Thursday, May 1, 2008

Thoughts on Delhi's First Childbirth Film Festival



A few of Birth India's Members

Delhi’s first Childbirth Film Festival - organized by Delhi Birth Network and the Kriti Film club - came to a close yesterday evening! The last two nights have been a wonderful exploration of birth practices and experiences from around the world! I was particularly pleased to see that our audience was also quite diverse – several doctors I’d worked with in government hosptals, NGO’s, and private practice attended. Additionally, Bhimla Ji, an experienced Dai with Asha, also accompanied me to the films and gave a short intro about her work as a Dai.

Before I write a little about the films, I would like to mention some thoughts on a similar film viewing needs to be held at UNC, Chapel HIll. It is so important for women and men in college to start exploring birth, our bodies and sexuality before pregnancy even becomes a concern. To have choices in birth, we must know how birth - both natural and medicalized - shapes our society and ourselves. Ideally this education should start when we are born, but, unforunately, for the majority of people, this education usually comes after a disempowering birth experience.

From observing the dynamics between most pregnant women and their mothers/peers, I have come to believe that our birth trauma is generational – our concept of birth is shaped by the birth experinces of our mothers and our soceity. Only two generations back, women were birthing under “twilight sleep”, a drug induced state in which women lost all memory of their birth. It was routine to strapped women to the bed with lamb’s wool to prevent injury caused by the drug’s violent side affects. This is only one example of our generational birth trauma. The media's violent depicitons of birth only worsens this bondage by overshadowing positive birth experiences. The fact that a year ago I knew very little about birth or my body testifies to the need for increasing education and awareness among women and men in my age bracket! I hope that showing these films to my campus will begin to deconstruct our trauma and fear based understandings of childbirth, our bodies and ourselves as human beings.


We viewed two films on the first night, Tuesday the 29th:

BIRTH IN THE SQUATTING POSITION
Produced by Polymorph Films in association with MoysA(C)s and Claudio
Paciornik, 1979. (10 mins, Brazil)

“Filmed in Brazil more than two decades ago, this extraordinary video shows a string of entirely hands-off natural birth. In all of the births shown, the baby is allowed to make its way out of the birth canal untouched, to land softly on a blanket placed beneath the squatting mother. The few times we do see a pair of gloved hands appear onscreen, they are there only to reach out to catch the baby's head, after the baby's body has flopped toward the nest of fabric below. In each birth, the mother's body is left to its own devices during the final stages of delivery, in silent testimony to a woman's innate knowledge and power in labor. One baby is seen turning its shoulder as it leaves its mother's body, unaided by midwives or doctors' glimpse of the birthing wisdom that babies, too, possess. None of the parents are interviewed, but their faces, tears, and gestures tell us that birth can be as rapturous as it is laborious.”

This was my first time seeing this movie. The simplicity this film was really a wonderful way, if not slightly shocking because most people are not accustomed to seeing births that are this hands off, to start the film festival. The calmness of the women and gentle way in which the babies were born really set the stage for beginning to naturalize our concepts of birth.

THE BUSINESS OF BEING BORN
by Abby Epstein (83 mins, USA)

”Birth is a miracle, a rite of passage, a natural part of life. But birth is also big business. Compelled to explore the subject after the delivery of her first child, actress Ricki Lake recruits filmmaker Abby Epstein to question the way American women have babies. Epstein gains access to several pregnant New York City women as they weigh their options. Some of these women are or will become clients of Cara Muhlhahn, a charismatic midwife who, between birth events, shares both memories and footage of her own birth experience. Footage of women having babies punctuates THE BUSINESS OF BEING BORN. Each experience is unique; all are equally beautiful and equally surprising. Giving birth is clearly the most physically challenging event these women have ever gone through, but it is also the most emotionally rewarding. Along the way, Epstein conducts interviews with a number of obstetricians, experts and advocates about the history, culture and economics of childbirth. The film's fundamental question: should most births be viewed as a natural life process, or should every delivery be treated as a potential medical emergency? As Epstein uncovers some surprising answers, her own pregnancy adds a very personal dimension to THE BUSINESS OF BEING BORN, a must-see movie for anyone even thinking about having a baby.”

The audience reacted in many different ways to this film. These reactions coupled with this film really demonstrated how much the unifying essence of birth has been paved over by the heated and complex politics/economics of how we are born. It was interesting to compare this film to the way most wealthy Indians give birth. One doctor mentioned that if we were shocked by the cesarean rates of New York we should come to his hospital where cesarean rates commonly exceed 90%! This doctor also shared that he is pressured by the hospital to use their “facilities”, meaning operating room - he has received letters demanding an increase in his caesarean rate! In India, no formal data collection on medical intervention is being done and the risk of malpractice and or investigation is nonexistent. These hospitals are more interested in delivering your pockets than delivering your baby. Unfortunately, until something changes unnecessary medical interventions and caesareans will continue to climb under a cloak of little medical transparency. Sadly, being born is truly a business here in India.

