Childbirth in India

Childbirth practices in India are shaped by the prevalence of Hinduism[1] and joint-family living, India's young average population, the lower national average age at marriage, and disparities in social status and literacy between men and women. Inadequate maternal health care services in India are a result of poor organization, the huge rural-urban divide, and large interstate disparities coupled with stringent social-economic and cultural constraints.[2]

Social structure and organization

The joint-family system is one of the basic features of Hindu social organization. Therefore, since Hinduism is the primary practiced religion in India, the joint-family system constitutes the majority of family structures in India.[3] The joint-family system is described as follows: “In structure, it comprises a married man, his father, his grandfather and his collaterals within three generations. The different kinsmen along with their spouses and children occupy the same dwelling, eat and worship together, and enjoy property in common. They cooperate in economic activity and, even if the members are differentiated occupationally, pool their earnings. The joint-family provides nursing care for the sick and afflicted, social security for the unemployed, and support for the aged”[3] “They share the various routines, problems, and joys of social living, have strong feelings of mutual obligation during crises, and regard self-interest as being identical with family welfare. Their respect for the wisdom and justice of the eldest male permits him and his spouse to render decisions which affect each and every member of the unit”[3]

Marriage

“The median ages at marriage for women and men in Central India are slightly lower than the national averages. Early age at marriage is especially rampant in the villages, and among couples belonging to the Hindu and Buddhist faiths”.[3] Moreover, the age at which males and females get married in India have remained constant for several decades. In the 1960s, it was reported that the median ages at marriage in India are 16.4 years for urban women, 14.6 years for rural women, 23.0 years for urban men, and 20.2 years for rural men.[3]

Literacy

The literacy rate in India has improved considerably over time. The rate has increased from 43.56 percent in 1981 to 52.11 percent in 1991.[4] Literacy rates vary significantly among different regions of the nation. For example, the literacy rate is higher in south India than in the north. Also, a significant literacy gap exists between men and women. In 1991, the male literacy rate reached 62.86 percent and the female literacy rate was only 39.42 percent.[4]

Female and male relationships

In olden days, India was one of the countries in world where women had equal rights as men, Women goddesses were prayed and worshipped, which baffled many westerners., this portrays how well women lived in Indian society. Later years due to colonization and continues attacks, women were forced to limit to households, in order to protect them, that became a custom for quite a period, that changed in modern india where women are thriving similar to men.

Economic context

Farming is the largest single occupation in India. Approximately 28 percent of the Indian population lives below the poverty line with large inter-state variations.[2] Poverty in India is concentrated in the central and eastern states, therefore, poverty levels are significantly higher than the nation's average in these areas. The central and eastern states of India account for 55 percent of the total poor population in India.[2] Coincidentally, these poor states also contributed to half of the maternal deaths in India. This is most likely due to the fact that the use of maternal care services are very limited in these states.

Alternatively, the western and southern states of India are economically and demographically more advanced than the northern and eastern states. Subsequently, these states account for only 17 percent of maternal deaths most likely due to a higher use of maternal care services in these areas. Studies indicate that there is a negative association between the use of maternal care and maternal mortality ratio.[2]

In 2011, 69 percent of India's population was rural. Many citizens live in villages and are involved in agriculture, which to a westerner seems similar to a small town. The rural areas often have inhabitants that live below the poverty line. Alternatively, a portion of the population lives in cities, which is noted as the wealthiest portion of the population. However, the urban population includes many poor people from the countryside who often live in slums that contain a fifth of India's city dwellers. This portion of the population often works as laborers or in services. India has a huge urban middle class as well that are businessmen and professionals.[5]

Health context

In India deaths due to malnutrition, famines, and gastro-intestinal ailments are being decreased through improved agricultural production and distribution and the purification of water supplies.[3]

In addition, the Government of India and the World Health Organization have launched national programs of medical care and preventive medicine which, on the basis of recent surveys, appear effective in lowering the incidence of smallpox, cholera, plague, malaria, filariasis, tuberculosis, and venereal diseases.[3]

In regard to maternal healthy theories, age at marriage and fertility have been shown to be correlated. Also, poor states in India contributed to half of the maternal deaths in India. Therefore, there is a negative association between the use of maternal care and maternal mortality ratio.[2]

Health statistics

The percent of women in India who had an unmet need for family planning is 21 percent. 75 percent of women have one visit covered by insurance for antenatal visits. Fifty percent of women have at least 4 antenatal visits covered by their insurance. 67 percent of women in India have their births attended by a skilled medical professional. Only 8 percent of births resulted in a cesarean section. 48 percent of women went to their postnatal visits 2 days after their birth.

