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Through networking and education, Midwifery Today's mission is to return midwifery care to its rightful position in the family, to make midwifery care the norm throughout the world, and to redefine midwifery as a vital partnership with women.
Birth in India: One Chosen Perspective
by Diane Smith
© 2002 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today Issue 61, Spring 2002.]
Five years ago I tiptoed my entry in to India carrying within a latent, hidden familiarity with her people and culture. I was bringing with me my acquired midwifery skills and an aspiration to follow my resonance with birth as a life event that stands outside of the modern medicalized model. My aim then was to serve and experience childbirth in a world where death was part of the life plan, and birth was not controlled by medical interventions. I was taking big steps away from bearing witness to the legalization of midwifery in my home in British Columbia in Canada, and was following my bliss toward a cultural wisdom that revered birth as a sacred partner to death. At the time of my leaving home there seemed something awry in this fear-based plan to umbrella birth under a medical regime that is bound to the law rather than the eventuality of life. It was clear to me that women were paying the price of this conventional system, relinquishing their power and dignity to receive care. I couldn't in all good conscience be a player in a game that would monitor and manipulate the birth process beyond common sense and safety, to legally protect the practitioner before the honour of the birthing woman and unborn child. I couldn't embrace the guidelines of midwifery care that were being constructed to appease what appeared as a societal fear of death. When the opportunity presented itself I could travel to work in the Tibetan community in exile in Dharamsala, Himachel Pradesh, India.
Arriving, I had hoped I was bringing the best of what I had learned as sensitive, women-centered midwifery, a pioneered model born out of the women's movement in North America, which predated legalized midwifery. I had a notion that my views surrounding birth and death were more akin to the Buddhist philosophy of rebirth and that I could find a place where neither process was threatened or restrained by a medical legal system. I was less idealistic about another culture providing this for me than I was driven by a deep motivation to see women empowered in birth. My actual journey began by stepping into those Himalayan foothills. It continues to be a trek in understanding why we need to dominate our vital entries and departures into and out of life. I wanted to see birth and women restored to the original expression of Shakti, even within the realm of our futuristic scientification of life, a force that has affected almost all cultures on the planet, certainly including India and the Tibetan community in exile. Mine has been a spiritual journey out of a materialistic, mechanized world and into one that is increasingly becoming that way. It is a very personal journey, to deepen my experience of women, birth and culture. I now live in Auroville, in Tamil Nadu, a newcomer to this spirtual community of about 1,500 international and Tamil residents. Auroville stands as an experiment in human unity, having been called the city of dawn, and is situated within a rich and surrounding Tamil community of villages. It follows its own labourious course toward realization.
India, being the mother of civilization, retains an ancient heartbeat. India is also a wound of the world, catapulted into modernity, bruised and battered in the leap, an exemplar in time, a country of immense richness and diversity. From the west we look to India for what our souls have lost. From here in the east there is a gaze toward the west for what glistens in the name of progress. The two worlds have offerings to make to one another, and from my vantage point of southeast Asia I see the human spirit here being weakened in the exchange. With regards to childbirth there are gains in the availability of emergency care but the traditions around women's fertility and childbearing power are being highly threatened by the trend to give birth in a hospital setting. This, of course, is not a newborn issue, but a slow erosion that has been taking place over decades and decades of colonization, modernization and globalization. Most every midwife I know anywhere straddles these two worlds in her own way. I have chosen to practice in India for now, rather than become licensed in Canada, which is in many ways an answer to my quest to work within my own principles of care and attendance.
