“Ensuring a mother and child survive childbirth is the basic minimum. It should not be the ceiling of what you achieve,” says Janhavi Nilekani, the founder and Chairperson of the Aastrika Foundation, a nonprofit dedicated to transforming maternal healthcare. But the transformation of maternal healthcare in India is far from easy. “Poor quality of maternal healthcare is so normalised in India,” she says.
Astrika training session. | Photo Credit: SPECIAL ARRANGEMENT
The issue is harder to address, she adds, because it lies at the intersection of poor-quality healthcare and the lack of agency for many women in our country. Changing the narrative around childbirth is what the Aastrika Foundation, which turned five on May 9, has sought to do right from its inception, steadfast in “the belief that all childbearing women must have access to high quality, timely, respectful maternity care and fundamental rights, including privacy, the companionship of a loved one, informed consent, and an abuse-free birthing experience,” as the Aastrika website states.
Astrika team. | Photo Credit: SPECIAL ARRANGEMENT
One of the key objectives of the foundation, supported by Nilekani Philanthropies, is to establish midwifery as a profession with a trained cadre. “Midwives bring a lot to the table for every section of society and that is why it was important to us,” says Nilekani, a development economist by training. “It is a solution not just for underserved people but also for places with massive amounts of over-intervention.”
Janhavi Nilekani. | Photo Credit: SPECIAL ARRANGEMENT
The Aastrika Foundation currently has several programmes under its umbrella: Aastrika Sphere, their capacity-building programme, their Nurse Practitioners in Midwifery (NPM) programme, part of the Government of India’s 2018 midwifery initiative and a robust advocacy and community-building programme. “I think I started with a very clear mission, and we have done a fantastic job—tried to be focused and allowed for organic growth,” believes Nilekani.
Edited extracts of an interview
Can you tell me more about the midwifery model of care, something you hope to normalise in both the public and private sectors? Could you also explain the differences between this sort of midwife and the dais or traditional birth attendants who’ve historically been a part of this country’s birthing culture?
The midwifery model in the modern sense is a style of approach to childbearing which starts on the premise that pregnancy and childbearing are physiological processes, and the body has evolved, to some extent, to be able to handle it.
Medical approaches such as starting the labour with drugs, continuing it with drugs, using instruments to deliver the baby or resorting to a C-section, should be used only in restricted and justified cases. You start with the premise that the body knows what to do. Don’t start with the premise that childbirth is broken, and every childbirth is a death waiting to happen.
There is solid science behind the midwifery model of care. Intervention should be based on data, science and research trials in the midwifery approach, not based on being subjective or what individual practitioners think it should be. Women-centric maternal care is prioritised as well as the well-being of the mother and child from an all-round perspective—emotional, social, holistic well-being.
It differs a lot from the erstwhile dai system because the midwifery model of care is part of modern medicine in a way the dai system was not. It is very science-oriented and based on allopathic mainstream medicine. Midwives are extremely popular in developed countries—Canada, Australia, the U.S. and so forth—and they are well-trained. Even in India, a professional midwife has 5.5 to 6.5 years of training in the allopathic system.
In 2018, the Government of India established a new staffing cadre of ‘Nurse Practitioners in Midwifery’ (NPM), while in 2022, the foundation signed an MoU with the Department of Health & Family Welfare, Government of Karnataka (GoK), to launch the Nurse Practitioners in Midwifery programme in the state. How different is the NPM programme from the general nursing and midwifery programmes (GNM) in nursing schools?
There is a massive amount of confusion between dais, professional midwives and nurse midwives. Sure, there have been many cadres of nurse midwives, general nurse midwives and so forth, who have been given the responsibility of delivering babies, but typically they have been trained as obstetric nurses. There hasn’t been any large-scale effort to train them in the midwifery model, which centres on maternal care, [follows] best practices and [has] a belief in a logical process, till 2018.
