28/03/2016
It’s a pleasant February evening in Kochi. Rendition of Rag Chandrakauns by Pandit Hariprasad Chaurasia, accompanied by Ustad Zakir Hussain, adds to the serenity of a room filled with the aroma from scented candles. A woman, sitting on the birth stool, rests her face on her husband’s lap. Every nerve, every cell in her body concentrates to unfold the nature inside. A vigorous shivering. "Dear, we are almost there," her husband whispers, as she makes a final push. A baby’s cry pierces the air. The man hugs his woman weeping with joy. The baby girl is put on her mother’s breast, father cuts the umbilical cord. Smiling midwives wave their hands, leaving the new family alone to cherish the moments.
When Neetu Krishna, a 28-year-old banker in Thrissur, became pregnant with her second baby, she didn’t want to go to a hospital for delivery. Krishna had a traumatic caesarean section for her first baby two and a half years ago. Still, no one, including her husband, who himself was home born, was convinced about Krishna’s decision to avoid hospitals. But she was adamant.
"During my first pregnancy, I’d told my doctor that I want a normal delivery. Everything went perfect; I had my medicines and ultra sounds throughout, but I still ended up with a C-section, I don’t know why," Krishna says. "My discharge summary said I had an elective C- section. I felt cheated."
That experience prompted Krishna to do some research on VBAC (vaginal birth after caesarean) and natural birthing facilities sans medical interventions. After weighing all the pros and cons, she eventually decided to go to Birthvillage, a natural birthing center in Kochi, where Donna Mitchell, a mother of nine home-born children, was one of her midwives. Krishna delivered a baby boy weighing four kilograms in January. Her first baby was 3.6 kilograms.
Like Krishna, a tiny number of women in Kerala are opting for out-of-hospital births, as they seek to avoid a medically assisted delivery to instead have a sacred and empowering experience in the presence of their partner. Birthvillage, founded in 2010, handles an average six to seven births a month now, as against two to three when they started, according to Priyanka Idicula, midwife and director. Idicula claims a success rate of 98% for VBACs and as much as 98.5% for other natural birthing cases at Birthvillage. The transfer rate to hospitals in case of possible complications is 2% a year, and that situation arises mostly because of the woman’s fear and pressures from the family, she says.
Birthvillage allows the woman to take control of her labor. She can select her birthing positions based on her comfort, and the baby chooses it’s time to come out: no hullabaloo over due date. The center’s philosophy of involving the husband in labor and post-natal care gives a totally different experience to the parents, says Idicula, who argues that normal deliveries through induced labor and labor with epidurals (pain relief drugs) and episiotomy (surgical incision of the perineum) in a hospital are not really natural births.
"Pregnancy is a normal life event; it is not an illness requiring any medicines or assistance of instruments," Idicula said. "No debate, there are genuine complications that need advanced medical care. But it’s a small percentage."
While Krishna chose an assisted birth at Birthvillage, mothers like Reba Paul, a Malayalee writer based in Bengaluru, selected a totally unassisted childbirth at her home eight years ago. As a custom, she visited hospital till her 36th week. But the death of her mother due to MRSA (Methicillin-resistant Staphylococcus Aureus, a superbug resistant to antibiotics) contacted from a hospital, prompted her to opt out of medical system. Paul says a completely healthy pregnancy very rarely turns complicated, and even if there is any problem, it can be detected early.
"Only recently has birth become the domain of doctors and hospitals," Paul said. "We reached a stage where we can no longer think of pregnancy without fear. It’s a betrayal against women."
People like Paul are championing normal births, as surgical births are rising in Kerala. The percentage of C-sections is as high as 41% in the state, according to a report by ICMR School of Public Health. The World Health Organization, which recommends a C-section rate of 10% to 15%, has said at population level, C-section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates. C-sections can cause significant and sometimes permanent complications, and should ideally only be undertaken when medically necessary, it said in a report in 2014.
"With surgical births as high as 41% in parts of Kerala, it is likely that as many as half may be getting unnecessary operations," Dr. Neel Shah, an assistant professor at Harvard Medical School and the head of an NGO 'Costs of Care,' wrote in an e-mail to Stance. "The risks of harming the mother like severe bleeding, infection, organ injury are three times higher with surgery compared with normal birth. Surgical births also require longer recoveries and cause more pain and suffering."
Not all doctors share this view though.
"Pregnancy is not that much straightforward now. Maternal complications are very common," says Dr. Lalamma Joseph, a retired gynecologist from government service. "You are living in a stressful environment and this reflects in pregnancy too. Besides, many women are not medically fit these days and they can’t expect to have a normal delivery."
Some mothers also want to deliver their baby on an auspicious date so that his/her future is secured. For some others, a C-section provides an easy and painless delivery. "So it’s not always the care provider who insists on a C-section," says Dr. Joseph.
Differences apart, supporters as well as opponents of clinically assisted delivery are unanimous about one thing: life style is a major factor determining natural birth. Life of Hilal and Biji Hilal, naturopaths and farmers from Palakkad, underscores this. Their first three children were born in hospitals without any medical intervention, and this experience led them to go for an
unassisted home birth for their fourth child two and half years ago. Biji Hilal's diet included only tender coconut water and half or uncooked food in the third trimester.
Many such unassisted home births are taking place in different parts of Kerala, as advised by this couple.
However, Dr. Manoj Babu R., an obstetrician and gynecologist at Cherthala’s Kinder Hospital, is strictly against attempting home births.
"In the west, birth centers are common. There midwifes go to expecting mother’s home, and in case of complications, the mother can easily be shifted to hospitals," Dr. Babu said. "Here we don’t have such facilities. So institutionalized delivery is safer."
Supporters of clinically assisted delivery point to the low newborn mortality rates in Kerala. The state’s neo-natal mortality rate was 13 per 1,000 compared with 35 per 1,000 at the national level. However, doctors like Babu and Piush Antony, a social policy specialist at UNICEF, don’t connect these factors together, saying institutionalized deliveries and access to medical care are the main reasons behind such an achievement.
"Quality of ante-natal and neo-natal care, proper nutrition, access to medical care all work together in lowering the numbers," says UNICEF’s Antony. "It can’t just be attributed to increased C-section."
Circa 2014. A 31-year-old woman with hyperemesis (severe vomiting and weight loss) in the first trimester and blood spotting thereafter was prescribed hormone medicines and 10 month-long bed rest by her doctor. That made her more anxious. In the two-minute appointment, her doctor pooh-poohed her whimpering, dismissing it as common symptoms among all pregnant women, and clearly overlooked a case of prepartum depression. She was heading for a possible C- section, perhaps even a pre-mature baby and a bout of postpartum depression.
But her determination, her husband’s support and care from Birthvillage, all worked together to rewrite her destiny on that February evening in Kochi two years ago.
(Photo credit: looseends via Foter.com / CC BY-NC-SA annegbt via Foter.com / CC BY-NC-ND
Waleed Alzuhair via Foter.com / CC BY-NC-SA
Jlhopgood via Foter.com / CC BY-ND)