We showed three films on Wednesday the 30th:

BIRTH DAY
by Naoli Vinaver (10 mins, Mexico)

“This film is the birth of the film maker's third daughter's home waterbirth, lived and narrated as a family-centered event.”

I love this film more every time I watch it! The film begins with a beautiful shot of the lush green beauty of Xalapa, Mexico. Before the birth, Naoli shares how her passion for midwifery and is shown making bread with one of her boys and pulling beets with her husband, who is a sculptor. Because of this background on her family and home, I felt that this film was an extremely intimate experience even for an outsider. My favorite part is when Naoli said that when she was walking toward her husband, she didn’t feel pain, rather the contractions felt like “love bursting out.” It certainly did look like love bursting out when she calmly delivered her baby and celebrated after with her entire family in the tub!

BORN AT HOME
by Sameera Jain (60 mins, India)

“Born at Home observes indigenous birth practices and practitioners in parts of
India (rural Rajasthan, Bihar, and the urban working class area of Jahangirpuri in
Delhi). Poised between social reality and the eternal mystery of childbearing, the film poses a critical question. When dais or midwives are known to handle about 50% of births in India, why does the state not recognise the inherited and low-cost skills of the almost one million traditional practitioners in the country? Natural birth clinics and home births are increasing in numbers in the west, but our brand of progress continues to undermine our vast and centuries-old knowledge base. There are innumerable instances where modernity has only served to reinforce prejudices. The film presents an intricate delineation of the figure of the dai who is almost always a low-caste, poor woman. Unlike medical science to whose life-saving power the best of dais pay homage, indigenous birth methods are holistic, conceiving of childbirth not as pathology but continuation of organic life. Gender and class issues are juxtaposed with images of the post-partum massage, the ritual bath, and finally the miracle of an actual birth. Mind-body, earth-cosmos become one unified whole when, negotiating the nether world of pain and labour, a new life thrusts it way up into the sun. The dai's hands are experienced and empathetic as she guides the process.”

I love this film because it was a rare and intimate peek into the world of the Dai and childbirth in India, a country where such things are usually not open to outsiders! The film really corrected the common notion of Dai being crude, backward practitioners, yet commented that just like biomedicine, the world of the Dai contains the best and worst practices. After watching this film, everyone in the audience was really questioning why the valuable skills of the Dai are not being supported by the Indian government! Government endorsement of Dai is a very complex issue – the government fails to craft programs that consider the enthnomedical knowledge of Dai, instead they lay down senseless ultimatums like immediate cord cutting, something many Dais believe to be extremely dangerous for the baby. Although, since the Dais I work with practice in a city where birth is becoming increasingly medicalized, they feel it’s important to be able to distinguish between damaging interventions and those which may save a women's life - to defend and preserve their traditions, they need a basic understanding of the medical world that threatens them. Providing them with this basic understand is impossible if government programs do not endorse Dai’s valuable skills with programs that fit their learning styles and culture.

Additionally, one of my favorite things about watching Born at Home was for those 60 minutes, we were completely on Bhimla’s turf, something that never ever happens in India! Since one of the objectives of the film festival was to portray the naturalness and beauty of birth, it was a great honor have had her there to represent a legacy of women who have guided countless babies into the world, sans technology, assisted by age-old insights, love, and trust.




Bhimla

It is so important for the Dai to feel that they are included in our natural birth movement, as they face so much prejudice from "Western" face of maternity care we sometimes appear to represent. So much of the time I spend with the Dai revolves around validation and empowerment in the face of degradation.

The last film was a water birth conducted locally with Delhi’s only other doula, Divya Deswal. Since this film, about 6 more water births taken place at Phoenix Hospital in Delhi! Watching this beautiful birth gave me hope that things can and are slowly changing.

After the films, I was able to meet Paige Trabulsi, an amazing doula who has been working in Bangalore and started the Bangalore Birth Nework. I’ve posted a link to her blog under the “Blogs I like” section on this page!

Thanks to everyone that came last night! I hope this has began to clear the way for further birth centered advocacy, education and celebration!

Friday, April 25, 2008

Cesarean Awareness Seminar and Film Showing in Mumbai!

April 22, 2008:

I spent the 18th and 19th of last weekend in Mumbai, otherwise known as “Bollywood”, attending a cesarean awareness seminar and birth film showing, organized Birth India’s founder, Ruth Malik. In typical Indian fashion, I dashed into the humidity of Mumbai running late due to plane delays and a very confused taxi driver. Thankfully, the seminar had barely starting when I slipped in beside a woman that I would later come to know as “Red” (more on her later!).