There are 700,000 traditional healers and dais (midwives) in India. 70 percent of the nation's babies are born at home and the dai's work is a living tradition. Ironically, modern hospitals and public health clinics fully represent allopathic medicine. There is a precarious balance being kept here between these paradigms of care. Women are being coerced and convinced by government advertising programs to leave the home and all that is traditional to give birth in environments that suggest safety and promise degradation. It is my feeling that we face a highly critical time here of losing a primal force—an ancient way—to a superficial, transient understanding of the birth process. The scales remain tipped toward tradition, while the trend is galloping toward the worst of western medicine's offerings in childbirth technology. I am grateful to be sending down roots into an India that provides me the freedom to witness change, to practice the art of midwifery without tied hands, and to have a role in recultivating women's power in childbirth through teaching and serving women. The sorrows lie in seeing women being beaten, ridiculed, abandoned, butchered and neglected in their hospital experiences. The joys are in remaining at home within tradition, teaching village dais and adding to the enhancement of their skills and in providing attitudes of sensitive care to government-trained midwives in the small health center here in Auroville, Tamil Nadu where I live.
With the trend toward hospital delivery schemes running parallel with general trends in modernity, my faith is maintained by the fact that most women in the country can neither afford to get to a clinical setting—or stay in one. The government offers next-to-free care and the stories women share of their experiences in these institutions raise many questions about why all of a sudden women are having cesareans, routine episiotomies and are treated so subhumanly by their trained caregivers. In my teaching sessions with village midwives in various parts of the country it is the women living closest to towns and cities who are being taken in for clinical "deliveries." Because the majority of Indian women live outside these catchment areas, the dais continue to do their work, though not untouched by the trend. In my previous article dated December '98 [Issue 48] I outlined their situation and the content and context of the workshops I have been conducting for them, as an effort to strengthen them in the face of this movement. This work has shown improved care with the pockets of women I have met and worked with. Myself and "Jagori," with whom I have worked closely with in providing these teachings, are in the finishing stages of a reader and manual for training village midwives. We are intending that this production, which stands outside of mainstream teaching material, is compatible with the indigenous dai and her inevitable growth into a new society.
Word of mouth and storytelling in India is women's ways of sharing their experiences. I am hoping it is an influential mode in the revolution to make birth a sane and dignified experience. Giving women a voice and a listening ear creates the critical look women must take at their own experiences to see change happen for the better, not the worse. Witnessing dais coming to sensible conclusions about the value and quality of their work and listening to the accounts of the poor quality of care women are receiving in hospitals are the truths that will hopefully activate change in the right direction. Experiencing the shared gratitudes of assisting women through birth in a dignified and respected way is heartwarming. Listening to stories of abuse during childbirth and examining why and how it can be different is heartbreaking. However we speak and whatever our stories are, I have come to see that it is a partnership between the midwife and birthing women which will create change and empowerment. Unfortunately women's lives in India are curbed and sorted out by external elements out of their control, and it is unthinkable for the abused woman to imagine what could be better for her in such a time of vulnerability as birth. I find that I just keep telling stories and have a few to share with you that illustrate the inborn strength of the women I have met, the freedom to work outside of stringent imposed guidelines and perhaps how we can effect change one woman at a time.
This is my favorite story of informed choice, a catch phrase and protocol for registered midwives. Momta was eight months pregnant with her fifth child when she attended one of my first workshops given in Delhi in 1997. The night it finished she went into labour and I was called to come see her where all the participants were staying over until their trains left the next day. Momta would have a 46-hour train ride to Bodh Gaya that evening at 10 p.m. I found her in early labour and she was quite determined to get home and have her baby there with the dai who had delivered all of her others. This seemed like an awfully long shot to me given her multiparity, and we decided to send her to the home of one of the Jagori women for the day, where she would have the company of women she knew and the local midwife Sharfi would attend to her. Sharfi had had a long night—two deliveries and a sick grandchild—and she was feeling poorly. I would do what I could to help out, respecting that I was on their turf and a visiting foreigner, taking this as an opportunity to watch a dai at work. Sharfi was in no patient or forgiving mood and wanted this baby out sooner rather than later. She came and went from the house throughout the day, grumbling about this and that while raucous parades filed by the tiny slum house celebrating Krishna's birthday. It was a loud and very hot Delhi day. Sharfi announced Momta fully and ready to push, but I couldn't agree from her outward signs of labour. She got mad and left the house and told me to carry on with Momta.
