Munmun Mukherjee is a good patient. She lies quiet on the white stone delivery table of the government hospital in Kolkata, but for an occasional low moan. Even this is muted, the edge of her voice flattened, as if she knows that she needs to be on her best behaviour. A slim, dusky woman, she looks tidy even in her tired, crumpled nightie.
It is late January, and the reluctant Kolkata winter has already slipped away. Deep in the fold of the evening, there is a warm traffic of activity inside the labour room of this large hospital. The ancient ceiling fans hum like an order of monks. A couple of postgraduate students and house staff flow in and out the room, a gaggle of three nurses chats at the table, a cleaner mops the white floors. The doctors in the labour room are essentially doctors in training—recent MBBS graduates or postgraduate students.
The table alongside Munmun is empty, a brown blood stain in the middle has seeped in so obstinately that it looks like a marbled pattern. The next table, too, is empty, with a conspicuous brown stain on it, memories of deliveries past. The fourth table is bound in waxy black material, reserved for patients with HIV or hepatitis, also empty.
Munmun is the only patient in the room, her stone table is hard and cold to the touch. A young doctor called Romit, part of the house staff, strides up to check her. “Still a long time,” he shrugs.
“Please daktaar babu, ami aar parchhi naa [Doctor, I can’t take it any more],” she says.
“Tchaak,” he says crisply. “There can’t be any pain. “
It has been a long, long haul for Munmun, and she is quieted by exhaustion and apprehension in equal parts. This is the second hospital she has been admitted to that day and both have treated her with superb disdain, throwing her in wards bursting with women without beds, making her plead for water, dismissing her pain. Some of the women lying next to her in the ward of the Kolkata hospital said they had been slapped during delivery, and she felt anxious for herself.
The stories of giving birth in a public hospital are troubling. I first heard them from a young MBBS graduate who was disturbed by the verbal abuse and routine violence—slapping and pinching—that he witnessed in the labour room. I started noticing the story in other places—this news report on endemic corruption in the public health system mentions a nurse covering a woman’s mouth and hitting her leg when she cried in labour. This study evaluating a central government maternity health scheme in rural Uttar Pradesh took note of the “bad behaviour of PHC [primary health centre] staff, being scolded during delivery, lack of privacy.”
I remembered that in a Santhal village in Birbhum, when I asked why no one had a birth certificate, I was told everyone delivered at home. The tribal women said they hated going to the local hospital because the staff there treated them like animals. “We actually handle our goats and buffaloes with more care,” a young woman had scoffed.
The accounts of women being scorned and slapped and mistreated in hospitals come in the face of a terrific rush to institutionalise childbirth. India was tasked to meet the United Nations Millennium Development Goal to reduce the maternal mortality rate to 109 deaths per 100,000 deaths by 2015. The year the goal was laid down, the rate was five time higher at 540, among the poorest in the world outside of Africa, higher than that of neighbours Pakistan, Bangladesh, Bhutan and several times that of Sri Lanka. The answer, the government decided, lay in bringing women to deliver in hospitals, and it introduced the Janani Suraksha Yojana in 2005. The maternal mortality rate dropped to 178 in 2010-12 but India is still likely to fall short of the UN goal.
Moreover, severe problems like malnutrition among mothers and endemic corruption in the public health system persist. Among the least analysed of these is the routine, even if low-level, mistreatment of women while giving birth in hospital. The evaluation reports commissioned by the National Health Mission consider the quality of hospital care in terms of infrastructure and cleanliness, but do not address the behavioural aspect of care. (Interestingly, the reports barely mention healthcare users, like et ceteras stuffed in hurriedly.) A study by the international research organisation Population Council, however, acknowledges that it does not adequately capture the “bad behaviour of the staff” and the authors express regret for not being able to witness a delivery in progress.