The first speaker was a Canadian La Leche League leader I, as a somewhat intimidated “to be” doula, had met in Delhi last December. Averil spoke on the impact of medical birth on breastfeeding. When a woman has a highly medicalized birth involving excessive drugs or a caesarean section, breastfeeding is much harder to establish. It is important to note that after an intervention filled births, breastfeeding is the most crucial factor in bringing about optimal physical/emotional health for mother and baby. With sky rocketing caesarean rates and profit hungry formula companies, today’s mommas need more breastfeeding support than ever! Here are some additional of the highlights I jotted down:

1.Did you know that breastfeeding within the first hour can reduce infant mortality rates by 22%? In India, that equals 250,000 babies!

2.The infant’s instinct to breastfeed peaks at 20 minutes, this instinct progressively lessens an hour after birth. After this peak, the infant goes into a dazed state lasting 1-2 days, making establishing breastfeeding much more difficult.

3. The composition of a mother’s milk perfectly fits a baby’s gestational age and nutritional needs. For example, for a premature baby, a mother will naturally produce milk that is higher in fat and other important nutrients.

4.Colostrum, besides being extremely high in antibodies and nutrients, plays the important role of lining the gut of the baby, closing up holes and preparing the stomach for mature milk. Mother’s worried about not having enough milk in the first few days following birth can seek comfort in the fact that infant tummies are the size of a marble and are perfectly satisfied by a feeding of colostrum 8-12 times a day - colostrum truly is liquid gold!

5. The formula many of you were fed 20 years ago would be illegal to feed babies today! The unnatural chemistry of formula - made from cow’s milk that has been dehydrated to remove saturated fats and reincorporate with vegetable fats – causes babies to fall a coma-like sleep as their tiny bodies attempt to digest this gastronomically foreign substance. Although the deep sleep following a formula top up may bring needed rest for a new momma, formula drastically changes the PH of a baby’s tummy, damage that may take weeks/months to rectify or, in some cases, can never be repaired.

6. In India, only 23% of Indian women feed their babies within the hour, the most essential factor in establishing breastfeeding.

7. The USA has one of the lowest rates of breastfeeding of all most all Western countries – 71% of mothers make an effort to initiate some breastfeeding, yet, 6 months following birth, only 36% of women report that they are breastfeeding
(http://www.nrdc.org/breastmilk/benefits.asp)

- To learn more about India’s new fantastic breastfeeding initiative please visit: http://www.bpni.org/

- To learn more about La Leche League in India or your area, please visit: http://www.llli.org/India.html

- For more information on the detriments of formula: http://www.nrdc.org/breastmilk/formula.asp

- For more information on why breast is best: http://www.nrdc.org/breastmilk/benefits.asp

The next presentation, given by Dr. Manisha Gogri who is also a Childbirth Educator and Mothersupport group leader, examined steps people can take to prevent an over medicalized birth. You can access some of these resources through several websites:

1. Here is a list of questions that can help you explore your childbirth choices and asses whether or not your doctor provides mother-friendly care: http://motherfriendly.org/resources/10Q/

2. For more resources on choosing a caregiver and your right to choices in childbirth, visit: http://www.childbirthconnection.org/article.asp?ClickedLink=247&ck=10158&area=27

Dr. Manisha is a shining example of the growing number of physicians dedicated to advocating and supporting the manifold benefits of natural birth!






On the Saturday the 19th, we showed three films:

1. Breast Crawl – This video was a partnership between the Indian government and UNICEF to demonstrate the new born baby’s ability to spontaneously crawl to the Momma’s breast: http://breastcrawl.org/video.htm
Note: Although this film does portray a baby’s amazing ability provide for its own needs, I think it should have been filmed in a way that provided more privacy for the women and her child – welcome to the Indian way of doing things!

3. The Business of Being Born – Ricki Lake’s new film about the state of maternity care in the US: http://www.thebusinessofbeingborn.com/
“Birth is a miracle, a rite of passage, a natural part of life. But birth is
also big business. Compelled to explore the subject after the delivery of her first
child, actress Ricki Lake recruits this filmmaker to question the way
American women have babies. The film maker gains access to several pregnant
New York City women as they weigh their options.
Some of these women are or will become clients of Cara
Muhlhahn, a charismatic midwife who, between birth events, shares both
memories and footage of her own birth experience. A must-see movie for
anyone even thinking about having a baby.”

3. Birthday – A beautiful film showing a family-center home waterbirth of filmmaker cum midwife’s third child! I recommend that all expectant mother’s watch this film!


