking more of herself than her baby,” Malik said over the telephone. She got admitted in the South Delhi hospital and her doctor performed a caesarean.
When she saw her son the next day, she was filled with a sense of dread. She felt unprepared for the baby, after all, she hadn’t even managed to birth him properly. “I struggled to connect with my baby,” she said. “I felt ashamed of meeting other mothers. I felt like a fake.”
This was 14 years ago. But Malik remembered it like it happened yesterday. “From the haze of drugs and pain of the C-section, I plunged into postpartum hell.”
Four years after her son’s birth, Malik was hospitalised in Mumbai for her second delivery. Another caesarean was performed on her. This time, her obstetrician decided that Malik wouldn’t be able to pull off a VBAC, or vaginal birth after caesarean, which is generally perceived to be a more complicated birth, even though Malik was prepared to labour as long as she could hold out. Once again, she found herself overruled.
Afterward, she would ask friends, acquaintances, even women she had just met, about their birth experiences. The answers were inchoate. She lost friends rapidly. “People resented it," she said, "I think, because it took them back to an unhappy memory. Or, made them feel ashamed, made them feel that they should have resisted. There was no conversation about childbirth in India.”
She added: “Yet this conversation – about the dissatisfaction with medicalised births, the voicelessness of women on the delivery table, the notion of obstetric violence – had begun to take place in the West. I could see it on the blogs. The internet saved me in a way.”
In 2008, Malik set up the Birth India network. The idea was to maintain a database of midwives, doulas (birth support assistants) and other birth educators across the country, and equally, to end the silence on the experience of birthing in India.
She painstakingly built up a directory of about 40 childbirth professionals, including Lamaze birthing educators, and post-natal care specialists such as lactation teachers. Lamaze instructors practise the birthing module introduced in 1951 by the Paris-based Dr Fernand Lamaze. This includes breathing and relaxation techniques during labour, the involvement and emotional support of the father and the guidance of a specially-trained nurse.
The Bangalore Birth Network was also established around 2008. In 2009, the Healthy Mother Birth Centre opened in Hyderabad as a midwife-led practice, and in 2010, another midwife-led clinic called Birth Village was established in Kochi. A company called Mumbai Midwife began to offer birth services in the city in 2007. In 2011, the Fernandez Hospital foundation in Hyderabad initiated a two-year training programme for midwives.
Most significantly, one private hospital in New Delhi – the well-regarded Sitaram Bhartia Hospital where Malik delivered her first baby through caesarean section – had a change of heart.
In 2001, Abhishek Bhartia, the director of the hospital, was startled that four out of five babies in the hospital was born by caesarean. In 2002, he set natural birth as the principal mode of birthing practice in the hospital. This has brought down the caesarean rate in the hospital from 79% in 2001 to 28% in 2015. They have started a module of Lamaze-style birthing classes, and Bhartia is vocal about the need for midwives to lead birth.
“Birth is not a medical condition, it has been medicalised,” wrote Bhartia in an email. “It is a natural but specific human condition, and midwives are trained to handle this as such.”
These are tiny steps, and minuscule numbers, all within the same affluent, internet savvy socio-economic demographic. This is, in fact, the demographic that can afford expensive private options, perhaps the fanciest luxury birthing boutiques, yet it chooses to eschew private care. Some opt to birth at home with a midwife or doula, some in these new clinics, and some in hospitals with midwives or doulas serving as consultants alongside doctors.
In India, midwives have no place in the system. There is no independent qualification for a midwife. It is at best a six-month module in the Auxiliary Nurse and Midwife degree. On the other hand, midwifery is a degree in medical practice offered by premier universities including some of the Ivy Leagues in the United States, and redbrick universities with solid reputations in the United Kingdom.
The absence of a cadre of clinically-trained midwives is the principal reason why natural birth is a luxury organic choice for the privileged. The handful of clinically-trained midwives and doulas working in India charge in the range of Rs 35,000-70,000 per birth. The absence of the midwife cadre from the Indian healthcare system means the systemic absence of natural birth practices. In contrast, Sri Lanka, another South Asian country which was a British colony, increased the number of trained midwives twenty-fold between 1941 and 2001. Its maternal mortality ratio, at 29 for 100,000 live births, is embarrassingly better than India’s 2015 figure of 174.