The total fertility rate per woman in India is 2.5.

The average life expectancy in India is 66 years old. For women, it is specifically 68 years old and for men it is 64 years old.

In 2015, India's maternal mortality was 174 per 100,000 live births. In 2005, it was estimated that the maternal mortality ratio in India is 16 times higher than that of Russia, 10 times that of China and 4 times higher than Brazil. Among developing countries, India contributes to the largest amount of births in the world a year, averaging 27 million births. However, unfortunately, India also accounts for 20 percent of global maternal deaths in year.[2]

Pregnancy behaviors and beliefs

Prenatal Care

Prenatal care access and utilization is largely affected by socioeconomic status, geographic location, and maternal education and autonomy. The use of prenatal care increased 12 percent from 1992 to 2006, but this increase was due to greater utilization by non-poor women. Poor women's utilization of prenatal care remained relatively stagnant, at only 6.3 percent. Geographically, some Indian states have significantly lower rates of prenatal care. For example, according to 2006 studies in Uttar Pradesh, only 9 percent of women receive prenatal care, as opposed to 72 percent in Tamil Nadu.[2] Higher rates in Tamil Nadu could be a result of the Janani Suraksha Yojana program, which financially incentivizes women to have birth in a health facility and receive a tubal ligation after 1 to 2 births.[6] This program has also resulted in a lower maternal mortality rate (MMR), lower fertility rate, and higher female literacy rate.

Views of pregnancy, birth, and infertility

Pregnancy is perceived positively in India, and most married women are extremely happy to learn of their pregnancy. Fertility is highly valued, and community members may begin to look negatively upon a woman if she is married for a year without any sign of pregnancy.

Preparation for birth

In preparing for birth, Indian women who live with their husbands generally seek counsel from their mothers-in-law. The advice of maternal figures is highly valued, and expectant mothers will follow the childbearing rituals passed down to them by their mother-in-law. Sleep positions, eating habits, and level of activity are all influenced by the views of older women of the family. Aside from what is told to them, women receive very little knowledge regarding birth itself. Often, women are very fearful for their birth, as they have only been told of the pain from others.[6]

The maternal figures of the family, especially the mothers-in-law, pass on customs regarding nutrition, hygiene, and daily activities during pregnancy. Frequently, “cold” foods such as fruit are avoided during pregnancy for fear of causing sickness or stillbirth. In some traditions, women may only drink hot tea and rice milk.[6]

The older women of the family determine each expectant mother's activity level and sleep habits, following family tradition. Some women are told to increase their activity levels in order to prepare the body for the hard work of labor, while other rest throughout pregnancy to save energy. Sleeping may also be regulated, and some women never sleep on their back or turn over during pregnancy.[6]

Labor and birth

Support During Labor

Pain is expected during labor and is seen as part of the natural labor process. There is little knowledge about options such as epidurals in some communities.[7] Depending on birth location, some women receive pain relief from warm water and massage, while other receive little support or even human touch. In hospital births, private hospitals have a higher rate of pain relief. One study found the rate for private hospitals to be 9.9 percent while the public hospitals had a rate of 0.9 percent.[8]

During labour, the mother and child both need adequate monitoring. Inadequate monitoring during labour can increase the chances of the baby going into distress which can potentially lead to the death of child before birth. It is also known as stillbirth. It is an unfortunate scenario that the largest number of stillbirths, more than 330,000 every year, happen only in India.[9]

Female relatives and neighbors may support the mother by serving tea, heating water, and helping with wrapping the newborn after birth.[10]

Birth location often determines the amount and type of supportive behavior. Women who give birth in hospitals are generally supported by nurses, although the extent of this support varies. Some express dissatisfaction with the lack of physical touch and comfort in the hospital. At home, women are supported by the “wise women” of the family with massage and warm water, although this also varies by family.[6]

Birth Attendants and Health Care Providers

On average, 83.1 percent of births are attended by skilled health personnel. However, this varies greatly by region. Traditional birth assistants (TBAs) attend 37 percent of home births in India. These TBAs often lack knowledge and literacy regarding safe birthing practices, but could have a large influence in reducing maternal mortality if properly trained. If educated properly on birthing positions, sanitary practices, weighing of the baby, maintaining adequate newborn body temperature, and handling postpartum hemorrhage, maternal and infant health in India could improve dramatically.[11] The other 63 percent of home births are unattended, and women who deliver in a health facility or hospital are cared for by nurses and doctors.

