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Abysmal quality of maternity care in India needs transformation, says development economist Janhavi Nilekani

Professional midwifery is needed in urban India because every woman, regardless of her wealth, ought to have a right to high-quality treatment and respectful maternity care, says Janhavi Nilekani.

July 23, 2022 / 12:46 PM IST
Janhavi Nilekani (Illustration - Suneesh Kalarickal)

Janhavi Nilekani (Illustration - Suneesh Kalarickal)

In 2016, when Janhavi Nilekani was pregnant and shuttling between Bengaluru and Harvard University in Cambridge where she was pursuing her PhD, she noticed a stark difference in the level of maternity care.

Nilekani opted to give birth in Bengaluru, but said Caesarean-section rates in the city were extremely high and unnecessary.

“I was a perfectly low-risk woman and I didn’t want to have major abdominal surgery for somebody else’s profit or convenience,” she said.

For a vaginal delivery, she couldn’t find a doctor who would not perform an episiotomy – an incision made in the perineum during childbirth for the baby’s head to pass through.

“An abundance of research evidence indicates that it’s quite harmful,” Nilekani said.

When she tried to convince the obstetrician about the findings of global research and what the guidelines were, she was told that the studies were based on white women and not Indians.

“I never agreed with that because I feel the onus should be on obstetricians to prove that Indian women are aliens from Mars,” she said.

Finally, Nilekani made her way to Hyderabad to find a doctor who ticked all the boxes and she gave birth without any tears, cuts, and stitches.

Dissatisfied experience

Janhavi is the daughter of Infosys co-founder and Aadhaar architect Nandan Nilekani and author and philanthropist Rohini Nilekani, one of the couples in India to sign the Giving Pledge. As of March 2022, Janhavi held over 8.5 million shares in Infosys.

A development economist by training, Janhavi Nilekani was inspired to start the Aastrika Foundation, an NGO set up in 2019 under Nilekani Philanthropies to skill healthcare workers.

It runs a digital learning platform, as well as physical training programmes in clinical and simulation skills in Karnataka. The foundation supports the National Midwifery Training Institute in Karnataka.

“Aastrika comes out of my personal experience with pregnancy and childbirth in India, where I was dramatically dissatisfied,” Nilekani said. “It’s a pretty abysmal quality of care across the country and while I think people are very familiar with the poor quality care in terms of poorer socio-economic groups and high infant and maternal mortality rates, it was a shock to me how bad the system is from top to bottom.”

While the NGO works to skill healthcare workers, the Aastrika Midwifery Centre is a private sector spinoff. Setting up in the private sector was a strategic choice, she said, because a third of all births in the country are in the private sector.

World Health Organisation recommendations say that Caesarean sections births should not exceed more 10-15 percent of all births in a country, and there iss some evidence to show that this number could be upto 19 percent for better outcomes. In India, according to data from the National Family Health Survey-5, 22 percent of deliveries were Caesarean sections, with it being more common in private sector health facilities at 47%.

“Unless care improves in the private sector, to some level, it will continue to falter for all other socio-economic groups because people aspire to copy the wealthy, and if the wealthy are getting terrible healthcare it spirals through to the whole market,” she said.

Nilekani stressed that to address the needs of the urban Indian market, professional midwifery needs to have a presence, which is what led them to come up with the centre.

“Maternity care sits at the intersection of women’s empowerment and the issues in healthcare. In India, we just accept that the price to pay to become a mother is a cut to either your uterus or your vagina. Something which I really felt very troubled by was how much it was normalised,” she said.

Nilekani said every woman, regardless of her wealth, ought to have a right to high-quality treatment and respectful maternity care. Verbal and physical abuse, lack of privacy and confidentiality, and the lack of informed consent in maternity care are all things that continue.

Mothers’ rights

“Part of our vision statement is that every mother has a right to not only high-quality treatment, but the fundamental rights of privacy, confidentiality and abuse-free experience, a companion of choice,” she said.

The foundation works with the Central and state governments on its projects. Over 2,000 certificates have been issued to nurses, nursing students as well as midwives who completed its online training module.

Nilekani had initially focussed on air pollution before shifting her attention to maternal health and maternity care.

“I don’t see this is that different from my training. Development economics very much includes public health - diverting from air pollution, which really affects the lungs, to maternal health was not a huge thing. I still see myself as a policy person who works in public health and public policy with a focus on health system strengthening and maternal health,” she said.

Janhavi said she made it clear to her parents that she wasn’t keen on entrepreneurship but added that they influenced her desire to work in the development sector.

“My mother started working in development and in philanthropy when I was fairly young. Throughout my childhood, she was in that sector and I really was inspired by that. And then perhaps even more so when my father went to join the work on Aadhaar. That definitely influenced my decision to go to Harvard for a PhD in public policy in particular,” she said.

In terms of learnings, she said the work at Aastrika is influenced by the work done at EkStep Foundation set up by her parents in 2014 to provide learning opportunities for schoolchildren.

Nilekani said her father, a cofounder of Infosys, advises her since she doesn’t have the training in business to become an entrepreneur.

The key reason to open the Aastrika Midwifery Centre was not to open a chain.

For Nilekani, the idea was to transform the private sector, which is aspirational and can influence how the quality of care can be improved for the 19 million women who don’t give birth in private hospitals.

“That is the key reason I’m doing this – it’s not to become an entrepreneur,” she said.
Haripriya Suresh