The wider problem of birth abuse, or obstetric abuse as it has come to be termed, is not limited to India alone. The conversation around this has gathered steam in the last decade. In 2007, Venezuela became the first country in the world to define the concept of obstetric violence. Subsequently, Mexico and Argentina have also legislated on obstetric violence. In 2014, the World Health Organisation released a statement titled, Prevention and Elimination of Disrespect and Abuse During Facility-Based Childbirth. In 2012, the first international Human Rights in Childbirth Conference was held in The Hague in the Netherlands. The third edition of the international conference will be held in Mumbai in February 2017.
Natural vs normal
Natural birth refers to giving birth as free of medical intervention as possible. The idea of what is natural is, of course, a continuum – even the most drug-free birth is likely to involve a number of diagnostic scans to chart the progress of the foetus, the mother will likely have a gynaecologist on call, she may take vitamins during her pregnancy.
Still, this is distinct from the so-called normal delivery. Little is normal about the normal delivery: the epidural anaesthetic given to reduce labour pain, the pitocin given to induce or augment labour contractions, the cut of the perineum to aid the baby’s passage through the uterus that is known as episiotomy, the flat-on-your-back position in which women are made to lie on the delivery table for birth. Movement during labour helps ease discomfort and aids the passage of the baby.
Even so, the normal delivery is more natural than the caesarean, which requires surgical intervention, and on occasion, general anaesthesia.
To understand the difference in approach between natural birth and medicalised birth, consider the language. Natural birthers speak of birth, the medical system calls it delivery. Midwives and doulas refer to pregnant women as clients, doctors and hospitals as patients. For the medical system views childbirth as a fraught medical condition that has to be managed, while natural birthers see it as a specific but natural episode.
A short history
The medicalisation of birth has taken place over the past 100 years, accelerating since the 1950s, rooted in the ideas of modernity and science. The medicalised birth in a hospital is seen as the more scientific, more hygienic option and was promoted by many Western nation states in the 1900s. The postwar years saw an expansion in hospitals: the National Health Service, or NHS, was set up in 1948 in the UK and the US government increased funding for hospitals after World War II.
The argument that is made for medicalised birth is that it has brought down maternal deaths. Research, however, has shown this to be a false assumption. Using historical data from Britain, US, Australia, New Zealand and continental Europe from 1880 to 1937, Irvine Loudon, the author of the seminal study Death in Childbirth showed maternal mortality rates were the lowest for home births supervised by trained midwives. More to the point, maternal mortality rates were very high in the regions where births were mostly overseen by physicians, and where surgical interventions were encouraged.
So why did the maternal mortality rate plunge dramatically across all these countries after 1937? The catalyst was the use of antibiotics, including penicillin. Not medicalised birth.
The caesarean bomb
Among the handful of women I interviewed, two reasons consistently emerged as the primary red flags for eschewing private healthcare. The first is the high incidence of caesarean births. And the second is the deeply-wounding lack of autonomy women experience in the hospital system.
The latter, interestingly, is a problem faced by women across socio-economic categories. Last year, I reported on the humiliating treatment given to poor pregnant women in a labour room in a Kolkata government hospital.
The caesarean problem is far more acute in private healthcare – at 31.1% of all births, this Mint report calculated that it is nearly three times more than the norm laid down by the World Health Organisation. In 89 of India’s 318 districts where private healthcare accounts for at least 10% of births, the caesarean rate is above 50%. And in every state that I checked in the National Family Health Survey data for 2015-2016, the caesarean rate in private healthcare ranged from two to four times the C-section rate in government healthcare.
