Labour of Love

There’s a rumour doing the rounds that the Duchess of Sussex, Meghan Markle, will break royal tradition and engage a doula. “Meghan Markle hires ‘specialist hand-holder’ as birthing partner" read one headline, accurately describing what a doula is, but, inaccurately, the fact that she would be around for Markle’s spring delivery. The plot thickened as Hello magazine revealed prospective doula Lauren Mishcon’s convoluted connection with the royal family—the law firm of her husband’s grandfather handled Princess Diana and Prince Charles’ divorce.

Though Mishcon went on to deny the claims—using a wink emoji and everything—closer home it’s no dredged-up rumour that the trend of doulas, professional midwives and natural births is slowly gaining ground among well-to-do urban Indian women.

The growing inclination to engage doulas and professional midwives, or opting for natural, alternative birthing practices, is a nod to old birthing traditions. Usually, these entailed women having the support of older women from the community during the process of childbirth—someone who provides knowledge and wisdom passed down generations. As modernity and medicine take the place of historical support systems and joint families give way to nuclear structures in urban India, a professional doula provides similar assistance, but with dedicated training and knowledge of the medical aspects of birthing and labour.

Though doula training in India is hard to come by, internationally trained and certified doulas are helping other aspiring birth-support providers to learn the requisite skills, through non-medical, professional programmes that teach positioning, massages, relaxation techniques, gathering information on hospital procedures, making a birth plan, communication, self-care, trauma-care and pre- and peri-natal psychology.

In contrast, professional midwives are trained to deliver children and usually have a degree in nursing. Within the country, professional training lasts six months and is clubbed with nursing specialization, but some women are now doing courses abroad and gradually introducing midwifery as a stand-alone profession, both independently and with hospitals, given the emerging demand for natural births.

“India’s traditional dai is almost extinct and we have lost an entire knowledge system that was carried through women," says Subarna Ghosh, co-founder, ReRight Foundation, an NGO that works in the field of reproductive rights. Ghosh claims midwifery, a profession long associated with untouchability and discriminatory caste practices, can be a solution to the country’s maternal health challenges. “Midwifery has been proven to be the ideal way to beat increasing Caesarean surgeries in low-risk mothers. Midwives can help us counter the shortage of doctors and drive us close to universal health coverage," she says.

Rise of the midwife

Kanika Aswani, 34, a therapist from Mumbai who now lives in Goa, delivered her baby at her home in Andheri West, in the presence of her husband, brother, sister, mother, a doula and a professional midwife from the UK. The family helped set up the birthing pool, kept the water at her body temperature and made sure the beds were covered with double-sheets and shower curtains in case she wanted to move. Her husband wiped Aswani’s forehead with a cool washcloth, and massages and motivation were forthcoming from the others. She delivered her baby in the water, with soft lighting and the support of her loved ones. She held the baby almost instantly to her skin, and her husband cut the umbilical cord with the medical-grade apparatus provided by the midwife.

She says that even though she always had a doctor on call through her pregnancy, this was a significantly better procedure than the intrusive and impersonal birth she knew she would have had to endure in a hospital. “I felt birth was a private and intimate process. A child comes into a safer space, surrounded by people they will be brought up by. The hospital didn’t make sense to me," she says. “That’s the kind of support you want. And not something disconnected. This is a more intimate and connected way of being."

Lina Duncan, who delivered Aswani’s baby, was the only professional midwife in Mumbai at the time—a fact she herself found surprising. In the nine years she lived in the city, she worked in collaboration with Indian doctors, since she could not be licensed as a midwife here. She started from a majority expat client base, but found she was eventually working more with local women towards the end of her stint.

“When we interfere with the birthing process and make them lie on beds and strapped to all kinds of gadgets, that’s when the Caesarean rates go up because the baby doesn’t like lacking oxygen like that," she says over the phone from the UK. “Women can be in the shower, leaning on the sofa, walking around the balcony, walking up the stairs. If birthing was slow and you’re on a clock and the waters have gone, we would ask them to walk up 12 flights of stairs, get to the roof, have a walk around. And then as soon as we got back down, boom, the whole birthing process had ranked up a gear and then before you knew it she’s pushing and the baby is coming," she adds.