The sun was going down and the others were preparing for the long train ride home. Momta wanted to return to be with them and get on that train herself. In the rickshaw ride home she asked me to come to Bodh Gaya with her. I simply couldn't, but asked her if she just wouldn't come home with me to where I was staying. She agreed and I went on ahead of her and prepared the house quickly as an alluring nest for her to birth in. She stopped on her way to the train station with her friend Lalita and I was like a suitor seducing her to spend the night. I ever so gently and coercingly examined her and found her 5 centimeters dilated with, of course, a very stretchy cervix and well applied head. I told her she would have the baby around midnight and wouldn't she just rather stay here, my attempt at providing informed choice! No, she definitely wanted to go home, so off they went, four piled into a rickshaw into nighttime Delhi traffic with Momta perched on a lap to avoid the discomfort of the continuous bumps, all toward the long train ride to Bodh Gaya. I received a call four days later to announce that Momta had her baby on the train at 12:30 in the ladies compartment and was happy at home with her fifth girl and her familiar midwife to massage her. I felt proud of her determination to get home despite being told she would deliver soon, and satisfied to know that she had an easy birth on the train with Lalita and other women passengers!
Veronica was another story altogether. I was giving a workshop in Bihar, truly the underbelly of India. It is the most corrupt, degraded, impoverished state in the country while once being the cradle of education and birthplace of the Buddha. I was working in a protected nunnery with Sister Pilar, who is famous in the region for her tireless work with women. Veronica, her given Catholic name, came to us in the early morning wanting to deliver there with us. She was maybe five feet tall, skinny as a whip from malnutrition, standing on the tiniest feet, with a hemoglobin of perhaps five and signs of a UTI with a slight fever. She was eight centimeters dilated, in active labour with her second child on the way. It would be an incredibly hot day and she didn't want to travel to a facility that might better serve her with all these risks presenting. We had the clinic next door for antibiotics and basic emergency equipment. It seemed safer to keep her than send her on a five-hour journey in the heat, in a rickshaw on roads that couldn't really be called roads, to a hospital that might not actually serve her. Our heroism and the use of antibiotics began!
There was myself, my translator, a visiting healer from France and Sister Pilar. Veronica began to push around 9 a.m. with a full bladder and after using peppermint vapours, mud packs, ginger compresses and soaking her hands in warm water, I realized only a catheter that would empty her bladder. The one from the clinic was of a huge diameter and it took two hours to find one in Gomia that would fit. At noon I drained her bladder with great satisfaction watching urine the color of dark tea exit. She carried on pushing, continuing to try many different positions.Through mid-afternoon there continued to be slow, slow progression. Baby was fine. By 4:30 I wasn't as happy with the heart tones and our energy was beginning to deplete in comparison to hers. After a few contractions of bradychardia I insisted that nearly eight hours of pushing was enough and now we had to have the baby out. She was supported in a standing squat, her legs lifted up in a standing McRoberts—if you can imagine—and she pushed like hell to deliver her son. He was born flat and came round slowly with stimulation. His survival is nearly another story altogether but I believe he was kept in this world by the skilled hands and energy work of the woman from France. He appeared to be hovering in and out of a convulsive state, though stabilized by the healing work that was going on continuously. I began my wait for the placenta.
This took another eight hours in total. It was by now nightfall and any travel was completely out of the question. Bihar is littered with dacoits and Naxolites (bandits and freedom fighters). Nobody goes far from home at night, and brutalities in the dark are common. There was no option for transport after we began to wait. The local female physician was out of town. We waited. Though Veronica's uterus was firm, and there was no bleeding, as the hours wore on her heart rate and respirations escalated. She would only smile at us, and that was my only consolation things were okay. Her anxious family was otherwise. Custom in Bihar is to reach up inside the uterus immediately after the birth and tear the placenta out for fear it will rise up in the body and create bleeding. The bleeding and death that result from aggressive removal doesn't seem to relate to the action in the minds of the people. I was being accused of not having taken it out fast enough by a very angry mother. I attempted a manual removal after a couple of hours and felt it falling to pieces in my hand, and thought it better to just wait. I tried again after four hours to find it still more stuck and forgiving of its place on the uterine wall. We put out a call for the returning doctor to come to us in the aid of a more aggressive removal. She replied she would if she first knew who was the dai and who was the family. If either were of importance and this young woman died, her life would be in danger. We weren't, I guess.
