In terms of the healthcare system in India, times are very much a-changing. As a rapidly developing country, developments are being made from State to State however it is evident health inequalities are still rife throughout. Government funded healthcare is available to those in poverty, however the quality of some of these services are limited. From my experience, if you could afford to have private healthcare, you did.
A breastfeeding advert on Indian tv!
Maternity Services vary similarly across the country. India accounts for 15% of global maternal deaths (WHO et al 2015), has an under 5 mortality rate of 48 per 1000 live births (compared to the UK's 4 per 1000) (UNICEF et al 2015) and has a neonatal mortality rate 13 times higher than the UK (WHO 2015). The reasons for this are complex, however key factors are access to healthcare services, the urban/rural divide, the prevalence of Traditional Birthing Assistants and less thorough or regulated Midwifery training. Gender inequality, Laws around terminations and different traditions also influence women's birthing experience and the overall culture around birth.
My experience was in a small, charity-run hospital in a small village outside of the town of Palampur.
I was lucky enough to experience two births (within half an hour of each other, typical!) and a lot of Antenatal Appointments in my two weeks volunteering at the hospital. I was welcomed by the most lovely Midwives and Doctors who relentlessly plaited my hair, drew henna tattoos on my hands and told me how unfashionable my Western clothes were. They taught me an awful lot about Midwifery in India, their culture and their beliefs and welcomed me with open arms into their lives. By the time I left, I was receiving marriage invitations from the Midwives, WhatsApp chats with the Doctors and even a handful of dinner invitations!
Here's the main differences that I experienced:
- Medicalisation. Despite not having heaps of resources or expensive machines (no CTGs, dopplers or computers!), they worked in a very medicalised model of care. The caesarean section that I saw performed probably wouldn't have been recommended in England and care was very paternalistic with the Consultant/Doctor taking the lead. Choices were not fully explained and informed consent was rarely achieved. Women birthed on delivery beds (which didn't even have an end of the bed, just stirrups) in a semi-recumbent position, no birthing partners were allowed and every primiparous woman had an episiotomy. No ifs, no buts. (I asked why they do these routine episiotomies, the response was 'Well how else would the baby come out?').
- The Role of the Midwife. Midwives were more like Obstetric Nurses. Although they told me part of their training involved delivering babies themselves and taking a lead in care provision, I saw very little evidence of it in practice. Doctors were at 'the Business end' and Midwives retrieved equipment and did odd jobs in the meantime. There was very little emotional support from Midwives (or anybody at that) for the women but I was informed that this is their culture for hospital births. A review of Midwifery education in India by Sharma et al found that there was a distinct lack of confidence and competence in Newly Qualified Midwives, so I don't blame the Midwives for this. It seems that fundamentally their training programme needs developing which then hopefully will equate to better experiences for women, alongside better maternal and neonatal outcomes.
- Birth location. There is a massive push for births to happen in hospitals and it seems that women tend to consider factors such as cost and proximity to home more than those we would consider, such as maternal experiences, birth attendant, birthing environment, water analgesia etc.. A new 'Midwives on Bicycles' campaign has started to provide homebirths with a safer attendant, however I feel this is more to reduce the number of traditional birth attendants, rather than improve the home birth numbers. Nearly all homes in Himachal have electricity and running water, however that can certainly not be said for many of the other States in India. When considering cleanliness and access to services, this suggests that hospital births may actually be somewhat safer for some women.
- Hierarchy. One of the strangest things I found about the Maternity team was the hierarchy. When the Consultant walked into the room, all of us (including the other doctors) had to stand up and say 'Good Morning Ma'am!'. Three doctors would be present during Antenatal Examinations. In turn, each of them would palpate the woman's abdomen, starting from the most junior to the most senior doctor. You did not speak to the Consultant unless spoken to. I suppose this all resonates back to the Indian Cast system and although it's not used anymore, there is still a strong sense of social class structure within Indian society. It was very interesting to see this, however not massively conducive to inter-disciplinary communication or team working!
Personally managed births to go: 3 (!!!)
References:
Sharma, B., Hildingsson, I., Johansson, E., Prakasamma M., Ramani, K. and Christensson, K. (2015) ‘Do the pre-service education programmes for midwives in India prepare confident ‘registered midwives’? A survey from India.’. Global Health Action 7, 8
UNICEF, World Health Organization, World Bank, UN-DESA Population Division (2015) Levels and trends in child mortality 2015. New York: UNICEF
World Health Organisation (WHO) (2015) Global Health Observatory country views [online] available from <http://apps.who.int/gho/data/node.country> [31 July 2017]
World Health Organization (WHO), UNICEF, UNFPA, World Bank Group and the United Nations Population Division (2015) Trends in maternal mortality: 1990 to 2015. Geneva: World Health Organization
