The man with the stick
I followed consultant obstetrician Dr Evita Fernandez through the throngs gathered outside a government hospital in Hyderabad, India. Despite it being winter, the blinding sun was positioned high in the sky and I hadn’t yet acclimatised to the intense heat. The people seemed desperate to get inside, but weren’t being successful as a man on the door was yielding a stick to anyone who pushed forward. Frowned faces continued to surge onwards despite the obvious barriers. I looked towards Evita, her calm persistence to gain access gave me some reassurance as we moved closer to the door; this was my first time in India, my eyes were darting around. The man looked up suddenly and caught sight of us at the back of the crowd. He shouted, and the people instantly parted, making a human corridor for Evita and I to walk through. I felt confused. ‘Follow me’ Evita instructed, just before she bowed her head towards the guard who ushered us through the hospital door. We were inside. ‘Why did he do that?’ I asked Evita. ‘Unfortunately, Evita said, there is a hierarchy of class and colour’. I sensed this was as uncomfortable for her, as it was for me.
I knew the visit to this hospital was going to be difficult. One of my dear friends, Lesley Page, had given me some insights. But really, nothing could have prepared me. I anticipated the dank and prison like environment of the maternity hospital, and was aware that there is little understanding of the value and importance of maternal and neonatal health in India. Resources are limited, mis-aligned, and a multitude of factors influence maternal and child health. I felt a sense of dread as we approached the labour ward. I asked why there were so many barriers – crash gate constructions between each corridor and stairwell, ‘to keep people out’ Evita revealed.
We approached the double doors leading to a vast clinical area, the labour room, which consisted of partitioned areas each containing one or two steel trollies. I saw glimpses of women through the glass walls of the cubicles, and then Evita drew my attention to something. ‘Why do they not protect the dignity of women?’ I looked to where she was inferring and saw the flesh of a woman, her bare buttocks, then her genitals as a health worker manoeuvred her to change position. I felt immediate nausea and alarm, disbelief. A consultant obstetrician approached us, as she recognised Evita. Evita spoke to her and she welcomed us – a conversation ensued, and Evita turned me ‘they are busy, as usual’.
An invitation to ROAR
I spent more than three weeks in India, with Evita and Indie Kaur. Evita is a phenomenal obstetrician, committed to developing professional midwifery in her country. Evita is also influencing at a global level – she is part of several organisations and groups committed to improving maternity services around the world. Indie is a senior and inspirational midwifery leader from the UK. A consultant midwife previously working in London, and now developing midwifery capacity with Evita. Prof Soo Downe and I were invited to deliver workshops to obstetricians, nurses, midwives, doulas and all maternity workers, on the importance of compassionate and respectful maternity care. The invitation came to us after Evita became aware of our book, The Roar Behind the Silence: why kindness, compassion and respect matters in maternity care, and she had bought 50 copies when it was published to use with the nurses, midwives and obstetricians working in Fernandez Hospitals.
The day I arrived Indie and Evita explained to me that the Indian government had introduced a policy whereby women are given money to go to hospital to give birth. This had been implemented without consideration of resources or capacity, which has left public maternity hospitals unable to cope – overburdened with women and families seeking attention during childbirth – and then not receiving appropriate ‘care’. So I was seeing the consequences of this compulsory measure.
We were ushered into the centre of the room, and there I saw the horror, women led flat on the steel trolleys, naked from waist down, alone, in labour. I saw their naked genitalia as they splayed their legs, some in obvious active labour – others quiet and subdued. And all the time, attendants, some of them young nurses, chatted with each other, and carried on working oblivious to the fact that women on their watch were being abused, their human rights violated. The young obstetrician was still with us and unconscious to our horror when Dr Evita gently asked her why the women weren’t being covered, or the screens drawn, to protect their basic dignity. ‘We need to keep an eye on them’ she answered ‘just in case the baby comes out’. The women all had IVs in situ, and I was informed it was pitocin (oxytocin), though there was no titration, the drug was running freely, unmonitored. A single woman lay quiet, on her side, in the last room. She told Evita she was being observed, awaiting induction. Her face was full of fear, her body listless, and the coverless metal frame she lay on was dirty – smeared with the blood from previous women.
When we left, we were quiet. I was trying to rationalise what I’d just witnessed. Was this a cultural norm, or was it the result of loss of hope and desperation, and becoming desensitised from reality a coping mechanism for the staff? What I found alarming was the fact the workers we saw and met in this room were women. Women treating other women disrespectfully. Would these women want the same treatment for themselves of their families? It was hard for me to digest what I had witnessed, and I didn't sleep that night. And it seems this violation of childbearing women is widespread throughout India.
This shocking image was taken by Indie whilst visiting a maternity hospital last year, and represents the horror for most childbearing women in India. There are so many violations apparent in this one moment. Imagine the fear of the women, the degradation and humiliation they must be feeling. Look at the degrading scene. One of the women is covering her face. The other woman, who actually has a companion is compliant - her supporter looks afraid too. Where is the advocacy from these health care workers, for each woman? In his outdoor clothes, the doctor takes a phone call between a woman's legs, her vulva and vagina exposed. She hears what he is saying. They all do. One worker looks bored, and disrespectfully and disgracefully leans her gloved hand on the woman's leg. There is NO confidentiality, no kindness, no respect. Appalling. Do you think the two women health workers would want to be treated this way, if they had children? Why is this acceptable to them?