Over the last 10 years, various attempts have been made to make the service of trained professional midwives available to expecting mothers in India. In 2008, Vijaya Krishnan founded Healthy Mother in Hyderabad—it operates the Healthy Mother Sanctum, India’s largest natural birth centre. The centre has seen over 1,000 births. Two years later, in 2010, Priyanka Idicula, who did her training from the National College of Midwifery, New Mexico, started Birth Village in Kochi, and, a year later, the Fernandez Hospital in Hyderabad introduced a two-year training programme for in-house nurses. Evita Fernandez, the latter’s managing director and senior consultant obstetrician, who initiated the training programme, says she did so when she realized 10 years ago that the process of childbirth had become “horribly medicalized".

“My aim is to get the midwife to be accepted by the women and the obstetrician community. This is a 70-year-old hospital and for 60 years they were used to doctors. I had to break that," she says. “And today we have women who are coming to the hospital only to see midwives. The vision is that every pregnant woman who enters the hospital should want to see a midwife first and an obstetrician only if required."

Rinku Sengupta, senior consultant, obstetrics and gynaecology, Sitaram Bhartia Institute of Science and Research, Delhi, agrees. She believes this will not only lead to lower intervention, but create a synergy wherein doctors will see only women who come in with high-risk pregnancies, while the midwives can effectively tend to low-risk women. “We are trying to train our nurses. Sometimes labour is such a private affair and trained midwives can manage well on their own. You don’t have to keep jumping in," she says.

The C-section phenomenon

With growing suspicion over the disproportionately high number of Caesarean sections at both public and private hospitals, women find themselves disillusioned, confused, in need of support from midwives or “advocates for mothers", as doulas are often called. The National Family Health Survey 2015-16 (NFHS-4) reveals that 19.9% of all births in urban government hospitals and 44.8% in urban private hospitals were C-section births. To put these statistics into perspective, the World Health Organization states that the international healthcare community considers the ideal rate for C-sections to be 10-15%. This is worrying, given that intrusive procedures for low-risk pregnancies should be an anomaly instead of the norm. But higher hospital bills and a general reliance on obstetricians have led to a more scalpel-driven approach.

This has also led to a need for supplementary, well-rounded care by professional support-providers. And with greater access to information online, international developments in birth support are starting to find mention among Indian birthing networks and expecting mothers on the internet. Ruth Malik’s website Birth India, which was founded in 2006 and provides a network and directory of doulas and midwives, has over 2,500 followers on Facebook. Malik gets close to five-six inquiries every week about alternative birthing and prenatal and postnatal care. Delhi-based Divya Deswal has been certified by the Childbirth and Postpartum Professional Association (Cappa), US, for more than 10 years now, and has had over 350 clients so far. She even runs a training programme for aspiring birth companions in the country, via video seminars.

“A woman well supported by other women from the community has always been a part of India’s childbirth tradition. In the current biomedical model of care, doulas can bring in the personal touch that women hope for," says Ghosh. In 2016, she worked on a research paper titled Childbirth Narratives: Voices Of Educated Urban Women, and found that a few upper-class, educated, urban women are questioning the predominant model. They are willing to break the mould of medicalized birth in order to gain greater control over their bodies and choices.

From disillusionment to doulas

Seema Kazi Rangnekar was almost completely dilated close to a month before her due date. She didn’t have time to travel from her Bandra home in Mumbai to the hospital in Breach Candy, where she and her husband had planned for their first baby to be born. They rushed to a private hospital in the neighbourhood, and Rangnekar says she surrendered to the prognosis offered by the medical practitioners there.

She waited in tremendous pain as a room was readied for her. The anaesthetist was called. In a state of panic, Rangnekar was forced to take an epidural. “I said I want to see how it goes, but he was on leave and they had called him on emergency," she says. “So he said, ‘No, you have to take it now. I have to go, I have guests at home,’ and he shouted at me, saying I was behaving like a child in college."

At 7.45pm on 14 February 2008, Rangnekar was given an epidural. At 8.20pm, her daughter was born. “I couldn’t push her out because I was completely numb. And they had to use forceps to get her out. She was born groggy because of the medicine," she remembers. “The minute the doctor went, the staff also disappeared because it was time for dinner. I was left lying on the birthing table with my legs in the stirrup. And I felt so horrible. This is how a woman is treated right after the birthing process," she adds.