As I sought out the stories of women in the packed labour wards of Kolkata’s public hospitals, they spoke cautiously of adequate medical attention and shrugged when asked if they had been shouted at or hit. “That’s how it is, isn’t it?” frowned a wan-looking girl, sitting on the soiled cement floor of a ward with her two-day-old child. Verbal accounts of the violence weren’t forthcoming, neither was official permission to enter the labour room. I finally decided to go undercover, with the help of two young MBBS graduates, to observe what goes on within.
Munmun had awoken abruptly around midnight the day before, with a sharp spasm of pain. Around 3 AM, her mother admitted her to the nearest hospital, BN Bose Memorial Hospital, in Barackpore. There, the girl lay untended till the doctor on duty examined her at 8.30 AM, and referred her to the Kolkata hospital. But when she walked down the three floors, no ambulance was waiting. Cab, her husband decided, but it was several minutes before they realised there was a taxi strike. Munmun had laid down by the side of the road by then. A crowd collected, and anger crystallised. They managed to collar the ambulance driver. Munmun was admitted to the Kolkata hospital around 2 PM in the afternoon, where she shared a bed with two other women (lying horizontally on the bed). Around 6 PM, when Munmun started crying quietly, her mother fought with one of the nurses until she walked Munmun to the labour ward.
Forty minutes after he left, around 8 PM, Romit is back accompanied by a young lady doctor, Shikha, who is in charge of the delivery. Romit is a house staffer—an MBBS graduate of the college—while Shikha is a postgraduate student. It is time, they decided. The man pulls up a step-ladder to Munmun’s side, climbs up and pushes down with both hands on Munmun’s stomach without telling her. She gasped, and half sat up in pain.
“Lie back right now,” barks Shikha from the foot of the table. “We have to do the pushing for you because you are not. Ekdum jhamela korbe naa [Don’t make trouble].”
Romit injects her with a local anaesthetic, and goes back to pushing. Shikha is joined by an MBBS intern who looks distraught. “What I will do now is an episiotomy,” she explains. “See, this is the perineum [the area between the vagina and the anus]. We need to make a small cut here to enlarge the passage for the baby.”
A 2005 article in The Journal of The American Medical Association found that the routine episiotomy has no benefits. In 2006, the American Congress of Obstetricians and Gynaecologists called for restrictions on the episiotomy. In this Kolkata hospital, however, the episiotomy seems to be standard procedure.
A nurse brings a tray of surgical instruments. Shikha works briskly with her tools—dark, thick blood is pooling below Mukherjee’s waist on the table. “Can you see the cut? Now you will clearly see the baby’s head,” she asks. The intern—a young man—peers gingerly, and nods.
Blood is dripping onto the white floor now, sickeningly swift, like fat blots of ink on a paper napkin. The cleaner mops it up, and her swabs leave behind oversized brush strokes. The air is heavy with the overripe smell of blood.
My head too is heavy. I am standing back from the head of Munmun’s delivery table, the only way to accord the pregnant woman some privacy. I grasp the ledge nearby, setting off a clatter of trays. “Come here. What can you see from there?” Shikha smiles. I pull my lips into a smile and refuse.
The wet floor has started to spot again. “It’s a boy, can you see the scrotal sacs?” Shikha asks the intern. She slaps a slimy greyish bloodied mass on Munmun’s stomach. “Hold him, hold him, don’t let him fall.”
Munmun grasps the mass without looking. Her eyes are closed, forehead beaded with sweat. A nurse takes the baby to the little chamber. This is the second time I see any of them in action that evening.
Shikha is plunging her hand up Munmun’s vagina. The girl bites her lip and squeezes her already-closed eyes. A bloodied mass, almost the size of the baby, is slapped onto the table near her knees. She flinches at the sight of this. Romit smiles at me and says it is the placenta.
“We need to sew up the cut,” Shikha tells the intern. “Quickly…the effects of anaesthesia wear off in half an hour,” she says. It is a minute to 9 PM, nearly an hour since the anaesthesia injection.