My summary of my trip would not be complete without mentioning the privilege I had to meet to two amazing midwives who, over the course of the weekend, discovered that they had worked with the same midwife at a birth center in the Philippines – it’s a small world, especially the baby world!
Red, the first midwife I met, has been working in a rural charity hospital located in a village in Gujarat. I felt an instant connection to her as her experience in Gujarat echoes my experiences in a government hospital. After meeting her, I was truly inspired to become a midwife!
Lina, the second midwife I met, has spent the last 20 years traveling around the world as a midwife. She spoke a ton of languages and was a storehouse of knowledge about birth and life in general! I wish I could have spent more time pouring through book a overflowing with handwritten stories and pictures of births she has assisted – she said she had five more of these treasures back in the Philippines!

These two women made my 36 hours in Mumbai one of the inspiring and encouraging experiences of my life! I feel so privileged to have had the opportunity share with them stories, tears, frustrations, and dreams.

Friday, April 11, 2008

New Opportunities!

Wow, a lot has happened since I've last posted - my Mom came and visited, I escaped from Delhi's heat by taking a short three day trip into the mountains, and I have become caught up in two new wonderful opportunities to connect the West to my work here in India!

First, I would like to publically thank my Mother for all the emotional and physical support she has give me over the past ten days: she has filmed hours and hours of Dai meetings, and brought smiles to the faces of everyone she has encountered! Thank you, Mom.

Since one of my main goals for this project was forging lasting connections between maternal health issues in India and abroad. I am thrilled to announce several opportunities that make it possible for me to bring my experience home and bring home to my experience.

First, I have begun to film different areas of my work, especially my Dai meetings. The financial support of the Mahatma Gandhi Fellowship has given me the ability to dedicate a portion of my summer to editing and organizing my footage into a tangible depiction of my experience.

Second, I have began working with the founder of Birth India, an independent coalition of doctors/midwives and individuals dedicated to promoting the benefits and best practices related to natural childbirth, to forge links between foreign individuals who are interested in working or volunteering in India . We are creating a cross-cultural maternal health exchange program which helps foreign doctors/midwives/doulas volunteer or work in clinics, hospitals, med-schools and NGO's! For more information on Birth India, please visit their newly constructed website at: http://www.birthindia.org/

I am very excited to see how these new opportunities evolve over the next month and a half before my departure. On the 18th - 20th of April, I will be traveling to Mumbai to attend a conference on Cesarean section and further organize the maternal health exchange program. On April 29th and 30th, Birth India is bringing Delhi's first Childbirth Film Festival to India Habitat Center.




My Mother and I after a Dai meeting

Wednesday, March 26, 2008

Matrika

Matrika (Motherhood and Traditional Resources, Information, Knowledge and Action) began a as 3-year research project focused on North India’s traditional midwifery practices. Matrika’s methodology ventured outside of the government’s medicalized training models to explore the enthnomedical knowledge of the Dai through interviews, workshops, legends and songs. I highly encourage everyone to spend some time reading through the information on Matrika’s website: http://www.matrika-india.org/


This blog post contains a summary of key concepts Matrika has used to illuminate the enthnomedical world of the Dai.

Conceptual Pillars of a Dai’s Perspective on Childbirth and Health:

1. Microcosm-macrocosmic view of world - patterns of life and health mirror the minutia of our cosmos. The microcosmic-macrocosmic understanding of the world is founded on philosophies of equilibrium, life energy and harmonious attraction.

2. Concept of Jee – force or energy of life. Although Jee transcends the realm of physical sensations, it is often allied with heat and can be physiological defined as a pulse or rhythm within the body. Physical and emotional health is a product of unobstructed Jee. In India, the flow of Jee is regulated by many traditions such as massage and yoga.

3. Narak – The meaning often rendered by Narak can be translated as the hell or domicile of demons, although the Dai often illustrate Narak as a place deep beneath the earth where the energy of life and the body reside. The Dai’s perspective of Narak, as sacred and nurturing, diverges radically from that of the Pundits, holy texts and caste-oriented people, who identify Narak as “filth” or “pollution”. For many people the concept of Narak encompasses both birth and menstruation; thus menstruating women are prohibited from visiting temples, mosques and interacting with holy texts. Nanak’s association with pollution lends insight into why most Dai come from low caste backgrounds. Since the Dai often deviate from polluting concepts of birth, for them, Narak represents the time in which a women’s body is “open”, preparing for birth though releasing of bodily fluids and lochia. Matrika says that Narak, “Signifies the inner world of the body, which is invisible to the human eye.” The aim of many of the Dai’s therapeutic practices are to positively influence the inner-body without compromising the outer-body. Non-threatening techniques include massage, herbal therapies, and alternation between hot-cold foods/poultices and enforcement of privacy. Matrika also sights that postpartum discharge is connected to the concept of “bad blood” - blood that the Dai believe nurtured the baby and, now with its task finished, must leave the body after the birth. Matrika is keen to point out that skilled Dai can plainly distinguish between normal amounts of discharge and postpartum hemorrhage.