Veronica's vitals were wildly out of normal range and her smile continued into the wee hours. It felt eerie at times. Was this some strange symptom of shock? I asked the French healer whose hands were round the clock on the unstable infant, "Tell me, is she going to make it?" She placed her skilled hands on Veronica's head for some time and confidently answered. "Yes." I, in all confidence, replied with "Good!" And this exchange felt completely relevant and positive in the face of those eight hours of pushing and a retained placenta, being with this young very compromised woman and uncertain baby. We waited, monitored her vitals, and as we were about ready to make another attempt, the physician walked in. I remember her elegance in her sari compared to our sodden clothes, and our drawn and sweaty faces after the marathon. She walked, grabbed a used glove, blew it inside out, made no introductions, plunged her hand inside Veronica and pulled out a measly, mealy placenta, told me I could have done that and left. I never thought I could have, having met the resistance I did as it seemed to fall apart in my hand. I wondered if the time was just right for plucking that fruit or if it was actually a more aggressive maneuver than I knew. The baby breastfed, Veronica had a nap, her vitals returned to normal and we took turns napping. At sunrise I returned to find her dressed and wanting to go home now, "Please." I insisted she have breakfast and we observe her up and about a bit. She complied. I have a photo of this young girl looking over her shoulder at me as she was leaving. The look on her face was one of primitive gratitude. Our minds never met, but our hearts did as she placed full trust in us while her family raged outside the hut door. I was never directly offered the sweets that came with the mother the next day because I was still being held in blame for not taking the placenta out. After months and a return visit apparently the baby boy is fine, and life goes on in Bihar for Veronica and her family.
The next three are Auroville stories. A guest from France wanted to have a homebirth with me and avoid any contact with a hospital. She'd had her first two children in a progressive Leboyer-like clinic in France, ten and twenty years before. She went post dates with those babies, was induced and experienced all of the horrors that we all know so well to accompany induction, with primarily 20 and 30 hours of active labours. I was happy to serve this healthy, beautiful 41-year-old woman. An opted-for ultrasound at 40 weeks showed everything fine. And then her due date passed. One week, two weeks and into the third I was seeing her every day charting fetal movements and listening to the baby's heart tones. She was wandering around in absolute radiance and trust, and I too felt confident with her and her healthy baby.
A little pressure from family was coming via phone calls from France. She thought another ultrasound wouldn't be a bad idea to calm them and I agreed, curious about placental function and fluid levels. We had the blessed option of walking into any ultrasound clinic in Pondicherry, receiving the results and doing as we wished with them. The service is not attached to an obstetrical system, but is used routinely by those in awe of the machine and wishing to know the sex of the baby, in order to make a selection of a boy against a girl. It's a business for the technicians and on the good side would serve us. This woman was enjoying sex for stimulation, homeopathics, long walks, visualization, massage, motorcycle rides on bumpy roads to provoke her labour, and the excitement of an occasional bout of labour starting and then stopping after a few hours on three different days. She chose to avoid a hot Thursday afternoon into town for the ultrasound to appease me and her family, and said she would go in on Monday. I remained happy with the baby's daily heart tones and movements, and remained allied with her in faith.
She began her labour (of course) on Monday morning before heading into town for the ultrasound, and we enjoyed a lovely lunch together that midway saw her into a more active labour. At full dilation and the onset of pushing her waters broke with a show of heavy meconium staining and we heard for the first time decels in the baby. She saw the concern on my face at the sight of the thick green waters and registered her own at the sound of the baby's heart rate. I had a hand inside of her to be assured the baby was descending with each push. My free left hand was an added expression to the tone and intention of my voice, for her to take deep breaths and send all of her energy into her baby's well-being and push him out. She said, "You're nervous, your hand is shaking!" I replied no, look at my hand, and it appeared before us as steady as my inner command to still it! She gave birth to a 3.5-kilograms boy after three more pushes. Afterwards she said this experience was the undoing of mountains of grief from her previous births, along with her recollection, which raised laughter and amusement each time she spoke of it as we enjoyed another good meal and French champagne in the evening. She said though my free hand was rock steady, those two fingers inside were trembling! I was so happy to not have to work within guidelines that are imposed just in case, for the sake of the law, and walk along her road of faith with her.
