There is an Urgent Need to Humanise Childbirth in India

Childbirth, in most parts of the world, is celebrated as a happy occasion. However, many women are also subjected to pain, abuse, insults, disrespect and even death during the process of child birth. Horiuchi et al (2016), McKay (1982), Leboyer (2011), and Tew (1990) have attempted to comprehend these dehumanising practices.

Abusive childbirth practices are reported from around the world. One such shocking incidence was reported from India in the month of May in 2015. Munmun and Sarina Bibi were physically and psychologically abused in the maternity ward of a public hospital in Kolkata. They were asked embarrassing questions such as: why they were ashamed to spread their legs in the hospital when they had no qualms about doing so with their husbands? They were forced to stop shouting.  Unnecessary episiotomies (surgical incision between the vaginal and anal canals to supposedly widen the birth canal) were performed on them (Chattopadhyay 2015). 

In Brazil, a woman named Adelir was arrested at midnight and forced to undergo a caesarean delivery (also C-section) against her will. The reason cited for this was the apparent danger she would have put her child’s life in, had she not undergone a C-section. Adelir wanted a normal delivery for her third child, as she felt that the caesarean delivery during the birth of her first two children had been unnecessary. This sparked outrage and protests in Brazilian embassies all over the world (Turner and Hill 2014). Another woman, Barbara Saboya, was informed by her doctor that instead of a normal delivery as planned by her, he had decided to perform a C-section so as to be on time for a birthday party that he had to attend. Barbara immediately fled to Rio de Janeiro and had a normal delivery. She became another icon for the Brazil-led humanising childbirth movement (Nolen 2015)

Childbirth brings with it not just physical pain, but also psychological fears, traumas, and postpartum depression. Dealing with these problems alone is difficult. A woman requires care, respect, and gentle guidance especially during this time. When women are humiliated, physically abused, and denied basic comforts, care and a healthy birthing environment, it is a matter of grave concern and disgrace for all of humanity.

Genesis of the Problem

The inhuman practices seem to have their origin in the perception of women’s bodies in the 19th and 20th century studies of human physiology. The use of the allegories such as “engine-object-path” (where uterus is the engine, foetus is the object and the vaginal canal is the path) to understand the phenomenon of birth is evident in some classical obstetrics text books (Rezende 1992). This reductionist approach undermines the agency of the woman and the biological and sociocultural significance of the process (St John and Davis-Floyd 1998). In his autobiography, James Marion Sims, the founder of modern gynaecology, exhibits a strong distaste for examining the female pelvic organs which perhaps inspired him to invent the modern speculum (Chattopadhyay 2015). As Parker (2012) puts it: 

“the ancient thought on physiology distinguishes between two kinds of openings of the women’s body: One, the mouth and anus that can be ‘closed voluntarily’ and the other, the vagina that ‘stays open’ and leaks sexual lubricant, menstrual blood, lochial discharge, and yeast infections (leucorrhoea). Further, women’s womb was considered to be the ‘source of all diseases.’"(Chattopadhyay, 2015) 

These conceptions of women’s bodies increased their vulnerability to abuse during childbirth since most obstetricians were males.

Till the first half of the 20th century, childbirth was performed at home with assistance from midwives. Since the later part of the 20th century, it has been progressively medicalised around the globe under the influence of industrial and technological development (Rattner 2009). Due to this, pregnancy has been conceptualised as a pathological condition and the pregnant mother a patient (Hausman 2005). This leads to pregnant women’s loss of control over their own body. The medicalisation of childbirth ensures the regular monitoring of pregnancy by doctors and enhanced medical interventions such as use of electronic foetal monitoring (EFM), induced labour, epidural anaesthesia, episiotomy, and delivery by caesarean section (Hausman 2005; Behruzi et al 2010). 

Healthcare is now considered as an industry where the technical component is given more emphasis than the care aspect. The industrial rationality of enhancing productivity is applied to the healthcare system. As a result, caesarean births are performed like a production line to increase efficiency (Hanlon and Picket 1984; Rattner 2009). Gradually, women begin to believe that labour is an infirmity where operations may be needed to fix a setback through a caesarean. Thus, the incidence of caesarean births, most of which are unnecessary, has skyrocketed within few years. 

This depersonalisation of women leads to many kinds of abuses during childbirth. d’Oliveira et al (2002) have discussed four kinds of abuses such as neglect, verbal, physical and sexual that women patients in general and pregnant women in particular undergo in the hospitals of Africa.

It is beyond doubt that as women get acquainted with utilising healthcare services, maternal death rates decrease. However, the disrespectful treatment of women’s bodies and dehumanising practices accompanied by this, “disregards the rights of women by undermining their rights to life, health and bodily integrity” (WHO 2015). 

Brazil has a high incidence of obstetric violence. Doctors forcefully persuade women to have caesareans so that they can earn more. Lack of beds in the hospital is cited as a reason to force the speeding of labour and operate upon women during childbirth. In India, poor women who have normal deliveries are often given labour-inducing drugs, and have to experience unsafe surgical techniques to accelerate their delivery while being derided and embarrassed, verbally, and physically (Chattopadhyay 2015; Nolen 2015). Driving women to experience a caesarean delivery is a standard practice in the United States (US) and Canada, since it results in lesser foetal deaths, and thus fewer law suits against the obstetricians. This is the pattern in numerous nations despite the fact that caesarean operations have higher chances of infections, and involve heavy blood loss, blood clots in legs and lungs, and nausea (Hausman 2005). 

Humanising Childbirth Movement around the World

The humanising childbirth movements encompass diverse forms of activism. Although humanisation may have several meanings, almost all the organisations striving for humanising childbirth agree upon women’s human rights and provision of evidence-based care as the core values of their movement.