4. The cosmic significance of the Mother-baby umbilical cord connection - postponing cord cutting, until after the placenta is released is a strong tradition, imperative among most Dai. The Dai believe that severing the cord directly after birth or before it stops pulsating aborts the important flow of Jee between Mother and the baby. Many Dai often claim that the baby’s life source is housed in the placenta; when a baby has problems breathing the Dai sometimes rouse the flow of Jee by placing the placenta on a hot surface.
Some traditions regarding the placenta often seem contradictory.
Due to caste and gender inequalities, tasks related to the placenta are sometimes assigned to a woman who hails from a caste lower than the Dai. Some communities honor the placenta by burying within in the home and praying to incur health and prosperity for the child.

All the Dai I have interacted with completely discount biomedicine’s practice of immediate cord cutting. The Dai from Asha NGO have commented that delayed cord cutting helps the child breathe and decreases the amount of shock they experience. In their support, there is actually no scientific reason to explain instant cord cutting - many doctors and midwives have begun to delay cord cutting until after the cord stops pulsating to ensure that the child receives an optimal amounts of blood and oxygen. In 2007, the American Medical Association published a study which found that delaying cord clamping for a minimum of 2 minutes after birth has both immediate and delayed benefits for the baby. For babies born at term, both newborns and infants reaped the benefits of an increased blood volume and iron status. (http://jama.ama-assn.org/cgi/content/full/297/11/1241).

5. Hawa-Gola – Though often used as a pair, the colloquial translations of Hawa and Gola are ‘wind’ and ‘round’. Burra Hawa, or bad wind, pertains to the activity of damaging spiritual forces. Though many Indians laugh because the chapattis I roll are not ‘goli’, within the Dai’s context, gola has come to describe energy (which was believed to have formed the baby) leaving the body in the form of ‘bad blood’, known in biomedicine as postpartum hemorrhage. The Dai consider postpartum retention of Hawa-Gola extremely dangerous, they describe a retained placenta by saying the placenta has “moved high into the body”. Often pain after childbirth is attributed to the gola searching the womb for the newly born baby. Symptoms of this ‘searching’ are identified as the sudden cold or shakes women typically experiences after their warm child is leaves their womb. Many Dai control shakes and cold by feeding the mother warm food and placing a heated clay pot on her abdomen.

6. Bemata – Among Dai, Bemata is conceptualized as an old women who resides underground, sculpts babies out of the earth and inscribes futures on children’s foreheads after birth. Bemata posses a dual power to harm and nurture: she grows and protects the baby in the womb but becomes the cause of complications if she does not flow away with postpartum bleeding within six days postpartum. Matrika describes Bemata as “diagnostic tool” used by the Dai to evaluate the postpartum health of the baby and mother, as they do not posses biomedicine’s practice of Apgar scoring etc.


The Shortcomings of Traditional Midwifery are Multifaceted:


Matrika has made it a point to examine the common notion that traditional midwifery practices are always unsafe and the cause of birth-related complications. Matrika wisely points out the Dai typically serve sections of the population victimized by poverty, malnutrition, polluted water (approx. 6-70% of India’s water is severally polluted!), lack of resources and violence related to caste-gender inequalities. Matrika calls for the grip of poverty to be held as equally responsibly for maternal complications as the guiding hand of the Dai.
The question is not whether or not the Dai and poverty stricken mothers reject emergency procedures but whether or not they even have access to life saving services. When we take this view, the problem becomes focused on what the Dai do or do not do and more focused on the access and lack of resources. Matrika illustrates this problem by saying that even if a medical practitioner – trained in all the latest life saving procedures – was present at birth, they would not be able to implement most their knowledge sans the assistance of proper equipment and a surgical environment. I have seen that the policy of institutionalized birth fails when even when women are institutionalized in hospitals, as many government hospitals lack the resources necessary to perform life-saving procedures!
Besides poverty, another impediment to the call for “Safe Motherhood for All” stems from the fact that WHO and Unicef do not include Dais in the category of “Skilled Birth Attendants”, defined as a person who is capable utilizing pharmaceuticals during birth. There has been little attempt to partner with or educate Dai, even though they are largely responsible for all the births in rural and slum areas. Dais are considered unable to obtain qualifying skills due to the fact that they are often illiterate and come from low castes and socioeconomic standings. The situation is worsened by the fact that Dai are often blamed and insulted by medical staff when they bring woman to a hospital after identifying a complication.
Since Asha has recognized the fallacy of position held by most policymakers and caregivers, they have worked with the government to provide many Dai with training and delivery kits. Giving Dai acess to resources and information has helped them identify and eliminate detrimental practices and work more smoothly with the medical system when problems arise.
Hopefully, advocates of Safe Motherhood will dig deeper into the social/economic reasons behind maternal deaths and will come to see the Dai as one of the missing links to increasing the efficiency of their initiatives.

