Natural births: Bringing back the midwife


Photo: BirthVillage

Birthing centres like BirthVillage in Kochi are part of a growing trend

Dusk-tinted light filters in through the reed curtains covering the large windows of the birthing room. It casts long shadows on a large king-sized bed covered with a bright cotton bedspread. Multicoloured cushions are scattered across it and a small, ornate lamp on the adjacent table lends a warm glow to the wood-panelled walls of the room, giving it a homely, comforting aura.
At the foot of the bed is a sturdy birthing stool. The crescent shaped seat with its hollow centre lets you give birth while upright. A rope of knotted batik fabric slithers down from a hook affixed on the ceiling and performs a similar function.
“Lying down on a bed with your legs in stirrups is the most commonly perceived position while giving birth,” says Priyanka Idicula, co-founder and director at the BirthVillage in Vytilla, Kochi, and a certified professional midwife. “BirthVillage utilizes gravity (squatting/standing) to help babies get into an optimal position to descend and come out.”
Or you could opt for a water birth, she says, walking into an adjoining room and pointing to the cerulean, inflatable birth pool that occupies most of the space. “Sitting in a warm tub of water helps a woman in labour to relax,” she says, adding that it is also gentler on the baby, who has been in a fluid-filled, amniotic sac for nine months.
A water birthing room. Photo: BirthVillage

A water birthing room. Photo: BirthVillage

Idicula’s own birthing experience contributed to her decision to set up BirthVillage, south India’s first natural birthing centre, in 2010. “I had a normal delivery, but I cannot say it was natural,” she says. While normal refers to any vaginal birth—induced using drugs or manual techniques, assisted using forceps or a vacuum can also fall under normal—a natural birth is completely spontaneous and there is absolutely no “invasive” intervention.
BirthVillage employs what is called “The Midwifery Model of Care”, in which a professional midwife leads the entire birth process from the time of discovery of pregnancy to the early nurturing and caring of the baby. This model works on the principle that pregnancy and birth are normal life processes and should be treated that way. It is a holistic approach, says Idicula, which calls for deep involvement with the parents-to-be at every step.
Services include prenatal and postnatal check-ups, fitness and Lamaze classes, nutrition counselling and baby-care training. “Lamaze classes empower women by offering information and teaching them what to expect, thereby enabling them to take responsibility for their own health. A pregnant woman should be encouraged to eat healthy and be physically fit till the last day. She is not sick, after all—she is just carrying a baby,” says Idicula.
A Lamaze class in session. Photo: BirthVillage

A Lamaze class in session. Photo: BirthVillage

Pavithra Atul Sarma, founder and CEO of Passion Earth, a fair-trade gifts business and a childbirth educator based out of the UK, agrees. “Birth isn’t a medical phenomenon unless it is made into one,” says the mother of two, who has had both an obstetric and natural birthing experience.
Her first child was born via C-section (in retrospect, an unnecessary one, she says), while the second was a water birth at home assisted by two midwives. “(Medical) interventions often impede the natural flow of hormones, whereas a wait-and-watch approach can work wonders,” she says. “You should trust your body to produce the cocktail of hormones required to ensure that the mind, body and baby are all in sync and doing what women have been doing for ages.”
Idicula’s simple block-printed kurta and ready smile are far removed from the scrub-clad, stethoscope-toting image one associates with a medical professional. And that infectious energy and warm presence is manifested in every corner of the BirthVillage: the space looks (and feels) different from an average maternity ward.
Tucked away on a narrow road bordered with white, bougainvillea-draped walls, the BirthVillage is easy to miss, except for the small white signboard that proclaims its presence in varicoloured letters.
Trees shade the red-roofed homestead inside. Posters with fun, spunky messages form a collage at the entrance. Photographs of babies—grumpy babies, bawling babies, smiling babies, fat babies, slender babies, sleepy babies—cover the walls in the waiting area, which smells faintly of incense, not disinfectant.
Photo: BirthVillage