Three years later, in 2011, when it was time for her second baby, Rangnekar did things differently. She engaged a doula,who, literally and figuratively, held her hand through the process of labour and delivery, helped her with exercises to ease the pain, gave her sips of water, guided her through the correct breathing patterns, told her how to push, and ensured her husband sat behind her and held Rangnekar as she delivered their son.

She looks back on the memory fondly. “When I had my first baby, I had my mum, who had been present for my sister’s delivery just a few months before and she had a very long labour. So she told me to just take the epidural. If I had a doula, they would have talked about it differently."

Today, Rangnekar has traded in her corporate job as senior manager at the German Chamber of Commerce to become a certified pregnancy fitness and nutrition educator from Cappa. She runs her own birthing centre, Sama Birthing and Beyond, and is one of a handful of trained doulas in the country who are providing support and information to expecting mothers, and even their partners—whether it is breathing techniques, lactation classes, or allaying fears about medical procedures and intervention.

Though research in this field is limited in India, a 2013 study conducted in the US and published in The Journal Of Perinatal Education, titled Impact Of Doulas On Healthy Birth Outcomes, found that doula-assisted mothers were “four times less likely to have a low birth weight (LBW) baby, two times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breast-feeding".

Obstetricians, however, have a mixed opinion on doulas and tend to view them with a certain degree of scepticism. “Doula is a great concept, but how they can work along with the doctors, caregivers and nurses needs a long learning," says Dr Sengupta. “I have seen some people who are not meeting the caregivers and just coming at the time of labour. The whole team has to work together. If the mother is only listening to the doula and not the doctor, then it’s a problem," she adds.

But Deswal, who runs BirthBonds in Delhi, and typically charges a client ₹35,000 for her services as a doula, makes it a point to factor in an introductory meeting with the obstetrician concerned. Also included in this package are three visits in the prenatal period, being present during the delivery, “from the time they need me to the time the baby’s at the breast", one postnatal visit within 24 hours at the hospital, one postnatal home visit, and another if required.

A class apart

In south Delhi’s Phoenix Hospital, Deswal stands near a whiteboard in a room on the lower ground floor, with a group of five curious, expectant (and expecting) couples looking to her for guidance. Clueless husbands worry about the pain their wives will need to endure, while women ask more specific questions about the growing rate of C-sections and the administration of epidurals.

Deswal begins her class with an analogy. “My son played pro-tennis and practised the same shot—forehand and backhand—15,000 times in the 12 years that he spent 6 hours a day on court. To expect he will miss an important shot in a match is unheard of because he has hit it so many times he can do it in his sleep," she says. “And yet we see sportsmen falter so many times at the last minute. We’ve all watched cricket. What is the difference between being able to lift the ball to that distance to the boundary or it being short?" she asks. The answer, she explains, is physics. “If you arrive at a point of anxiety to a point of hopelessness and disempowerment, muscles get tight and then the uterus muscle will also tighten. So its effectiveness to open up and work will decrease," she tells me after the class. The analogy helps women approach labour with an ease that she says will scientifically help them manage their pain better.

“A lot of people come to a doula for different reasons. Indian women say they need support, someone they can lean on, they hope their husbands don’t panic. The theme is safety," she says. “When they feel safe and heard, a lot of physiology already changes. And it affects birth. Research says that people with doulas need less pain medication, less intervention, they have more positive experiences, their breast-feeding is longer," she adds.

I ask Deswal how she would describe her role in the birthing process if the term doula didn’t exist. She fondly remembers advice that stayed with her before she had her first baby—her grandmother telling her that childbirth should be carried out haste khelte (in good spirits) and that gave her the strength during both her deliveries. “I would be proud to say I’m a dai," she says. “And if not, I’d be proud to say I’m a woman. Women nurture. I would be the wise woman—the woman or the aunty everyone traditionally called. I’m that woman in the chain link of other women passing down womanly wisdom," she adds.

And that is perhaps symbolic of the overhaul birthing systems in India need, in a world where rural women with poor access to healthcare have “too little too late", and privileged urban women have “too much too soon". Deswal closes by telling me something she once read that resonated with her—if doula was a drug, it would be unethical not to take it.