India has exceptional maternal health, regulatory and consumer laws to protect pregnant women, but to make this a reality for many women, there needs to be practical support, respect for, and recognition of, the human rights of pregnant women, including her right to privacy.

Human rights in childbirth do not stop with the right to informed consent and refusal. Informed consent is one of the many rights that need to be maintained in healthcare systems to ensure that care is truly respectable, safe and effective.

The right to privacy insists that the legal and healthcare framework supports healthcare choices without imposing moral judgments and preferences. More generally, the right to privacy protects a woman’s right to make personal decisions about sexuality and reproduction, without interference from the state.

For a pregnant woman, this means having the right to choose the where, how and with whom she gives birth.

Respecting the right to privacy personalizes maternity healthcare

Healthcare systems that truly support the right for women to make personal decisions about the circumstance in which she receives care and gives birth will develop and adapt birth options to suit women, as opposed to systems set up for the convenience of institutions and careproviders.

In maternity healthcare systems that uphold a woman’s right to privacy…

• • hospitals, birth centers, and homebirths are all legitimized by law and in the eyes of healthcare professionals;
  • women birthing in hospitals are adequately supported to give birth vaginally, but are not denied interventions if they are wanted or needed, nor are they forced or coerced into interventions if the mother doesn’t want them;
  • autonomously practising midwives can provide primary care to women as long as her pregnancy and childbirth remains uncomplicated (low-risk);
  • women can choose to give birth at home, knowing that she can have a skilled birth attendant attend her birth and that she will have meaningful backup support of emergency care without judgment;
  • a woman can legitimately choose to give birth without a skilled attendant or with a traditional birth attendant (not because of lack of access but because of preference).

In healthy maternity care systems, the diverse needs and preferences of women are both socially and legally respected and supported. Every mother is unique and will prefer unique circumstances to give birth in that feel best for her and the law and health care needs to recognize and support that.

So, does India have a healthy maternity care climate presently?

The legitimate range of birth choices for Indian women is very narrow.

These are the typical scenarios for the Indian women:

• Women in cities can choose a private hospital birth with an obstetrician for a high financial cost. Even in private facilities, care is standardised and women are pushed to adhere to hospital systems over their own needs or preferences. In many private hospitals, women are driven to have caesarean sections for reasons that are not evidence-based, which in turn is driving up the cost of care and shifting the burden of poor care onto mothers.

• Or they can also attend busy, over populated public hospitals where they will not be seen by a known care-provider. Women in remote rural areas can travel to the nearest government hospital/health center and wait in a very long line to access basic medicalized services. Resources are so limited that they may be waiting for hours before they see the doctor, they may have to share a stretcher with another labouring woman or they may be denied much needed medication.

• Alternatively, they can stay at home to birth but there is a risk that this will be without the assistance of a skilled birth attendant or medical support if needed.

What is a professional autonomous midwife?

In India, an autonomously practising midwife does not have legal recognition. The only “professionally recognised midwives” in India are General Nurse Midwives (GNM)- these are hospital trained nurses who take an additional minimal amount of training to include midwifery in their care- or Auxilary Nurse Midwives (ANM)- health care workers in the primary and sub health centers who primarily deal with preventative infectious disease care and family planning services. They cannot and do not operate outside the hospital framework, nor do they provide primary care to pregnant and birthing women.

This is inconsistent with the definition of an autonomous midwife given by the International Congress of Midwives (ICM).

In substance, an autonomous midwife is a primary caregiver for a healthy pregnant woman with a low-risk pregnancy and birth. GNMs and ANMs are not trained to provide primary care to women. While hopes were higher for ANMs initially when training programs started in the 1950s, over the time their scope of work charged and at this point, “[h]er activities for maternal and child health are limited to distribution of iron folic acid tablets and immunization to mothers and children.” (1) GNMs and ANMs are trained to provide support services for women and require continuous supervision by, doctors and/or obstetricians. In the truest sense, they don’t live up to the definition of an autonomous midwife.

Autonomous midwifery and medical obstetrics are two separate professions.

Trained midwives can confidently support normal, non-complicated pregnancy and birth, and know when to refer a woman to an obstetrician for assessment of a suspected complication. Trained midwives dedicate the time, patience and knowledge to supporting a normal, healthy delivery and then continue to provide post-natal care and support for mother and baby. Midwives are not surgeons, they can not perform instrumental births (use forceps or a vacuum to assist birth) or perform cesarean sections.

Obstetricians, on the other hand, are surgeons. They are trained to look for problems, assess risk and diagnose complications. They assist women through complicated pregnancies and perform surgical interventions. Obstetricians can, but do not, provide post-natal support for mother and baby in areas such as breastfeeding, parenting, eating and sleeping issues, unless it requires medical intervention or diagnosis. This is an advisory service that trained midwives excel at providing and that mothers really value.