The majority of TBAs, who attend 37 percent of home births in India, are married and have not been to school. They may be trained or untrained, but the trained TBAs are generally younger with less work experience, and are paid for their services. The untrained TBAs are older, more experienced, and are generally unpaid.[11] Most TBAs entered the field after either attending several family births, birthing their own child, or following the footsteps of a family member.

Some women experience disrespect by hospital staff during childbirth.[12]

Location of birth

The decision about where the birth is to take place is made by the woman's father or brother.[10] According to the World Health Organization (WHO), 61 percent of births in India take place at home, and the majority of these are not attended by a skilled birthing assistant. Seventy-six percent of mothers reported using the sitting or squatting position for their last birth. The remaining 24 percent birthed in the supine position.[11] Eating and drinking customs, as well as rest, activity, and movement during labor, are determined by the mother-in-law or other older maternal figure in the family.

Placental delivery

After the placenta is delivered, the cord is cut and an herbal oil, face powder, or ash mixture is rubbed on the cut section. The placenta is buried near the home, or in some communities burned. Nine days after birth, a ceremony is conducted at the placental burial site to announce the name of the baby.[6] At home births, the baby is sometimes not caught after being delivered and remains lying on the floor until the placenta is delivered.[10]

Technology in birth

The cesarean section rate in India was 8.2 percent in 2008, which is below the WHO's recommended 10-15 percent. However, this number is higher in some private hospitals. The use of interventions such as episiotomies, induction, and cesarean section varies between private and public hospitals. A study of women in Delhi found that the cesarean rate in private hospitals was 53.8 percent while the rate at public hospitals was 23.7 percent. The same study reported that the episiotomy rate in private hospitals was 74.9 percent compared to the public hospital rate of 57.8 percent. The rates of induction of labor were found to be 30.8 percent and 20.6 percent.[8]

Postpartum

The Postpartum Period

The postpartum period begins after the delivery of the placenta. In Hindu communities, a “sutak” or “pollution confinement” period, which is a length of time for which the mother and baby are considered unclean, follows the birth. The mother and baby are in a place of confinement, usually a room in the home, during the “sutak” period. This can range in length from 3 to 10 days, and no family or community members may interact with the mother and baby during this time. At the end of this period, a “kuan pujan” or “ceremony at the well” occurs, in which the mother and baby are purified and considered clean.[13] In Muslim communities, this period does not exist. The baby is sprinkled with holy water in a ritual bath.

Rites of passage

Women receive a henna tattoo after birth, which is meant to prevent depression and sickness and promote bonding between mother and baby. A ceremony is conducted on the ninth day postpartum to announce the name of the baby at the placental burial site. Additionally, the “kuan pujan” ceremony is performed around the same time to signify the cleanliness of mother and baby.[6]

Hindu women may follow the “hot” and “cold” balanced diet. “Hot” foods are those high in protein, sodium, and acid, while “cold” foods are those that are sweet or starchy. Many women are advised to avoid cold foods to avoid sickness, and have more hot foods during the postpartum period to relieve stomach pain.[6] Other women in India generally continue to heed the advice of their mothers-in-law regarding the postnatal period.

Contraception

According to the World Health Organization, 54.8 percent of women utilized contraception in 2008. Female sterilization constitutes two-thirds of contraception use in Southern India, and is popular throughout the country. In some areas, there are financial incentives for undergoing tubal ligation after one or two children. Women who are Muslim, educated, or of higher socioeconomic status are more likely to choose more traditional, temporary methods of contraception instead of sterilization. Poor women typically experience more unwanted pregnancies, and therefore worse birth outcomes, due to lack of contraception access. Sterilization is less common for women who have not yet had a son.[14]

Newborns

Rites of passage

Many women mark their babies’ faces with “bindi” and tie small threads around the baby's’ wrists, ankles, and neck to ward off evil spirits. On the ninth day postpartum, a ceremony to name the child is conducted at the site of the placental burial.[6]

A male baby is considered preferable in Indian culture. Despite laws prohibiting sex-selective abortions, they still occur, and have caused an unbalanced male to female sex ratio in India.[15] Due to their higher status, it is custom in some areas to wait until the male baby is at least 1 year old before cutting his hair. In this ceremony, done at a Hindu temple, the family offers thanks for the blessing of a son.[6]