This twin delivery coincided with the Twin Towers disaster in NYC. I had two women in labour that day. Vigi, down on the beach with ruptured membranes and no labour, and Satya, a walk-in whom we didn't know. I was taking turns being with both of them, Satya being at the lead with her labour active. We felt the baby posterior and went the day long with her. At 8 p.m. she was fully and beginning to push. At 8:30 I was holding onto a huge bag of bulging membranes to protect ourselves from becoming soaked in the bursting of them. They broke, and as I removed my hand a tiny little girl shot forth without any resistance in the flooding of the waters. The nurse and I looked at each other in shock at her size and placed her instantly on Satya's chest and it was then obvious by her fundus there was another on the way. I looked down to see the tiniest toes sneaking out and, like her sister, she flew out breech with only the assistance of my hand to hold her. She joined her sister and we covered them both and watched them slowly come round, taking their first breaths on top of beating hearts. My goodness, twins! They both weighed just over a kilo and the first one took to the breast within forty minutes. Adhering to protocol and sending them into the government hospital seemed cruel as we watched them doing so well, huddled together at their mother's bosom, warm and happy. We knew that there they would be separated from each other in the hospital. Satya and I suspected their stability came from this triangled comfort. Anita on duty recollected how her underweight infant had been treated in the hospital and suggested we keep them, while Satya wasn't interested in going anywhere. I was happy to keep them and watch the twins carefully through the night.
Satya was surprisingly happy to receive two daughters at once and proud of the twin aspect, while her mother-in-law was stomping around outside, literally pulling her hair our, distraught with the reality. Would two boys have been better? It was sad to witness her lack of wonder in the fact that these little miracles were born thriving. Other relatives were seemingly happy and jubilant with their arrival. The girls did well through the night with a supplement of dextrose water every couple of hours. The second twin never did make it to the breast and by morning was flagging a little. We agreed to send them in for special care at this point, reason resting with the seasoned physician at the health center who said that if she died with us, Satya's village was not reputed as a rational one; come death, we shouldn't risk the potential of revenge.
They all spent the week at the hospital and did well. I visited them there and then again upon their return home. The second visit was a disheartening one—to see the twins barely bundled, cool to the touch, in the haze of the cooking fire smoke, beside the goats and children and others passing in and out. This was the beginning of letting go and simply giving my advice on how best to nurse along their survival. Satya was caring but village style simply lacks in practicality. We offered her a free stay at the clinic to keep an eye on their stability but she declined because she had her other two children to care for and her husband was away working. I see them weekly and at nearly one month they have reached 1.6 kilograms and are managing reasonably well. Satya keeps them separated with the notion that if one goes down the other will as well, though I like to see them snuggled up together for warmth and their known contact. She insists on supplementing them with cow's milk, which I tell her is too difficult for them to digest but the women around her say it is the right thing to do. I visit, and I let go each and every time marveling that these little birds are surviving, and it is really a greater will than anyone's that will see them through. We waited a good sixty hours for Vigi to go into labour and she gave birth after three hours of active labour to a 4-kilogram son around the time the second tower was collapsing.
Last night's birth at the Health Center was a testimony to what I find over and over again with village women. The trained nurses have not had the fortune of experiencing birth as we have in the west, and come from very rough and course homelives. They learn that birth is a medical event, women are valueless and have had little initiation into the power of loving touch. I arrived to find Sumati in anguish, standing, scowling and bearing the beginnings of an active labour, with the nurse making three word sentences and offering no touch to her. She had been at home for two nights and a day in an early labour where the women forbid eating, drinking or sleeping but insist on walking. I began my work, which is neither unique nor unusual, when it comes to supporting a young woman with her first baby. Her hands in mine, we made good eye contact and I started with massage. The nurse on duty watched her face change from ravaged to relieved. A long afternoon of moderately active labour and no progress was disappointing, but most affirming was Sumati's response to touch and close contact.