There are also traditional birth attendants, like the dai who practice midwifery but have never received state-based training and/or recognition. Dais usually learn from and hand down knowledge to each other in a form of an apprenticeship. Dais still attend a significant portion of births for women in remote areas. Dais are sometimes sought by urban-dwelling women who want to birth at home. Dais provide such a substantial portion of informal maternity care that they deserve recognition, support and integration into state-based systems.

Different professions, different approaches

When it boils down to it, midwives are “experts” in normal, vaginal and physiological birth. Obstetricians are experts in managing complications during childbirth and performing surgery. An Obstetrician’s skillset is focussed on seeking out problems and using those problems to escalate care until they decide there is a need to use interventions to manage birth and delivery. Look at the “Labor and Delivery” section from the textbook William’s Obstetrics. Of the almost 200 pages on labor and delivery, only about 35 of those pages are dedicated to “normal labor and delivery” with an additional 15 pages about assessments (many of which are often interventions in themselves).

An obstetrician’s speciality is in managing an “abnormal birth” or birth that requires medical management or interventions in order to to ensure a good outcome. This is an important role, but should be confined to those in need. With proper care and management during pregnancy, the majority of births can be uncomplicated.

If, on the other hand, we look at training for autonomous midwives, their focus is on supporting normal, non-medicalized childbirth and on preparing a mother for labour, delivery and parenthood. The books student midwives read are not obstetrics books. Some of the content in obstetric textbooks and midwifery textbooks undoubtedly overlap, but midwifery books focus on supporting women through low-risk, normal pregnancies and birth. Autonomously practising midwives in other countries tend to have high rates of vaginal births, much greater success with VBACs (vaginal birth after cesarean) and with promoting breastfeeding.

In the US, part of the requirement to become a Certified Professional Midwife, students have to attend a minimum of 55 normal births, both in hospitals and out-of-hospitals. This means, the midwife is specialized in supporting vaginal birth in a variety of settings in the USA.

Why India needs midwives

In India, obstetricians have been put in charge of all pregnancy and birth. Difficulties arise with shortages of doctors and overemphasis on the medical supplies and technology. Staff respond to the institutional shortages by aggressively implementing standardised interventions or abusive processes that are not evidence based and detrimental to the health of mother and baby.  

One result is the now familiar complaint about skyrocketing intervention and cesarean rates. Also, medicalization of birth has strongly influenced social beliefs about birth such that the value and significance of normal birth to women’s and families’ health and wellbeing has been degraded, not just in healthcare settings, but also by pregnant women and/or their families.

Midwifery model of care for low risk pregnancies reduces the likelihood of women using epidurals, receiving episiotomies, having instrumental births and/or cesarean sections as well as increased rates of spontaneous vaginal birth and rates of breastfeeding (2). This means less need for ever-present medical personnel, less need for medical supplies and, ultimately, freeing up the financial resources needed to hire more staff!

While we need obstetricians and nurses, the women of India are starting to recognise that midwifery is an essential component of supporting the right to choice and making the birth climate healthier. GNM or ANMs alone cannot offer the midwifery model of care under which midwives autonomously provide non-interventionist, evidence-based, collaborative, continuous and culturally sensitive care in a holistic and respectful way.

In England there is a saying “Don’t throw the baby out with the bathwater.” The fight to reduce the maternal mortality rates in India cannot be at the expense of her rights and options so that the healthcare system controls her body, not her.

Foreign midwife and speaker in the upcoming HRiC Conference Lina Duncan believes that the heritage, intuitive knowledge, traditions and practices of the dais could enhance childbirth in India once again. According to her, “If only we could create a system that utilises best practice and a mutual respect for the medical, traditional and midwifery model of care, we could be onto a win-win method to not only save lives but also reduce maternal and neonatal mortality.”

We have seen glimpses of culturally attuned healthcare empowerment in India, like Dr. Abhay and Rani Bang’s SEARCH Foundation or Janet Chawla’s Matrika foundation, though there must be many others that probably are not so well known.

A last word

The right to privacy is about respecting women’s choices over her careprovider, her place of birth and how she gives birth. A thriving maternity healthcare system will support and respect the options that women make in pregnancy and childbirth.

Can India achieve the same? Can India diversify its legitimate settings of care to implement human rights in childbirth? Let’s collaborate to make it happen!

Come to the Human Rights in Childbirth Conference in Mumbai this February to discuss how we can, together, make pregnancy and birth better for all women!

(1) Mavalankar D, Vora K. 2010. The Changing Role of Auxiliary Nurse Midwife (ANM) in India: Implications for Maternal and Child Health (MCH). INDIAN INSTITUTE OF MANAGEMENT AHMEDABAD.

(2) Hatem M, Sandall J, Devane D, Soltani H, Gates S. 2008. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews. Issue 4. Art. No.: CD004667.

Learn more, say more and make birth better by attending the Human Rights in Childbirth Conference in Mumbai, India.

Sign this petition to make it mandatory that Indian hospitals declare their c-section rates!