Thursday, March 20, 2008

Dai (TBA) Meetings

Meetings with traditional Indian midwives(TBA) called Dai are conducted at different Asha centers located in slums scattered throughout Delhi. These slums include: Ekta Vihar, Tigri, Mayapuri, Chandipuri, Zakhira and Kalka Ji.
After observing the success of Asha’s empowerment programs, I realized that it was vital for the Dai groups to maintain a similar structure. Asha and I tried to create an environment where the Dai’s traditions were not overshadowed or marginalized by biomedical knowledge but, instead, wedded with more recent information Asha and the Dai have designated as necessary and helpful.
Initial Dai meetings begin with stating that the purpose of the group is to create a resource pool of individual, cultural and scientific explainations the Dai find helpful. The Dai are then asked to give their names and introductions detailing their background with Asha and midwifery - some of the dai have attended to the births of more than 1,000 babies! A few days ago, when I was standing outside talking with a Dai named Bhimla, a group of about 70 children gathered around us and, while tousling their gleaning well-oiled hair, she said: “See all these children? I have delivered every single one of them as well as many of their parents!” Amazing.

Bhimla, a famous Dai working in Ekta Vihar!



After introductions, the dai are asked to share ethnomedical traditions(I find this part of our meeting to the most fascinating) Common traditions include:
1. Delyaing cord cutting until after the baby is delivered – this ensures that the baby received sufficient blood and oxygen from the mothers. The Dai believe it helps the baby to be eased, rather than jolted, into the outside world. There is actually no medical reason to support immediate cord cutting. A 2007 study in the Journal of the American Medical Association has found that delaying cord cutting for up to two minutes has been shown to have immediate and subsequent benefits for the baby. http://jama.ama-assn.org/cgi/content/full/297/11/1241
2. Having a women sit on clean smooth bricks to enhance her ability to squat. Dai from Zakhira have also said that applying pressure to mother’s coccyx, using a thick ball of cotton or cloth, decreases the women's pain and pushing time.
3. Ensuring that the a mother drinks warm nutritious liquids – milk with ghee or dhal water – throughout her labor.
4. Bathing the baby in warm water directly after birth. If baby does not take its first breathe immediately, the Dai use gentle massage rather than harsh slapping or thumping!
5. Unlocking all the locks, windows and doors and untying the mother’s hair when she begins labor. Unbinding the surrounding energy, represents the sacred opening that is occurring in the women’s body.
6. Women are often sent to live with their mother’s for 40 days, which is about the exact amount of time it takes for a women’s body to return to its prepregnancy state! This practice helps the women rest and avoid pressure from over eager husbands!
The Dai have expressed a need for a basic understanding of current obstetric practices to help them distinguish supportive medical advances from potentially detrimental concepts and practices. Such information also helps them work along side and understand the escalating number of interventions women have begun to encounter at hospitals.
For example, a question that usually arises in our meeting addresses the practice of Dais administering oxytocin (Dai under Asha have adopt the policy of never administering oxytocin). The Dai tell me that the number of dai using oxytocin, obtained from a local pharmacist, is escalating. Although not all the Dai know exactly how oxytocin functions in the body, most all agree that an injection of oxytocin usually increases a women’s pain and often causes the women to be rushed to the hospital. Before I share more scientific description of oxytocin, the Dai are always asked to share ethnomedical traditions that bring similar to that of an oxytocin injection. After discussing their experiences, a brief and contexualized scientific description of oxytocin is given: why oxytocin is usually given and its physiological effects - a picture which the Dai can usually color in themselves. I then share some information about natural ways to induce labor or increase the body’s natural oxytocin flow, along with how different positions can help labor progress. At the end of the discussion, the Dai evaluate the information I shared and identify what they would like to be translated and illustrated.
The role I play at the dai meetings is two fold. First, I am compiling a description of the Dai’s traditional practices to help Asha preserve and validate the Dai's ethnomedical knowledge. Second, I help the Dai access outside resources and information that may provide answers to their questions. Above all, every minute I spend with the Dai contributes the a hugely to what I am learning about childbirth through working in India. I am continually realizing how much I have yet to grasp about assisting women in the profound experience of birth!
I will cherish the time I spend with the Dai for the rest of my life. It is such an honor to steep in their incredible amount of experience, vivid stories and strength as well as large doses of milky-
sweet chai! These beautiful women represent a legacy of wisdom that is being buried under the proliferation of today's medical technology and concepts of birth and health.