Part of the explanation may lie in cost: this report estimates that C-sections cost two to five times a vaginal birth. But there are more interesting reasons too. Dr Puneet Bedi, a gynaecologist with Apollo Indraprastha Hospital, New Delhi, said that the primary attraction of the C-section was that it allowed doctors to control their schedules. “Most of us slog for years to be doctors,” he said. “When we start earning decently in our forties, we want to enjoy a nice lifestyle. Finish work by 6 pm, go for a game of golf. Much better than waiting around for a woman in labour, no?” Bedi has the reputation of a maverick – an activist doctor unusually critical of his industry and unusually quick with a laugh.
He, however, pointed out that some of his patients ask for a C-section. The caesarean has, in other words, become a consumer choice. Sometimes, the reason given is astrological – a child should be born on an auspicious date or at an time. Sometimes, it is cosmetic: some women want their vaginas to remain tight. The easy availability of the C-section, it seems, has changed the ecology of birth options all around.
There is no data on the numbers of women who actively ask for a caesarean, but it is estimated to be minuscule. “Only about 1 in 100 of my patients have ever requested a C-section,” Dr Shaibya Saldanha, a gynaecologist and obstetrician who practices in private hospitals in Bengaluru, told the feminist webzine The Ladies Finger.
The media narrative, however, blames it squarely on women. When actor Aishwarya Rai gave birth to her daughter Aaradhya in 2011, the headline of The Times of India went: “The Aishwarya Rai effect: Not old or posh to push for delivery”. The message was: women are getting too full of themselves, or too lazy to have their own babies.
The most troubling aspect of this C-section story, and one which has largely escaped reporting, is the last-minute, rushed-to-emergency caesarean. The reasons given typically are "cord around the neck" and "foetal distress".
“The term foetal distress means nothing because it can mean anything,” said Dr Abhay Shukla, chuckling. Shukla is the co-author of the book Dissenting Diagnosis, a dissection of private healthcare malpractices in India. “One in four babies develops foetal distress. You need to examine the partograph (which charts how labour is progressing for mother and baby) to decide. But for that, you need to wait for labour to begin.”
The cord is not an anomaly either. “One in three babies develops a cord around the neck,” said Lina Duncan, a midwife trained in Australia who runs a practice called Mumbai Midwife. “This is not abnormal. I’d say only a few of these merit an emergency intervention. But I’ve seen doctors in Bombay announce ‘cord around the neck’ like a bomb and race the mother in for an emergency caesarean. Afterward, everyone admires the doctor’s heroic effort.”
Among the women I spoke with, the only one who dodged the C-bomb was Poornima Shree. Throughout her pregnancy, she prepared conscientiously for a normal vaginal birth. “My gynaec would give me five minutes,” she said. “And in that, I would ask her about diet, exercise, routine, everything I needed to do for a normal delivery.”
In spite of all of this, in the 39th week, her doctor recommended a caesarean, on the basis of a sonography that suggested “cord near the baby’s neck”.
“You know how you feel when you fail an exam after studying everything?” Shree said. “My body had betrayed me.”
Shree's husband went online, and read about Vijaya Krishnan’s birth centre in Hyderabad’s JJ Hospital. The couple watched a video Krishnan had posted on the myths about the cord around the neck. Krishnan told Shree that she had done everything right, all that remained now was to wait for labour. “She made me feel capable, more than I felt at the time,” Shree said. “My son was born in the 42nd week and he was born with a cord around his neck, and he was big! But I did it without even an epidural!”
When stories like Shree's are posted on the Birth India Network, they remind Ruth Malik of her mother. Why was she picking on the good doctor, her mother had asked her, she had a beautiful baby, didn’t she? At these times, Ruth felt that the memory of her births was not so lonely after all.
The question of consent
More difficult to address is the sense of having no say over your body and birth, of being locked in your house and gagged. This goes beyond the caesarean steamrollering, even the so-called normal delivery involves interventions for which consent is rarely sought.
Take the episiotomy, for instance, used routinely in birth in Indian medical practice. It involves a small cut to the perineum (the area between the anus and the vagina). The episiotomy is meant to aid the passage of the baby, and was once regarded as a standard good practice. But an influential 2005 study found that the routine episiotomy has no benefits. The American Congress of Obstetricians and Gynaecologists has called for restrictions on the episiotomy. In public hospitals in India, however, it is performed routinely on women without informing them.
