From C-sections to natural births: Midwives in Telangana transform maternity care

Telangana is the first State to successfully run a midwifery programme, setting an example for the rest of India.
Swaroopa, a midwife from the first batch of the State, helps a newborn breast crawl after conducting the delivery at DH Khammam. (Photo | Sri Loganathan Velmurugan)
Swaroopa, a midwife from the first batch of the State, helps a newborn breast crawl after conducting the delivery at DH Khammam. (Photo | Sri Loganathan Velmurugan)

HYDERABAD/ KHAMMAM/ MULUGU: It was a moment of profound significance at 11:24 AM on August 23 as a newborn took its first breath in this world. A Swaroopa Rani, the midwife who had conducted the delivery, breathed a sigh of relief. The labour room 6 at District Hospital (DH) Khammam had been fraught with tension for hours as the mother had arrived in an emergency. Hours later that memory seemed like a fever dream as Swaroopa gently placed the baby on the mother’s chest, and the newborn instinctively found its way to its source of nourishment – breast milk.

As the woman felt the tender touch of her newborn, she looked at Swaroopa and uttered a heartfelt, “Thank you, Madam.”This expression of gratitude held profound meaning because Swaroopa had just facilitated a natural delivery that could have otherwise required surgical intervention. She is part of the inaugural group of midwives who received specialised training through the Fernandez Foundation’s Nurse Practitioner Midwifery Programme (NPM), a collaborative effort between the Telangana government and UNICEF. In 2017, these three organisations came together with an aim to reduce the high rate of caesarean (C-section) deliveries, which accounted for 60% of all births in Telangana, according to National Family Health Survey (NFHS-5) data from 2019-20.

Midwives help a pregnant woman with a ball exercise routine at the Community Health Centre in Eturnagaram of Mulugu district | Sri Loganathan Velmurugan
Midwives help a pregnant woman with a ball exercise routine at the Community Health Centre in Eturnagaram of Mulugu district | Sri Loganathan Velmurugan

This data revealed that a significant portion of these C-sections were performed without any medical necessity and only 30% of them were actual emergencies. Superstitions about auspicious timing often fueled unnecessary C-sections, shedding light on the influence of cultural beliefs, said experts. Moreover, they identified additional factors contributing to the high C-section trend, including the fear of pain associated with natural childbirth, excessive medical intervention and profit motive in private hospitals.

A Health Management Information System (HMIS) report released in January by the health ministry revealed that the State had witnessed a decrease in caesarean deliveries, dropping to 54.09% in 2021-22.

However, this was more than double the national average of 23%. Considering the World Health Organization’s recommendation that the rate of C-section deliveries should ideally range between 10% to 15%, it has become clear that midwives, affectionately known as “pant-shirt ladies”, have a pivotal role to play in curbing the overwhelming prevalence of C-sections. They are not only tasked with providing respectful maternity care (RMC) but also filling the healthcare gap in regions with a shortage of doctors.

Telangana has emerged as the first State in India to implement a midwifery programme successfully. As the Union government looks to replicate this initiative on a national scale, there are valuable lessons to be gleaned from Telangana’s pioneering efforts, experts said.

Maternity care with respect

“May I touch you to conduct an examination?” Swaroopa asked the same mother. Due to the intense contractions she had experienced, tears in her vaginal area required suturing. “I will be administering local anaesthesia. It may cause slight discomfort,” Swaroopa informed her. With utmost skill, she employed continuous sutures, a technique she had honed during her midwifery training. Throughout the procedure, Swaroopa maintained a comforting dialogue with both the mother and her birthing companion, explaining the essential aspects of postnatal care. She also directed training nurses to leave the labour room and draw curtains to ensure the mother’s privacy.

DH Khammam boasts a team of seven midwives, with at least one available during each shift. Swaroopa, the most experienced among them, conducts daily exercise classes for outpatients (OP) when the other two midwives are occupied with routine checkups. Due to space constraints, the smaller room can only accommodate seven to eight women at a time. Women who previously underwent C-sections are usually restricted from doing the exercises and referred to doctors due to higher risks.