Monday, March 17, 2008

Maternal Health in India

I feel that it is necessary to paint a picture of the global maternal situation before delving into India's maternal health statistics. All the cited statistics can be found on the website of White Ribbon Alliance, an informal coalition that seeks to weave together the maternal health related efforts of various NGOs, INGOs, bilaterals and individuals.
Please visit:
http://www.whiteribbonalliance-india.org/introduction.htm

WRA Global Fact Sheet: - Every pregnancy, anywhere in the world, faces risk. An estimated 15 per cent of all pregnant women develop life-threatening complications.
- Globally, for every two people who die in traffic accidents, one mother and 20 children die from preventable and treatable causes (WHO, 2004).
- Every minute, 20 children under five die. That means nearly 30, 000 children die every day. 10.6 million children die each year (Black, Morris & Bryce, 2003). Of these 3.1 million are from South East Asia.
- Up to a third of maternal mortality and morbidity could be avoided if women had access to information and a full range of modern, safe and effective fertility control methods.
-For every three deaths of women in their reproductive years in developing countries, one is the result of complications from pregnancy and childbirth. In India, 15 per cent of deaths of women in the reproductive age are maternal deaths.
- Worldwide, unsafe abortions contribute to nearly 15 per cent of all maternal deaths. In India, nearly seven million abortions take place annually. Post abortion care is essential to safe motherhood. (Information kit, World Health Day ’98, WHO).
- Not enough mothers and children receive existing and affordable life-saving care. Globally, just 61 per cent of births are assisted by a skilled attendant, while in some low income countries the average is as low as 34 per cent (WHO, 2004).
- HIV/AIDS presents an ever-increasing threat to both mothers and their children. Women currently account for nearly half of all adults living with HIV/AIDS (UNAIDS, 2004). This not only compromises the health of women, but it also increases the risk of mother-to-child transmission of HIV.

The Birth Realities for a Majority of Indian Women:
In India, a woman loses her life to pregnancy related causes every five minutes! This adds up to 130,000 maternal deaths per year - almost all of which are preventable!
India’s mortality ration (MMR) has reached 407 deaths per 100,000 live births, approximately 4 x higher than India’s 2010 goal of 100 per 100,000 births. A grave disparity exists between maternal health other areas of development: there has been no sign of reduction in maternal deaths for the past 10 years!
This tragedy is confirmed by the MMRs of three states (Assam Madhya Pradesh and Utter Pradesh), which equal 700 deaths per 100,000 live births. Out of those women who do manage to survive, an estimated 30 out of 1,000 will develop chronic pregnancy-related conditions.
Medical Causes of Maternal Mortality in India:

24% = anaemia
23% = Haemorrhage
12% = Abortion
10% = Toxemia
10% = Puerpal Sepsis
7% = malposition
24% = eclampsia, malaria etc.
Additional Causes:
1. Early marriages and births – 50% of women marry before 18 years-old and half of those women conceive their first child by 19 years-old. A large number of maternal deaths occur in women with ages ranging from 15-19 years-old.
Note: There is significant social pressure in India to have a child within the first year of marriage; otherwise family members will question the mother’s fertility and condition of the husband/wife relationship!
2. Lack of access to Emergency Obstetric Care (EmOC)
3. Inadequate Nutrition – average weight gain of Indian women is only 7 kg.
Note: Many of the women I support in government hospitals have stomachs as flat as mine within minutes of their delivery!
4. Other medical causes include hemorrhage, eclampsia, obstructed labor, sepsis, unsafe abortion, anaemia and malaria.
5. Absence of skilled professional – only 42% of births attended by skilled (drops to 5-6% in some rural areas)
Note: Asha NGO has made huge progress in retraining their dais and outfitting them with government certified dai kits outfitted with basic sanitation amenities and clean razors for cord cutting. This has significantly reduced the need to cut cords with rocks and other unsanitary utensils.
6. Short intervals between births – 3 out of 10 births follow a recent birth that occurred less than 24 months prior.
7. High Parity, meaning 4 or more deliveries
8. No blood transfusion
9. Lack of support from family members, especially men
Repercussions of Maternal Death:
Scars of maternal deaths extend beyond just the family, disrupting the well being of society at large! When a woman dies, a good portion of a family’s income is also lost, and the ensuing financial burden often exacerbates the poverty of her relatives and partner. Studies have estimated that the risk of childhood death, for children under five, doubles or even triples when a matriarch is lost. Other studies have calculated that, across the board, children are ten times more likely to die during the two years following their mother’s death.
In India, girl children are especially affected, as they are usually forced to relinquish their education to care for abandoned siblings.

The bite of suffering and inequality that reality holds for the majority of women around the world proves that maternal health concerns should qualify firstly as human right issues! The discrimination and lack of care found in spheres of both poverty and plenty testifies to the need for reform and empowerment of women, families, and caregivers! The way we give birth matters!

As a famous French physician named Michel Odent said:
"To change humankind, it is necessary to change the way we are born."

