A mother with her child sitting on an open rickshaw, also called "van," on the main road near Patra village in West Bengal on July 8, 2013. Malavika VyawahareA mother with her child sitting on an open rickshaw, also called “van,” on the main road near Patra village in West Bengal on July 8, 2013.
PATRA, West Bengal — In this village 30 miles south of Kolkata, three generations of women have depended on Saira Bewa to deliver their babies.
On a languid July afternoon, Ms. Saira, 61, squatted on the mud porch of her house in Patra and narrated the story of how she became a midwife. “When I was a teenager, I used to help deliver calves and goat kids at our home,” said the great-grandmother, who goes by one name (Bewa indicates she is a widow). “That is how it started. Soon, I was helping deliver babies.”
In over 40 years as a dai, as traditional midwives are known in India, Ms. Saira helped deliver scores of babies in this village of 6,500, which has a predominantly Muslim population, armed with a basin of hot water, a blade to cut the umbilical cord and her bare hands.
Women in rural India have traditionally relied heavily on midwives like Ms. Saira, but after decades of stubbornly high mortality rates, in 2005 the Indian government introduced the Jnani Suraksha Yojana program, which offered cash to poor women and those disadvantaged by caste, or their status as tribes, who delivered at a medical facility instead of at home.
The number of institutional deliveries rose dramatically, from about 40 percent of all births in 2005 to over 70 percent in 2009, but the fall in mortality numbers has not been equally pronounced.
With more than 55,000 women in India dying from pregnancy and childbirth-related complications each year, health experts and nongovernmental organizations are now pushing the government to re-incorporate midwives into the strained health care system by training them in modern childbirth practices and equipping them to handle complications.
“Community needs are at a point that if you suddenly remove all of the traditional birth attendants and home-based attendants, there will be no alternate for a lot of people,” said Dr. Rajiv Tandon, a pediatrician and public health and nutrition expert.
A 2013 Unicef-funded study in India documented “serious, persistent gaps in safe delivery capacity at the primary level, especially subcenters and remote primary health centers.”
According to government figures released last month, India’s maternal mortality ratio, or the number of maternal deaths per 100,000 live births, has fallen from 212 in 2007-09 to 178 in 2010-12. But it remains among the highest in the world and still significantly higher than the Millennium Development Goal target of 109, to be achieved by 2015.
A United Nations Population Fund study estimated the number of registered midwives in India in 2008 to be 324,624 and that India would be short 25,620 skilled birth attendants to meet 95 percent of the demand by 2015. Midwives like Ms. Saira are not included in these figures as they fall under the category of traditional birth attendants instead of skilled birth attendants, which includes trained midwives, nurse-midwives and doctors.
For a long time, the Indian government recognized that it did not have enough skilled birth attendants and ran programs to retrain women already doing this work, which was found in one study to improve patients’ use of maternal health services. The emphasis of these programs was on cleanliness, which was seen as generally lacking in deliveries performed by traditional practitioners, who combined their experience with religious ritual and superstition.
But in 2005, the government decided to refocus its efforts to encouraging women to give birth in medical facilities. Himanshu Bhushan, a senior Health Ministry official in charge of maternal health, said a government review clearly showed that a majority of the traditional birth attendants, like untrained midwives, could not identify birth complications, which delayed treatment that could have saved women’s lives.
Even with incentives to give birth in a facility, a 2009 United Nations Population Fund study of five states that fare poorly on maternal and child indicators showed that in Uttar Pradesh 52.5 percent delivered at home and 50.9 percent in Bihar. An overwhelming majority of women who did not have institutional deliveries said they found home births “convenient.”
Saira with her two-year-old granddaughter at her home in Patra village of West Bengal on July 8. Malavika VyawahareSaira with her two-year-old granddaughter at her home in Patra village of West Bengal on July 8.
“Where is the need, unless there is a problem?” was Ms. Saira’s response when asked why women in her village were not going to hospitals.
Women in Patra also expressed an unwillingness to be put in the hands of a stranger, especially a man, and voiced fears of knives and of being cut open.
“The ride to the hospital rattles the bones” is how Ms. Saira described a trip in the open rickshaws on unpaved, rocky paths, where ambulances cannot reach, to the nearest bus stop a few miles away. From there, the only options for the poor are overcrowded tempos, the local train or buses to the nearest government hospital equipped to handle deliveries.
Those who can afford it go to the private hospitals, despite the high costs of such care. Those women who make it to the public hospital near Patra complained that they don’t receive the care they needed.
And institutional deliveries by themselves are not necessarily translating into better child care practices.
“We used to think that just because you had institutional delivery breastfeeding will take place,” said Nita Chowdhury, a senior official in the Ministry of Women and Child Development. “But we found that in facility after facility the health worker would urge the mothers to breastfeed their babies, but the mothers refused, saying they wouldn’t do anything till their mother-in-laws were present.”
Saving the lives of mothers and infants would require more than monetary incentives to deliver at a hospital, said Sarah Pinto, anthropologist and author of “Where There is No Midwife: Birth and Loss in Rural India.” Women like Ms. Saira, who enjoy trust within communities, should play an important role, Ms. Pinto added.
A primary health center in Patra village of West Bengal in July, 2013. Malavika VyawahareA primary health center in Patra village of West Bengal in July, 2013.
However, one major hurdle is that traditional midwives are resistant to giving up a lifetime of folk wisdom in favor of clinically proven practices.
For example, Ms. Saira said she insisted that the newborn drink water instead of breast milk in the first hours of birth, a common practice that is particularly harmful in areas where the water is likely to be contaminated. International guidelines recommend that a newborn be breastfed in the first hour of birth and continue to be fed only breast milk for the first six months.
What is especially dangerous to a child’s health is the discarding of colostrum, or the first breast milk produced by the mother, which doctors say is not only wholesome and nutritious, but also builds immunity in children. In Ms. Saira’s village, this first milk, which is thick and yellowish in color, is often discarded because it is believed to be curdled.
Bangladesh, India’s smaller and poorer neighbor, may have some lessons to offer. It is on course to meeting its Millennium Development Goals for maternal mortality, which declined from 830 in 1990 to 194 in 2010. A United Nations Population Fund report credits the reduced mortality rates to the Bangladeshi government’s investments in training community-based skilled birth attendants to provide care for pregnant women and mothers who deliver outside of facilities.
Syeda Hameed, a member of India’s Planning Commission, asserted that the Indian government recognizes the value of traditional midwives.
“It is true that despite the fact that and we have pushed so hard on institutional delivery, many women are still delivering at home,” Ms. Hameed said at a recent conference in New Delhi to promote breastfeeding programs. “These dais are the ones who are a bridge between life and death for them.”
“We are very supportive of not letting go of this institution of midwives,” Ms. Hameed said.
In the absence of a well-trained cadre of community-based midwives who can handle complications and with no government plans to retrain the traditional attendants, rural woman who don’t trust the health care system will remain vulnerable to pregnancy-related deaths.
Midwives in Uttar Pradesh told Ms. Pinto that even though local women were offered incentives to give birth in facilities, the government first needed to follow a popular proverb: “First, you set your house in order and then invite guests.”
This story has been facilitated under the OneWorld-POSHAN Fellowship grant.
Source: Medico Friend Circle List serve
Shared by Jagannath Chatterjee (firstname.lastname@example.org)
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