The first bath

If delivered by a TBA, the baby will most likely be bathed with warm water immediately by the assistant.[11] In some communities, women report waiting at least 9 days before bathing their baby, with some waiting as long as 3 months. It is believed to cause sickness and fever in a young baby. Incense is also frequently used after bathing the baby, as it is believed to kill germs and dry the hair more quickly.[6]

Food and drink

Newborns are given warm water, honey, mustard oil, tea, or goat's/cow's milk after birth, before breastfeeding is initiated. Most women initiate breastfeeding within a few hours after birth, and continue to exclusively breastfeed for 6–7 months.[11] The newborn is typically not weighed after birth in India. Several factors contribute to the absence of weighing, such as lack of access to scales at home, lack of knowledge of scale usage in the hospital, belief that the "evil eye" will come upon the baby, and cultural tradition passed on through the generations. Due to this factor, most babies are simply said to be 2.5 to 3 kg, even when they have not been weighed.[13] As India accounts for 40 percent of the world's low birth weight newborns, this is a large area of focus for improvement.

Circumcision

Circumcision is linked to both outdated hygiene practices and religious beliefs. Among the Muslim community, it is seen as a mandatory ritual.[16]

Mortality rates

As per 2018 data, the infant mortality rate is 29.94 per 1000 live births and the neonatal mortality rate is 22.73 per 1000 live births.[17]

References

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3. Driver, E. D. (1963). Differential fertility in Central India. Princeton: Princeton Univ. Press.
4. Dutt, A. K., & Sen, A. (n.d.). Provisional census of India 1991
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8. Nagpal, J., Sachdeva, A., Sengupta Dhar, R., Bhargava, V., & Bhartia, A. (2015). Widespread non-adherence to evidence-based maternity care guidelines: A population-based cluster randomised household survey. BJOG: An International Journal of Obstetrics & Gynaecology, 122(2), 238-247. doi:10.1111/1471-0528.13054
9. http://www.sankalpforum.com/enterprises/brun-healthcare/
10. Iyengar, S. D., Iyengar, K., Martines, J. C., Dashora, K., & Deora, K. K. (2008). Childbirth practices in rural rajasthan, india: Implications for neonatal health and survival. Journal of Perinatology: Official Journal of the California Perinatal Association, 28, S23-S30.
11. Saravanan, S., Turrell, G., Johnson, H., Fraser, J., & Patterson, C. (2011). Traditional birth attendant training and local birthing practices in India. Evaluation and Program Planning, 34(3), 254-265. doi:10.1016/j.evalprogplan.2011.02.012
12. Jungari, Suresh; Sharma, Baby; Wagh, Dhananjay (20 October 2019). "Beyond Maternal Mortality: A Systematic Review of Evidences on Mistreatment and Disrespect During Childbirth in Health Facilities in India". Trauma, Violence, & Abuse: 152483801988171. doi:10.1177/1524838019881719.
13. Bhattacharya, A., Dwivedy, R., Nandeshwar, S., Costa, A. D., & Diwan, V. (2008). ‘To weigh or not to weigh?’ Socio-cultural practices affecting weighing at birth in Vidisha, India. Journal of Neonatal Nursing, 14(6), 199-206. doi:10.1016/j.jnn.2008.07.009
14. Oliveira, I.T. d., Isabel Tiago de Oliveira, Jose G. Dias, and Sabu S Padmanas. (2014). PLoS ONE: Dominancy of sterilization and alternative choices of contraception in India: an appraisal of the socioeconomic impact. Public Library of Science. Doi:10.1371/journal.pone.0086654.
15. Jha, P., Kumar, R., Vasa, P., Dhigra, N., Thiruchelvam, D., & Moineddin, R. (2006). Low male to female sex ratio of children born in India. The Lancet, 367(9506), 211–218.
16. Sahay, S., Seema Sahay, Karikalan Nagarajan, Sanjay Mehendale, & Sibnath Deb. (03). Community and healthcare providers' perspectives on male circumcision: A multi-centric qualitative study in india. PLoS ONE, 9(3), e91213; e91213.
17. UNICEF. (2019). Cross sector indicators. Retrieved 29 April 2020 from https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1.0&dq=IND.CME_MRM0+CME_MRY0..&startPeriod=2016&endPeriod=2020