Hope Through Asha

I would like to dedicate this post the NGO that facilitates my meetings with the Dai (traditional Indian birth attendants).

Asha (the Hindi word for hope) NGO grew out of a young doctor’s response to a cholera outbreak that occurred in slums during 1988. Despite meager resources, Dr. Kiran Martin began treating patients at a table set up under a tree. These humble beginnings went on to develop into a one room clinic and eventually evolved into a full fledged NGO; which now serves approximately 300,000 people located in 46 slums scattered throughout Delhi. Asha was the first NGO to be recognized by the government – a step that is vital for Asha and the slum dwellers to obtain resources and support/permission for projects.

Asha's methodology of transformation revolves around empowering slum dwellers to amplify and sustain an array of environmental, medical and educational programs. Asha “adopts” slums and then implements programs that give people the power to lobby for government resources and transform ideologies concerning important issues, like sexuality and gender roles. Asha has found that the key to slum transformation is to create small clusters of women, men and children who are willing to advocate on the behalf of their communities. The groups achieve structure through appointing a president, vice-president, secretary and treasurer. The group empowerment theory was first applied to women after Dr. Kiran noticed how little control slum women had over their communities and families - women’s groups called “Mahila Mandals” have now become one of Asha’s most successful implementations. The Mahila Mandals meet once weekly to discuss a range of problems: sanitation, sexual health, safety etc. The Mahila Mandals improve their influence and ability to lobby for resources through identifying women who are willing to become CHVs (community health volunteers) and Lane Volunteers. Lane Volunteers are responsible the health and well-being of approximately 25 families living on their lane. LV's record the number pregnant women; obtain immunizations for all children under five; and spread awareness about gender issues/sexual health/sanitation.

Asha has also extended the concept Lane Volunteers into their “Bal Mandals”, groups of approximately 20-25 children. Granting responsibilities to both young and old creates noticeable solidarity in communities. Asha believes that educating the future generations - through Mandals and other educational programs - is a huge opportunity for prevention and correction of issues that rotate the wheel of poverty. For example, I often meet girls between the ages of 7-14 who can proudly list off the number of pregnant women, important awareness topics and immunizations pertaining to their particular row of houses.

Each Asha slum is outfitted with an “Asha Center” - a nexus for everything from Mandal meetings to trainings and health checkups. The centers - painted vibrant greens and blues - are peaceful sanctuaries away from the surrounding dust and chaos. The haven like atmosphere is further cultivated by beautiful collections of art work - flowers, animals, landscapes - painted on walls by volunteers from abroad. Such fingerprints of love have an amazing affect all those who work at the centers. Many times, during in the midst of a dai meetings, I am pulled away from my outlines by a picture of a vibrant butterfly or an inviting river(an especially enticing image now that the temperature are rising!)

The sucess of Asha also revolves around vibrant health programs that are well on their way to eliminating many of the diseases - dysentery, TB, typhoid, maternal illnesses, malaria, dengue fever and parasites - that typically fester within slums. Healthcare is implemented at a grass roots level by CHV’s and retrained midwives. Cases that can not be solved by CHV’s are referred to a number of clinics staffed by Asha doctors. Asha has also created partnerships with many hospitals for emergency cases. A number of buses and vans have been converted into mobile clinics in order to access people in places that are otherwise impossible. As many health problems result from unsanitary living situations and environmental pollution, Asha is motivating the slum dwellers to lobby the government for: developable land, clean water and adequate sanitation facilities. Asha is also working with the government to fight the AIDS-time-bomb that is currently ticking in India. New programs to fight alcoholism are being have also been started in many slums. are also

Due to the above programs, Asha’s health statistics are far superior to India’s national data:
+ The infant mortality rate in Asha slums is 26 per 1000 live births (the India mortality rate is 63 per 1000 live births, and in India's slums it is 100 per 1000 live births).
+ 95% of under-5s are now immunized against 10 vaccination preventable diseases in Asha areas - there is now virtual elimination of most of these diseases.
+ 97% of under-5 children are healthy for their age. In most Indian slums, only 30% of under-5s are healthy.
+ Every mother in Asha areas receives proper maternal care, whereas only 60% of mothers in India get antenatal care.
+ 100% of pregnant women in Asha areas have a skilled attendant present during childbirth, compared with only 43% in India countrywide.
+ There have been no maternal deaths in Asha slums since 2000.
+ The birth rate has fallen to 18 per 1000 population (the birth rate in India is 40 per 1000 population).
+ The number of patients suffering from tuberculosis has fallen steadily in Asha slums, and 100% of sufferers are receiving regular treatment(quoted from website).

To learn more about the amazing work Asha and slum dwellers are accomplishing, please visit:
http://www.asha-india.org/index.aspx