Photo: BirthVillage

Unconventional as it may seem, Idicula’s methods seem to be working, “I have birthed over 200 babies here,” she says, smiling. Her success rate so far has been around 97.8%, with only a few needing obstetric intervention at the time of labour.
A scalpel generation
In her autobiography My Story, the late Kamala Das describes the birth of her first child. “When the labour began, I put old records on the gramophone and chatted courageously with my cousins who had come to watch me have a baby,” writes the firebrand poet. “All of them sat outside my door, leaning against the veranda wall. The most excited was my younger brother who kept asking me every minute or so if the baby was coming out.”
Idicula says the culture of that time, which treated birth so matter-of-factly, has changed drastically over the past 40 years. “My parents were born at home. They were a generation that grew up in farms and watched animals give birth,” she says. “We are all freaked out by birth today. Look at what grandparents do today. They pace up and down, they are nervous. A lot of it has to do with being cut off from nature.”
The glut of information available on birthing today tends to exacerbate the fear associated with the birthing process, says Mumbai-based Lina Duncan. She is a trained midwife and co-founder of Birth India, a non-profit, non-governmental organization that seeks to support women through informed conception, pregnancy, birth and breastfeeding.
“Google is not a doctor,” she says. “Nowadays, we tend to hear a lot of horror stories (from labour wards) and everyone is online, full of anxiety and high expectations. It would be wonderful to hear our great-grandparents’ stories of their births instead, as it was a natural continuation of life, extension of family, a normal life process.”
Unfortunately, it is hard to get people to see it that way, says Idicula. “Families are nervous; they want the baby out quickly. This puts a lot of pressure on the health provider,” she says.
Cynthia Alexander, a Chennai-based gynaecologist who has been in the profession for over 40 years, adds, “I have parents telling me to go ahead with a C-section as they feel that their daughters cannot take the pain of labour. This generation has a far lower tolerance level.” (Disclaimer: Dr Alexander is related to this reporter on her sister’s side through marriage.)
According to a report published in The Economist on 15 August 2015, there has been a global rise in C-sections, one that is not driven by necessity but by the relative ease and time saved in the process, in addition to financial incentives for doctors.
“My caesarean experience was absolutely not required,” says Passion Earth’s Sarma, whose first child was born in London.
“My husband and I felt bullied and coerced into having one with our pleas for information dismissed and ignored by the medical staff,” she says, adding that she was depressed for almost a year after the experience.
Research does prove that women are more likely to suffer from post-partum depression, called “baby-blues”, after a C-section (vis-à-vis a normal delivery) but there are other physiological consequencesincluding increased blood loss, infection, extended recovery time and higher incidence of endometriosis.
The World Health Organization believes that no more than 10-15% of the babies in a country need to be delivered via C-section. Yet, the number of women opting to deliver via surgery continues to rise—and India isn’t far behind either, going by this report published on 6 January. This threshold has been crossed in multiple states in India, says the report, indicating that the numbers go up to almost 50% in some private hospitals.
Economics could be one reason: While the costs vary considerably across healthcare units, a C-section is certainly a more expensive procedure, generating more revenue for hospitals and doctors. On an average, a caesarean in a public hospital is a couple of thousand rupees more than a normal delivery, while in a private hospital, the cost of the procedure could even cross Rs1 lakh.
Doctors, however, do not completely agree. “It is possible that there is a monetary angle to the whole thing,” says Uma Ram, director, Seethapathy Nursing Home and Clinic, Chennai. “But I think it is more a function of convenience and risk-perception. Some people tend to panic if labour continues for a long time. People don’t know if they can go through that sort of pain.”
Superstition also is factor here, Dr Ram adds. “People request for delivery on a specific day or time and that can only happen when you schedule a section.”
Changes in our lifestyles have also altered the way we give birth, says Dr Alexander. “We are sedentary, eat a lot of processed food and are more prone to health conditions like polycystic ovary syndrome, obesity, gestational diabetes,” she says.
This impedes the chances of a normal delivery. “If your sugar levels are high, the weight of the baby increases, which makes it harder for us to do a vaginal delivery,” she says.