The Nurse Practitioner in Midwifery (NPM) programme is a cascade training model, where International Midwifery Educators train the Nurse Practitioners in Midwifery Educators (NPME) at the National Midwifery Training Institutes. The educator programme is 18 months long, with six months of intensive training, and 12 months of mentorship. The NPMEs in turn train the Nurse Practitioners in Midwifery or the practicing midwives at State Midwifery Training Institutes. The training programme for midwives is also 18 months long, with 12 months of intensive training and six months of mentorship.
This is very different from the general nursing and midwifery programmes as much more emphasis is placed on midwifery and is like a specialisation, post the general nursing programme. The NPM programme trains midwives in the International Confederation of Midwives (ICM) competencies, which are of international standards.
The requirements for an NPME and NPM are very different from a GNM. For an NPME, one requires a BSc in Nursing plus five years of experience in maternity care or an MSc in Nursing plus two years of experience in maternity care. For an NPM, one requires a bare minimum of a GNM degree, post which one can apply for the NPM training.
On the other hand, GNM can be done post-12th standard. The GNM and NPMs also differ in their place of practice. GNMs can work across healthcare verticals in healthcare facilities. On the other hand, NPMs will specialise in low-risk pregnancies and births, and practice at Midwifery-Led Care Units (MLCUs).
I know that your own birthing experience led to the formation of the foundation. Can you tell us more about it?
At the time I was pregnant, I was a PhD student at Harvard [University] and spent a chunk of my first and third trimester in Cambridge, Massachusetts and the rest in India. Since I was travelling back and forth, I was struck by the difference in the quality of healthcare between the U.S. and India. It is not that the U.S. is a global leader, but the difference between Cambridge and Bangalore was shocking. We were easily 30-40 years behind the U.S. in most aspects.
One was the ridiculous sky-high rate of C-sections. If you look at modern data, Karnataka’s average rate of C-section is 52%, and this was five years ago. God knows what it is now. There are many districts that have C-section rates of 70-80 % in Karnataka.
This is much higher than the norm of 10-20%, modern evidence-based numbers, that are appropriate for the well-being of the mother and child. We don’t randomly do knee surgeries and heart surgeries for joy. There is no reason to do this invasive surgery on women for no good reason. I even remember speaking to a nurse agency to hire someone for the 40 days after childbirth, and they asked me if I was going for a normal or caesarean as if it were a choice.
Another thing was the routine episiotomy. I could not find a single doctor who agreed to deliver my baby without an episiotomy, even though there is abundant research that says that it causes more harm than good: severe tearing, more morbidity for mothers and so forth. Even things like routine shaving, routine enema, and not allowing partners all the time in the room bothered me.
I looked at hospitals all over the country — Delhi, Bombay, Bangalore — and finally went to a U.S.-trained midwife in Hyderabad where I had a very good birth experience.
All this was in 2016. I was still a student at that time and went back to my PhD after this but, by 2017, realised that I wanted to move towards maternal health. I finished my PhD in 2018, after which I started working on Aastrika. We finally launched in May 2019.
Can you go into some of the maternal health challenges you sought to address through this venture?
Of course, we wanted to work on reducing infant and maternal mortality but we also wanted to arrest the massive growth in over-intervention. Just from the years we started the foundation, C-section rates have continued to climb ridiculously. We are regularly seeing 70-80-90 % in districts in India, which is insane. You are affecting the entire fertility future of this family for minimal cause.
Another issue is the strong usage of medications without it being needed. This is not just true of urban India but across the country. There are primary healthcare centres where it is standard to inject people with oxytocin to speed up labour even though it causes foetal distress. We are working to ensure that medical treatments come from the standpoint that what you are doing benefits women and children.
Finally, we do a lot of work in trying to stamp out abuse which is very rampant in childbirth across the country. Verbal abuse, complete lack of privacy and slapping happens frequently. In elite hospitals, you will not have physical or verbal abuse but if they are doing surgery on you for their convenience and not yours, it is a kind of physical abuse. It is your organs that will have consequences, not theirs. If not done for reasons of healthcare benefits, it is abuse.