Various forms of activism for humanising childbirth are evident in Brazil. Rallies such as We Are All Adelir (regarding Adelir’s forced C-section birth), for handing letters of dissent to Brazilian embassies, were organised worldwide on 11 April 2014. These rallies, coupled with Brazil’s Stork Network National Campaign and the Childbirth is Normal movement, led the Brazilian Health Minister Arthur Chioro to announce new health measures in January 2015. Under this legislation, it became mandatory for doctors to provide patients with a risk sheet of caesarean operations along with a partograph, while proving to insurance companies that the operation was necessary for patients to have them pay for the operation. 
In the US and Canada, doctors ensure that their patients opt for a caesarean delivery so as to avoid lawsuits and the loss of reputation, in case something goes wrong during natural childbirth (Tuteur 2010; Collins 2015). This has led to a flurry of rallies and demonstrations in North America. Most of these are spearheaded by an organisation called Humanize Birth. 

To increase awareness about the risks associated with a caesarean operation, and to help women take informed decisions, Simone Diniz, assistant professor at Sau Paulo University and member of the board of directors of the Network for the Humanisation of Birth (ReHuNa), has been actively touring Brazil and other countries such as India where there is a need to sensitise people about humanising childbirth. ReHuNa advocates for the adoption of best practices in perinatal care, and a reduction in unnecessary interventions in the process of pregnancy, childbirth, and breastfeeding. Many conferences are also being organised for promoting the humanising childbirth movement. 
The most recent humanising childbirth conference was organised in Brasilia in 2016. It aimed at reducing maternal and perinatal mortality and morbidity; reducing the rate of unnecessary caesarean operations; guaranteeing sexual and reproductive rights; humanising prenatal, childbirth, and postpartum care system with change of care model; and democratising healthcare services.

Major movements and organisations working towards humanising childbirth are as follows. Artemis^[1] is a Brazilian non-governmental organisation (NGO) actively endeavouring towards eradicating all forms of violence against women including obstetric ones. The UK’s Positive Birth Movement^[2] emphasises would-be mothers’ freedom of choice, access to right information, control and respect while aiming at eliminating negativity from childbirth. Humanize Birth^[3] is a grassroots NGO in Canada campaigning for women’s basic rights for respectful, peaceful, and humane childbirth (Humanize Birth nd). Birth India^[4] is a non-profit organisation striving to ensure women’s reproductive rights, eradicate abusive childbirth culture, promote best childbirth practices in India. Human Rights in Childbirth (HRiC)^[5] is a US-based global charity organisation working for promoting basic human rights of pregnant and birthing women.

The WHO mandates that the rate of caesarean operations be not more than 10–15%. However, it is observed that this rate is much higher in many countries of world, especially in private healthcare facilities. In order to prevent and eliminate disrespect and abuse during facility-based childbirth globally, the following actions has been prescribed in a statement released by the WHO which has been endorsed by over 90 countries (WHO 2015).

These are: (i) greater support from governments and development partners for research and action on disrespect and abuse; (ii) initiate, support, and sustain programmes designed to improve the quality of maternal healthcare, with a strong focus on respectful care as an essential component of quality care; (iii) emphasis on the rights of women to dignified, respectful healthcare throughout pregnancy and childbirth; (iv) ensure the generation of data related to respectful and disrespectful care practices, systems of accountability, and meaningful professional support; (v) involve all stakeholders, including women, in efforts to improve quality of care and eliminate disrespectful and abusive practices.

Contextualising Humanising Childbirth Movement in India

The prevalence of obstetric violence in Indian hospitals has been widely reported. While in government hospitals inhuman practices such as negligence, physical abuse (such as slapping and episiotomies) and emotional/verbal abuse (such as scolding, shaming, yelling, not allowing husbands by the women’s side) are common, in private hospitals, the incidence of (unnecessary) caesarean childbirths is very high (Chattopadhyay 2015; Rao 2015). Instead of the 10–15% ideal rate of C-section prescribed by the WHO, private hospitals in India have performed 40.9% C-sections according to latest National Family Health Survey 2015–16. This rate was 27.7% in 2005–06 (Kaul 2017). 

One of the important campaigns for humanising childbirth was started in Mumbai by an NGO called Centre for Enquiry into Health and Allied Themes (CEHAT). It organised a seminar by experts from Brazil and India at Mumbai in November 2016. After much deliberation, CEHAT (in collaboration with the Department of Medical Education, Maharashtra) promised to introduce a course for medical students on humanising childbirth (Iyer 2016). The NGO Birth India is also actively engaged in promoting safe and humane childbirth practices. A few healthcare institutions, such as The Birthplace (a Hyderabad-based maternity centre) and Tulip Women’s Healthcare Centre (in Mumbai) are charging an equal flat fee for C-section and vaginal births and are thus pioneers in the field of humanising childbirth (Kaul 2017). 

Except in the few instances mentioned above, no substantial effort has been made to tackle the issue in India. A systematic movement in India in this direction is much. The movement would have to eradicate the stigma associated with the female body (especially the pelvic organs) and encourage women to speak up about their traumatising experiences during childbirth. This may inspire doctors (both old and new) to be sensitised and become more compassionate to life-giving women instead of treating them as unclean, ailing, and unworthy patients. There is also a need to specially train young obstetricians to adopt humane practices while performing their job. State and central governments would need to create institutions to train and certify midwives so that Indian women would not hesitate to avail their services. A compulsory course on humanising childbirth for students of Obstetrics and Gynaecology may be a good start.