“Even in posh places, it is cut, cut, cut,” said Duncan. “I can’t forget the time I was assisting my friend’s birth. I asked the doctor if an episiotomy was necessary, and he looked at me, then said, 'Actually it’s not a problem for you foreigners because you have a lot of sex. Indian women have no sex before marriage, then they have sex once and get pregnant. Then they stop having sex.’ All this while, my friend listened to her doctor tell me about her sex life."
It’s not just healthcare staff however, families routinely mute the woman’s choice too. “I can still hear this husband telling the doctor, ‘My wife has never lifted a bucket of water. She’ll never push a baby out,’” said Priyanka Idiculla, midwife and founder of Birth Village, a midwife-led practice in Kochi. For this and an assortment of similar reasons, Idicula has banned grandparents during births in her practice. “I want the women to have the births they desire.”
At the heart of the consent issue, said Shukla, is the knowledge asymmetry with doctors. Doctors are experts, and when we go to them, we place our care in their hands. Yet we have rights as patients too, and the Indian Constitution has recognised these. In their book, Dissenting Diagnosis, Shukla and Dr Arun Gadre write that we have a right to receive information about our “proposed care; the expected results, risks and advantages of various alternative procedures; and the treatment options available”.
“But would you get any of this in our healthcare?" Shukla asked. “I always say that if you are a patient in India, you should be a doctor and a lawyer!”
The consent problem is not limited to India. Four years ago, when Adhunika Prakash had her first child in Ireland, her vaginal delivery left her feeling violated. “It was like nothing else in my life,” she said. “Although I had specifically said I do not want Pitocin [to augment labour], I was given the drug deceptively. I was forced to lie down on the table like a prisoner.”
Last year, when she became pregnant with her second child, she was in Aurangabad in Maharashtra. She explored the possibility of a home birth but it was too expensive to have a midwife move to Aurangabad for her birth. Only one gynaecologist she contacted agreed to supervise a home birth. (This too, she feels, is only because her husband is a doctor, although he is not a gynaecologist.)
As it happened, on the day that she went into labour her consultant was travelling. Prakash had her baby at home in the presence of her husband, her mother, her elder daughter and her cook. The hospital her husband worked in is three minutes away by car, and her husband had informed emergency care of a possible call. They dimmed the lights, and she sat in a tub of warm water, listened to an audiobook on water births and gave birth calmly. "It was the birth I was waiting for," she said.
This is a happy story in every way: a birth of your choice, a healthy baby, a healthy mother, the necessary precaution of a hospital nearby. But consider this from another perspective: how deep must the trauma be if it makes you avoid a hospital three minutes away even though your doctor is unavailable? That too a place where your husband works?
Consent. Autonomy. Dignity. The right to make your own choice. All the things that were taken away from Ruth Malik. The things no one was talking about. The things the healthcare system has no patience for. These are the things, the conversations, natural birth practitioners offer. And sometimes they can work like a spell.
“My second birth healed me,” said Shilpa Pavan. Her gynaecologist had rushed her into a caesarean for her first child because her bag of waters had broken, and her doctor diagnosed that her baby was in distress. Her husband noticed Krishnan’s clinic in the hospital, and when Pavan had difficulty breastfeeding the next day, he consulted Krishnan. She came to meet Pavan in her ward, and congratulated her, and she listened. Pavan found herself crying. “That was perhaps the only time in my stay that anyone listened to me in that hospital.”
When she was pregnant with her second child, Pavan headed to Krishnan and said she was willing to do whatever it takes for a vaginal birth after caesarean. Krishnan encouraged her but told her gently that ultimately birth was like death: you can prepare for it, but you can’t control it.
When Pavan's labour began, it lasted two days. She was exhausted by the time she had her girl, and fell asleep right after. When she awoke a couple of hours later, she felt well enough to walk down to the taxi from the hospital. “It was magic compared the haze of drugs after my C-section,” she said. “I had felt like a potato then. Everybody was mashing me, doing whatever they wanted. This time, I felt like a person.”