Munmun has begun to whimper, she bites her lip and squirms. “Don’t move,” snarls Shikha. “Kichhu hocche naa [you can’t feel a thing].”
In a couple of minutes, the doctor and intern leave without a word to Munmun. The nurses continue with paperwork. An ayah (midwife) arrives to clean the floor below Munmun’s table.
“Congratulations,” I say to the young mother, and start at my strange, flat voice. “Do you know what you’ll call him?” She manages a smile.
I notice then how bruised her lips are, the skin has scarred and bundled together, little mounds of red earth.
The hospital where Munmun delivered her child has one of the largest gynaecological departments in Kolkata, fed by a constant stream of young medical graduates from the attached medical school, one of the most prestigious in West Bengal, even India. In 2014, more than 26,000 babies were delivered here, according to the medical superintendent.
Romit, who studied here, is cheerful after Munmun’s delivery. “That one is a good patient,” he says, outside the labour room. “No drama, no screaming. You should see some of them, how they shriek.”
The young doctor doesn’t remember the first time he slapped someone in the labour room. Everyone slaps patients, all his MBBS classmates did and the postgraduate students do, too. It is almost a rite of passage. “There was one guy, he was so shy. He never lost his cool. The day he slapped his first patient, that was an event. We made him treat us to biryani,” he chuckles.
The government introduced the Janani Suraksha Yojana for “poor pregnant women” based on the international consensus that skilled assistance available at hospitals is better than the “unskilled” assistance available in a home birth. The scheme guarantees free treatment to women who deliver at public and certain listed private healthcare facilities.
From 2005-2011, it has helped raise institutional deliveries from 20% to 49% on average across nine Indian states, operating on a model that pays cash commissions to a network of local women health workers for bringing in pregnant women to hospitals. But this insistence on skilled assistance does not seem to extend to professional conduct on the part of healthcare staff, exposing increasing numbers of women to the unpleasant experience of giving birth, a difficult and private process, in an unfamiliar place before strangers who are often apathetic and disrespectful.
“Unfortunately, it is true that staff lose their temper,” says Dr Sikha Adhikary, state family welfare officer and joint director of health services, West Bengal, looking genuinely regretful. “But slapping? That is very rare. We are very concerned about such bad practices. Things are much better than they used to be, ten or even five years ago.” Incidentally, West Bengal has been doing well on a number of health indicators, and improved its maternal mortality rate to an impressive 113 by 2013.
A 2014 study in Kenya, another ‘developing country’ pushing to institutionalise childbirth, lists “pinching, slapping and beating, non-consensual care (coerced Caesarean sections), non-dignified care, verbal abuse” among behaviours that constitute abuse. The study also found that one in five Kenyan women shunned the hospital for delivery because of the abuse in the labour room.
The head of the gynaecology department at the Kolkata hospital admits to some shouting and anger in the labour room, but says he is very strict about it. “It is rare but you are right, this does happen. One of my patients told me, ‘Sir, please don’t misunderstand, but people shout at us.’ Patients don’t open up to me, but I knew her personally so she probably felt more comfortable than the others…whenever I have seen my students shouting at women, I check them.”
He calls me back some minutes later to clarify: “Labour is a very painful and long-drawn-out process, the second stage of labour especially is intense, and sometimes people [doctors, nurses] lose their temper,” he says. “But I remind my students, imagine your didi [sister], or ma [mother], or boudi [sister-in-law] going through this.”
A recent graduate of the medical college, though, has a different, and more troubled memory of his time in the department. After Deep completed his statutory two-month internship at the gynaecology department during his MBBS studies, he noticed many of his batchmates getting rebuked frequently at their next internship in the orthopaedic department. “The doctors scolded them for their brusqueness with patients, for dismissing patients’ complaints. [But] patients were slapped and abused all the time in the labour room. “Why are you screaming now, weren’t you screaming in pleasure when you were getting fucked?’ is a common refrain. This was the culture there, and it was not acceptable even in other departments of the same hospital. I couldn’t imagine specialising in gynaecology after that experience,” he says. “Yet the sight of a newborn drawing first breath is still sheer exhilaration.”