'When you were having sex, did you know know it would lead to this?'
In the end Soo couldn’t come to India, due to an accident, so Indie, Evita and I facilitated the workshops. The sessions were planned to include aspects of human rights in childbirth and bodily autonomy – ranging from childbearing woman’s inability to make decisions about her care, to lack of basic privacy and dignity, and outright disrespect and abuse. We used drama to demonstrate the issues, tailored according to specific needs of the each service we worked with. We travelled to and delivered sessions in 5 regions: Hyderabad, Telangana, Maharashtra, Tamilnadu, and Keralaand and approximately 600 delegates attended including nurses, midwives, obstetricians, doulas, support workers and childbirth activists. At each workshop - delegates got involved. Women and health care workers had informed us in advance of the practices in maternity services, how women were treated in general and what the specific issues for them were.
One common theme that emerged from accounts of maternity expereince was how women were birthing alone, 'not allowed' to have a birth partner of any sort. They were left alone, treated disrespectfully as described above, and beaten or humiliated routinely by doctors and nurses. This was one of the stories we worked with the develop a scene, which we enacted.
“I have to examine you. It will not hurt if you can relax.” The woman replies “how can I relax when I am in so much of pain.” The doctor answers “I am afraid I can’t help you there. Now draw up your legs I need to examine you. I have other patients waiting.”
The woman is afraid and says “please don’t these examinations hurt”. Nurse retorts “when you were having sex, did you not know it would lead to this?” Woman is holding her thighs together to protect herself against a vaginal examination. Nurse slaps woman on her thighs and screams at the woman “if you don’t allow me to examine you, I can’t help you, I will leave you and attend to other women. I need to know if you are progressing or if you need a caesarean”. The woman begs the nurse to let her mother in as she is afraid. Nurse refuses.
The photograph above is the scene recreated by 'actors' - I was the nurse, Dr Rajitha, who is one of the obstetricians from Fernandez Hopspitals played the part of the doctor, and Indie the labouring woman. We facilitated this particular workshop with nurses who are training to be midwives - exploring and internalising typical scenarios. After watching this short snapshot of disrespectful, abusive care, we invited participants to comment, with some prompt questions:
'Does this happen where you work?' At every workshop there was a resounding YES.
'Why do you think this happens?' Suggestions overwhelmingly alluded to lack of time, pressure of work. And of course, the notion that doctor knows best, and the belief that women should do as they are told. Learnt behaviours - delegates told us this is how it's always done.
'What do you think the obstetrician/nurse/midwife was feeling during this time?' We explored the potential back stories of each person involved, which opened up debates relating to fear, power structures and hierarchies. We all got to look through different lenses, and walk in the shoes of others. This was important.
'How do you think the woman feels?' This gave delagates the opportunity to really think about the woman's emotional wellbeing, and how isolating and fear inducing some of the actions are.
Would you like this to happen to you, or your sister?' Many of the nurses told us it already had. Some cried.
From cruelty to compassion - modelling behaviour
Following the discussions we revised the scenario, acting it again using kindness and compassion - here the images are demonstrating loving care - with one of the participants stepping in as the the labouring woman to experience how it felt. Evita is the woman's mother - as in the 'good' scene a birth partner was allowed to be present. Of course we were able to dispel the 'time constraints' myth; the replay took no longer than the disrespectful scene. It doesn't take more time to be kind.
Unnecessary medical intervention
In many of the hospitals both private and public, the Caesarean section rate is unacceptably high. India is a country that has both sides of the 'Too Little Too Late, Too Much Too Soon' dilemma that has become a global concern. 15% of the world’s maternal deaths occur in India (WRA 2018). Annually, over 44,000 women die in India of maternal causes, despite over 80% delivering in health facilities. India also has the highest number of stillbirths in the world (de Bernis et al 2016). And there are hospitals where medical intervention is performed routinely. We visited a maternity service and looked in the birth register - 151 Caesarians had been performed over a period of 10 days. Women aren't generally informed or aware of the risks associated with the procedure, nor is there any notion of choice.
Because of this, our workshops also included the concept of choice, and we used an example of induction of labour for post-maturity. The issues facing both the mother and her family as well as those providing maternity care are similar to those in other countries including the UK - though the 'doctor knows best' is firmly embedded in Indian culture, and this was clearly apparent during our sessions. Fear is palpable at all levels, and complexities overwhelming at times. I was particularly horrified to hear of increasing violence in some areas, where obstetricians were physically attacked by families if outcomes didn't match expectations.
But India is waking up...
Amidst it all, change is coming, with an increasing number of women and policy makers starting to pay attention to the disrespect agenda, and the exploitation of unnecessary surgery. Some government maternity hospitals are notably making changes and Evita and her team are part of the revolution. In fact Evita Fernandez is developing a professional midwifery programme - based on International Confederation of Midwives global midwifery education standards . Dr Fernandez and her team have a well established charity PROMISE which supports the developments, and recently the Indian government has invited Evita to lead more programmes of midwifery.
Evita Fernandez, with the help of Indie and others are really moving mountains in this amazing country, in challenging times. I am proud to know them both, and to have had the opportunity to ROAR with them, in India.
De Bernis et al (2016) Stillbirths: ending preventable deaths by 2016 Lancet. Volume 387, No. 10019, p703–716, 13
WRA White Ribbon Alliance India (2018) Accessed at http://www.whiteribbonalliance.org/india/