“This mother came in an emergency. Otherwise, I usually advocate birthing in a squatting position. Before undergoing the midwifery training, I was unaware of the numerous birthing positions,” Swaroopa shared, removing her blood-stained gloves as she headed towards the OP wing. Her guiding principle for RMC is to create an environment where mothers can freely express themselves — allowing them to shout, cry and move as they wish.

“In the past, it was common in labour rooms to mistreat mothers, including physical abuse and verbal insults if they weren’t cooperative. This behaviour was not limited to staff nurses but also extended to sanitation workers and ASHAs who were present in the labour room,” she said, adding that such practices are still common in most healthcare facilities.

While DH Khammam has separate labour rooms, other healthcare facilities like Nampally Area Hospital, Modern Government Maternity Hospital in Hyderabad and the Community Health Centre (CHC) in Khammam have a different story to tell. These facilities separate beds with curtains, making it impossible for husbands to accompany their wives as birthing partners. “Having the husband present during delivery often reduces the mother’s pain,” said K Mamatha, a midwife at Sathupally CHC, adding that she had only witnessed one such incident.

The CHC itself lacks sufficient space and resources for exercises and birthing positions. The shortage of supplies such as exercise balls, yoga mats and even a bathtub with warm water for water births remains a distant dream for both midwives and patients in government facilities. To provide high-quality care, the government must invest in infrastructure improvements, especially in smaller health centres, experts said.

The CHC, primarily serving coal mine workers from the Singareni Collieries Company Limited (SCCL) and their family members, employs only one gynaecologist. After the doctor’s morning shift ends, midwives handle an average of two deliveries per day, often successfully converting deliveries that could have required surgical intervention into natural births. In January this year, Mamatha performed a delivery of twins through normal birth, a high-risk procedure due to one of the babies being in a breech position lying bottom down in the uterus. Typically, such deliveries would have been conducted via C-section.

Parveen, another midwife at the CHC, has also facilitated Vaginal Birth After Caesarean (VBAC) deliveries, a procedure that even doctors at tertiary and district hospitals often avoid due to the risk of uterine rupture. The midwives said that ‘such miracles’ are possible only when the mothers express a strong desire for natural deliveries.

“In reality, many women can opt for normal deliveries even if they have complications. However, since a doctor is not available here, we tend to avoid risks by referring them to DH Khammam,” Mamatha explained. Out of the 60 recorded deliveries at the hospital, half were natural, while the other half were C-sections.

Improving ratios

Experts point out that there has been a notable shift from the previous 60:40 ratio of C-section deliveries in government hospitals in Telangana. A more equitable balance between natural and caesarean deliveries is now apparent, with a near 50-50 distribution.

For instance, the Nampally Area Hospital in Hyderabad documented 204 natural deliveries and 149 caesareans, with 40 of them involving first-time mothers. A similar trend can be observed in the gynaecology ward of DH Khammam, where the data reveals 285 spontaneous vaginal deliveries (SPVD), including 153 first-time mothers, and 396 lower-segment caesarean sections (LSCS), with 123 first-time mothers, were conducted. However, the column for Vaginal Birth After Caesarean (VBAC) in both hospitals remains at zero.

Dr Krupa Ushasri, the head of the gynaecology department at DH Khammam, explained that in the past, the number of first-time mothers opting for natural deliveries ranged from 30% to 40%. However, since DH Khammam serves as a referral centre for complex cases in the district, doctors often encounter high-risk pregnancies. In cases where mothers have previously undergone C-sections, doctors may attempt natural deliveries but tend to lean towards C-sections as a preference.

Notably, VBAC cases are typically transferred to doctors. It means that a significant number of women in the State, who have previously had C-sections, are deprived of the opportunity to opt for natural deliveries, a service that midwives are fully capable of providing.

Where the doctors are scarce

Not more than a month ago, some villages in Mulugu district faced road closures due to massive floods in the Godavari river, caused by heavy rainfall. In this challenging environment, a tribal woman, in her fifth pregnancy after two live births and two abortions, arrived at the 30-bed Eturnagaram CHC with preterm labour and a breech position. “On any other day, we would have referred her to the district hospital located 100 kilometres away for a C-section,” recounted G Swaroopa, another midwife from the first batch.