His classmate Romit has a different understanding of things. “It gets crazy in there, especially in the months of September to December. They all seem to have babies then. One starts shrieking and they all follow. We have to do our work after all,” he says. “Not everyone is a good patient like Munmun.”
Munmun seems pleased with the compliment, and is quiet for a few moments before speaking. “The doctors were nice, too. But they didn’t believe I had labour pain. They dismissed me.”
“You remember that?” I ask.
“Everything. The young man walked away when I said I had pains since the night. The young lady was teaching a student all through my delivery. I remember everything. That’s why it took so long, isn’t it?”
The general perception is that public hospitals deal with a huge patient load, and the resulting pressure sometimes results in the staff losing their cool. This hospital in Kolkata is certainly very busy, but on each of the three occasions that I managed to enter the labour room there was only one delivery taking place (I only witnessed the last minutes of one). At least three trainee doctors and three nurses were available to attend to the woman giving birth. I did not witness any hitting in the time I spent in the labour room, but the treatment on offer was troubling to watch.
* * *
Sarina Bibi’s baby is very large by normal standards. The baby girl weighed 3.5 kg, the normal weight of a newborn is 2 kg to 2.5 kg. Her episiotomy involved a large cut, which is proving tricky to stitch back, according to the doctors attending to her. One is a postgraduate student, the other a house staff member, a graduate with a bachelors-level MBBS degree. She is bleeding thickly, her dark rich blood draining rapidly onto the floor.
“She is losing a lot of blood,” one doctor tells the other. There is an edge of worry to his voice.
Sarina is keening and twisting ceaselessly, her voice a strange, uneasy siren. She is a dark, slightly plump girl but her cheeks look bloated with exhaustion. It is a sticky February afternoon and the statuesque fans are on full song. A nurse handed the doctors a tray for sewing up the episiotomy and retired to the long table at the end. A house staff doctor is holding on to Sarina so the junior doctor can complete the stitches quickly.
Sarina’s left hand fists the air repeatedly, while her right hand grips the side of table. Twice or thrice, she reaches out and grips the house staff doctor’s elbow, he shakes her off. He is standing with his back to her face. On impulse, I step forward and put my hand in hers. She clasps it hungrily, whitening my knuckles, burying my ring painfully into the thin flesh of my fingers. Blood has dried on her fingers into treacly grains, and darkened her fingernails. The sides of the table, near her hand, are stained with blood, too. The house staff doctor, senses my presence and turns around. He smiles slightly at me, and purses his lips with amusement when he sees my hand in hers. “Eii, don’t you ever clean your nails?” he asks Sarina, loudly.
A tall, imperious nurse at the table catches my eye, and grins as she shakes her head; a gesture of commiseration. “Eii meye, haath chaadh! [Eei girl, let go of her hand], she’s found a good bakra [goat],” she says, her voice carrying easily across the room. A ripple of sniggers ensue.
“One chorr [slap] would be enough,” the house doctor tells the other doctor, and they chuckle without looking at Sarina. She digs her nails in but to her credit, never drops her voice.
A girl is wheeled into the room, a thin, frightened-looking girl who is probably still in her teens. She is moaning and rocking as she dismounts from the wheelchair and clambers onto the next delivery table. She clasps the hand of a nurse close by and holds it close, the nurse places her hand on the railing at the head of her table.
“Ahahaha, hair open and flying,” the imperious nurse booms. “She’s putting on a matinee show for us.” Everyone laughs, including me. It’s a remark so catty that it’s funny.