After massage, homeopathics, visualization and a mini-education on oxytocin release it seemed only right to rupture the bulging bag of membanes at five centimeters. Her labour accelerated with this and nipple stimulation and the power in the clinic ended with the onset of a lightning storm. I lit candles and spent the next hour in witness of a most beautiful scene with her. The nurse on duty was somewhere else, I bolted the door for privacy and Sumati began to undulate in voice and tone, and her body rocked as waves do, her strong legs rotating in the hip sockets adding motion to her body as ocean. Lightening and thunder crashed and cracked the evening sky. She went from four to fully in forty minutes and surpassed the potential of having to go into Pondicherry due to an unproductive labour. Her triumph gave her the strength and endurance to push for two and a half hours. I met her husband on the terrace and half knowingly thought…big guy! Sumati presented us with a very big girl and a shoulder dystocia that took a rotation onto hands and knees and some good hard pulling to release her. All else followed positively and well. I deeply love these young Tamil women who respond so simply and so openly to a loving touch and the support of freedom of movement, as an alternative to the standard clinical care of abuse and assault. Another depth of satisfaction comes in having so often experienced the turning of tides of difficult situations into favorable ones, with the very basic human need offered: love and affection, encouragement and faith. It is new for them to receive this, something we take for granted in our ways of birthing in the west, and with the nurses witnessing the outcomes, a small and secret revolution is in the making.
In reflection I have discovered a still-mysterious country and environment that suits my soul's journey as a midwife. I see everywhere the cultural beliefs, status of women, supremacy of medical systems and styles of midwifery education that have likely formed the experiences women have when giving birth. I am fundamentally a loner, have yet to fit into systems all so well and am grateful to have been invited into India to do this work as I see fit, while the country sits precariously, pushing blindly against tradition toward modernity. I have great admiration for the sister's out there who so courageously work for women within medicalized systems on that front, and know I am of the breed that dais come from. Let us never forget we are working together in our different ways, with one common purpose: to uphold women.
I return to this article as the new year begins. It has been a busy few months, with some of that time away from Auroville in Delhi and the Himalayas finishing the book for village dais. I left the twins to head north when they were about six weeks old and was not happy with their weight gain, along with the village conditions they were enduring as newborn, quite fragile infants in need of special care. Satya assured me she would take them into the health center weekly to have their weight checked and their conditions observed. I arrived home six weeks later to discover they had both died, and the stories of how were grossly conflicting. Hers was that they got colds and she brought them into the health center where fevers took them both in the night. The nurses had to sigh, nay, this is not so. The twins were never brought in for checkups or for sudden fevers. The mother-in-law forbade her to ever bring them in and I realized then that they had slowly withered away in the village. Had they been boys they would be alive today.
Sumati's big, beautiful healthy baby girl had also died while I was away. Her mother-in-law had given the traditional oil massage to the baby when she was ten days old. For reasons of cooling heat in the body, they customarily pour oil into the ears and nose. She was far too avid in this care and poured quantities into her nose and throat that asphyxiated the sweet infant. I spoke with some dais last week whom I had worked with two years ago up near Chennai to understand why that extreme would be taken, and they said it took them three years to stop this unsafe practice in their area.
I began my journey in India knowing I was stepping into fathomless depths in understanding something about the human condition. To date I see that every culture has its way of ignoring or revering life, and fearing or accepting death. It continues to be a fascinating sadhana for me, seeing life through the eyes of birth.
Diane Smith is a lay midwife from British Columbia, Canada who has been working in India for the last six years. She has been conducting educative trainings for village midwives and government-trained nurses, and attending home deliveries, all in honour of women and childbirth.
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