However, after obtaining consent from the relatives, she managed to successfully conduct a natural delivery. As part of the State’s precautionary measures during the heavy rains, nearly all pregnant women nearing their due dates were shifted to the hospital. Even the empty ICU was used to provide beds to accommodate all the women.

While the C-section rate in the region is not high, four midwives have been deployed to address the shortage of doctors. Tribal communities, including Gothi Koyas, Gonds and Nayakpods, rely on this CHC not only in Telangana but also from the neighbouring Chhattisgarh State.

The midwives shared an anecdote of a lab technician who, six years ago, experienced shoulder dystocia during delivery at Hanamkonda GMC. This complication occurs when the baby’s shoulders become stuck during vaginal delivery. Unfamiliar with the technique to resolve it, the baby was pulled forcefully, leading to loss of sensation in one of the shoulders. “In such complicated cases, we try different positions to deliver the baby,” Swaroopa explained. While doctors and staff nurses are typically trained in just one birthing position, midwives are versed in at least four.

Despite the HMIS reporting 100% institutional deliveries in Telangana, midwives at Eturnagaram CHC find themselves dealing with complex home delivery cases in the area. “Tribal women often give birth in the forest and arrive at the hospital with babies covered in sand, umbilical cords cut with sharp stones and excessive bleeding with vaginal tears. Yet, some of the women do not let us touch them, holding their traditions close,” shared S Jyotsna, another midwife from the first batch.

With minimal infrastructure available in the current building, midwives eagerly await the opening of the new Mother and Child Health (MCH) Centre, a project that has been pending for almost a year due to doctor shortages.

The need for more midwives

The need for more midwives is evident. While the 353 midwives currently available in the State are well-trained and provide invaluable services to the community, an additional 1,512 midwives are required to support over 3 lakh mothers annually in public health facilities. The government is planning to establish State- and national-level midwifery training institutes and midwifery educator training courses in some government nursing colleges. However, no specific timeline has been set by the department to ensure an adequate number of midwives are available across the state. Such practice may compromise the quality of their skills, the government believes.

An official from the Health Department told TNIE that there hasn’t been a significant change in the rate of C-section deliveries, which was the initial focus of the project. However, the official believes that results may become more apparent in a few years. To address infrastructural gaps, the government is working to provide LaQshya certificates to these facilities and establish MCHs.

Regarding the promised monthly incentive of Rs 15,000 for midwives, the official said that none of them have received it yet. Instead, they are included in a team-based incentive (TBI) of Rs 3,000, with Rs 1,000 allocated to doctors and the remaining is distributed among staff nurses, sanitation workers and midwives.  “Not even a single rupee from that incentive has been received till now. A number of times, the midwives have submitted representations about promotion and regularisation to the officials in the Health Department and even the minister, but no action has been taken in this regard,” a midwife from the first batch said, citing anonymity, as she believes she will be targeted by the doctors if her identity is revealed.

The relationship between doctors and midwives is another sore topic as the former often view themselves as superior.  At some times, their unnecessary intervention hinders midwives from promoting natural birth.

“We find satisfaction out of doing this job, and though incentives and promotions are necessary, they are secondary for us,” Swaroopa,  known as the “pant-shirt lady” of DH Khammam, summed it up succinctly as she prepared the mother’s discharge card just 24 hours after the delivery.

What more needs to be done

Telangana is the first State to successfully run a midwifery programme, setting an example for the rest of India. While midwives play a critical role in reducing the high rate of unnecessary C-section deliveries and providing respectful maternity care (RMC), several of their issues remain unaddressed:

  • Infrastructure limitations in healthcare facilities need to be addressed to improve maternal care and delivery outcomes.
  • Collaborative efforts are required to train and deploy more midwives to meet the increasing demand for maternal care services. Currently, the State has 353 midwives and there is a need for 1,500
  • Ensuring incentives and promotions for midwives is crucial to motivate and retain these essential healthcare professionals.
  • The power dynamics between a doctor and a midwife often lead to a toxic workplace situation for the latter. This is also reflected in the fact that VBAC is discouraged by a number of doctors and it also hinders midwives from promoting natural birth.

(This article is written under the Laadli Media Fellowship, 2023. All the opinions and views expressed are those of the author. Laadli and UNFPA do not necessarily endorse the views.)

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