The girl grips the railing and cries. “Yes, yes, go on crying, go louder. Then you will pakka have a girl,” the nurse continues. The girl shuts up, not because of the threat of a girl child, I think, but because of that woman’s nastiness.
The doctors say they are finishing up with Sarina, it is almost an hour since she delivered the baby and the effects of the local anesthesia delivered before the episiotomy must have long gone. She lies in a moat of her own blood. The other girl’s presence has perhaps calmed Sarina, or perhaps the operation indeed is over. She looks up to see me for the first time, and I congratulate her. She says nothing. “Your mother must be outside,” I say, “I’ll tell them you’re done.”
“My mother isn’t here,” she replies. “My father died last night.”
“Ah, that’s why you were crying so much,” quips the house staff doctor. His colleague chuckles.
The labour room problem is not new, says Dr Sara Bhattacharji, who retired as the head of the celebrated low cost-effective care unit (LCECU) of the Christian Medical College (CMC), Vellore, which caters to the slum areas of the city. When Bhattacharji, a community health specialist, took over the unit in 1999, it had no labour room. “So many women came to me complaining of how they were slapped and pinched and treated like cows in the local hospital that I felt we should do something about it. In 2005, the CMC started a two-bed labour room in the LCECU.”
Bhattacharji, who has worked in the Christian Medical College ecosystem since her student years, says that the missionary dedication of the organisation means the work ethic is different there. “I’ve heard horror stories about the labour room from some of my CMC classmates working in other places.”
Central to this problem is the bogey of class. The patients who go to public hospitals are largely the poor. The Janani Suraksha Yojana is designed expressly for “poor, pregnant women,” according to the National Health Mission website. While the poor are romanticised in our political discourse, we shun physical contact with them in actual interaction. Take, for instance, how rare it is still for domestic staff to use bathrooms in their employers’ homes. (In homes where they do, this bathroom is typically used only by the help.) In the site of a public hospital, this disdain perhaps manifests in malpractice.
“Doctors and wealthy people [who wouldn’t go to a government hospital] see poor women as responsible for India’s population growth,” says Kerry McBroom, reproductive rights director of the Human Rights Law Network. She has travelled to hospitals across the country to monitor how women are treated. “If Shah Rukh Khan has three kids, no one says anything, but a woman in Haryana who has three kids cannot run for local office or access government benefits. Many doctors operate under the same set of assumptions. This also explains why doctors who participate in unethical and unhygienic sterilisation camps, operating on dozens of women at once are seen as heroes. Ultimately, doctors are disgusted by the fact that another poor person is coming into the world. And the attitude is contagious, infecting healthcare staff across the hierarchy.”
Matters seem to take an especially ugly form in the case of a marginal community like that of the Santhal tribals. Ayesha Khatun, who runs an education and health awareness non-profit in the Mohammad Bazaar bloc of Birbhum district in Bengal, has witnessed this first-hand while accompanying Santhals to hospital.
“Either the staff avoid tending to them, or they shout at them and abuse them. And they can get real nasty. ‘Why don’t you open your legs now, you weren’t so shy when you got pregnant,’ this is a comment I have heard over and over again. Beds are going empty but Santhals are made to lie on the floor. There is also the language problem—many Santhals are not fluent in Bangla. Then, there are cultural issues: Traditionally Santhals deliver squatting on the floor while modern Western medicine requires you to be supine. This is much more painful, actually, and they are shouted at when they try to squat. Santhals avoid the hospital as much as they can, certainly they will still have their first child at home.”
There is also a sharp sexist prejudice at work, points out Dr Puneet Bedi, consultant with Indraprastha Apolllo Hospitals, New Delhi, and an activist against sex-selective abortion. Gynaecology as a discipline, he contends, is premised on an attitude of disgust that derives from notions originating in the Hippocratic corpus—the collection of treatises by anonymous authors compiled in the name of the famous 5th century BC physician, Hippocrates. “The revulsion was transparent and unselfconscious in the textbooks I had as a student, in the language used for the female sexual anatomy,” he chuckles.