No one wants to take a risk when it comes to their baby, after all. “I wanted to have a normal birth,” says Ramya Thomas, a new mother who is currently on a break from work. “But my baby passed meconium (faeces) and my cervix wasn’t dilated so I had to be rushed into surgery.”
Doctors would rather be safe than sorry, too. “Look, things can go wrong if we wait for too long,” says Dr Alexander. “Today, with consumer protection laws being so strong, no doctor will want to take that chance.”
Idicula is clear on one thing—the obstetric and midwifery model of care work in tandem with each other. In the UK, for instance, a midwife is the first point of contact, she says.
Only if you suffer from a pre-existing health condition and do not qualify in the midwife system do you get escalated to the obstetric system. “BirthVillage is an option for healthy women only, which is around 80% of the population. We do not take on cases with pre-existing complication. In case of any deviation, prenatally or during labour, we ensure that the patient is transferred to the nearest hospital.”
The midwifery model of care
Sarah Gamp, the fictional midwife in Charles Dickens’s novel Martin Chuzzlewit, like most Dickensian parodies, treads the line between the grotesque and the comical.
The character—a dissolute, sloppy, drunkard with a sketchy medical background and described as, “a fat old woman, this Mrs Gamp, with a husky voice and a moist eye, which she had a remarkable power of turning up, and only showing the white of it”—was based on a real-life person, mentions Dickens in the preface to the novel.
“Mrs. Sarah Gamp was, four-and-twenty years ago, a fair representation of the hired attendant on the poor in sickness,” he writes.
Midwifery, thankfully, has come a long way since the days of Mrs Gamp. Today, it rests on reassuring principles: Monitoring the physical, psychological and social well-being of the mother all through the childbearing cycle; providing her with education, counselling and support from conception till early child care; minimizing external interventions as much as possible; and identifying women who require obstetrical attention.
A recently published Cochrane review that sought to compare midwife lead continuity models of care with others suggested that women who opted for a midwife experienced more spontaneous vaginal births, fewer early miscarriages and more birth satisfaction. “If you look at countries where the infant and maternal mortality rate is good—like Norway, Denmark, Sweden—the midwifery model of care is the predominant one,” says Idicula.
Closer home, there is evidence that despite spending a smaller percentage of its GDP on health than most countries at the same income level, Sri Lanka has considerably reduced infant and maternal mortality over the last 50 years by increasing the number of trained midwives in the healthcare system. Malaysia and Indonesia have similar success stories.
A trained midwife is different from a traditional birth attendant or a dai, cautions Idicula. “A midwife has gone through a specific college-based, medical education and is authorized to use life-saving drugs, administer intravenous medication, etc.,” she says. A dai, though a common sight in rural India even today, relies on skills that have been passed down from generation to generation.
Unfortunately, there is a definite lack of trained midwives in India. “We do not have a focused course for midwives here,” says Idicula. “It is simply a small part of the nursing course in India today”, unlike in pre-Independence India, where it was a separate discipline.
According to a National Library of Health report, the Central Board of Nursing and Midwifery was established in India in 1902 by the British to regulate the training and services offered by midwives.
After Independence, midwifery, which till then was seen as a separate profession, was integrated into the nursing profession. This inevitably weakened the efficacy of the model—greater emphasis was given to national health programmes, more funds were diverted to the medical colleges than the midwifery and nursing ones, and institutionalized births began to increase drastically.
“It is my dream to see a midwifery model of care throughout India. This would take the workload off doctors and lessen the ongoing concern India has with a high rate of neonatal mortality,” says Duncan, adding that the midwifery model of care is an effective one that provides compassionate, supportive and safe childbirth options.
While birthing centres like the BirthVillage in Kerala, Birthing Sanctuary in Goa and The Sanctum in Hyderabad have adapted this model of care, they are still outliers in the prevalent healthcare system.
“Since we do not have a separate degree on midwifery alone, the resurgence is coming from people educated in schools abroad,” says Idicula, the first Asian to win a dual scholarship from Lamaze International.
The reason it is seeing a revival, she believes, is that it addresses a special need that women want, which is “another woman’s face and force, that has somehow been replaced by technological advances”.
“Childbirth is one field that has always been about women supporting other women and I believe it should stay that way,” she says.