In an essay, Women and Medicine, Holt Parker argues that the Hippocratic treatise on the diseases of women makes a distinction between the mouth and the anus, which are holes that can be “closed voluntarily” as against the vagina which “stays open.” The sense of disgust is clearly palpable as the womb was seen as the “source of all disease” and women were said to “leak menstrual blood, sexual lubricant, lochial discharge after giving birth, and yeast infections (leucorrhea).”
These problematic notions were painfully evident in nineteenth century developments in gynaecology, particularly in the career of James Marion Sims, known as the father of modern gynaecology. The Encyclopaedia Britannica entry on obstetrics and gynaecology mentions how pioneers of gynaecological surgery like Sims had to fight the public outcry against the “exposure or examination of female sexual organs.”
Prostitutes were hired for vaginal examinations because “decent” women would not participate in such a procedure. Sims also designed the modern speculum, an instrument whose history speaks of the clinician’s distaste for the vagina as this excellent essay documents. “If there was anything I hated,” this essay quotes from Sims’ autobiography, “it was investigating the organs of the female pelvis.”
Like Deep in the Kolkata hospital, novelist and general surgeon Dr Kavvery Nambisan also sensed this revulsion when she completed her gynaecology internship at a rural hospital in Karnataka. “The doctors there jabbed and lunged and barked at their patients,” she says. “Gynaecology was the worst part of medical school.”
Of course, medical thinking is not the only indication of the revulsion for “leaking bodies.” Hindu religious practices have, of course, contributed richly to this domain by barring, banishing or excluding “impure” menstruating women from various aspects of community life. Sanitary pad manufacturers have long used sharp blue mouthwash fresh liquid to demonstrate the absorbent qualities of their products. Instagram recently took down poet and artist Rupi Kaur’s image of a girl with stained pyjamas because it offended user sentiments. (The happy consequence of this was that the image and her campaign went viral.)
The problem is compounded, Nambisan adds, by the fact that medical degree programmes have no time for the humanities in their syllabus. There is little scope for critical thinking and reflexivity. “It is probably the only professional academic programme without a humanities component in India. Engineering, architecture and business studies all dip into the humanities, law of course leans on it considerably.”
If there is any positive to this dispiriting exposition, it is the likelihood that the resident prejudices of gynaecology equalise women’s experiences across public and healthcare in India. Even women who check into the new ‘women-friendly’ clinics sometimes come away traumatised by their delivery. Might this partly explain the small but growing natural birth movement across the world?
* * *
Walking with her daughter to the labour room, Munmun’s mother Sankari Baidya pressed her hand and pulled her away for a quick chat. “This is the hardest part, I told her, you’re on your own now. It’s not only the pain, you will be in a totally unknown place, with unfamiliar people who won’t care. If you need water, shout. If you are in pain, shout.”
A slight, spry woman, Sankari is a straight-talker. All her three children were born at home—Munmun and two sisters. The same midwife attended to her every time. She was with people she knew, family, neighbours. They offered her tea, some warm milk, someone held her hand now and then, they recounted their own experiences of childbirth, she remembers being scolded too. “But they were on my side,” she says.
The government’s single-minded focus on institutionalising childbirth means India is squeezing traditional midwives out of livelihoods and losing out on an indigenous knowledge resource. Sri Lanka has increased the number of trained midwives twenty-fold between 1941 and 2001. The country’s maternal mortality rate, at 29 for 100,000 live births according to the World Bank figures for 2013, is embarrassingly good. Indian state policy, on the other hand, actively discourages home-births and midwives. A memo put up the Ministry of Health and Family Welfare freely admits: “It is true that we have to discourage home delivery.”
The Janani Suraksha Yojana has co-opted many dais as its agents (known as accredited social health activists) by offering them cash incentives for bringing in pregnant women for delivery but simultaneously gram panchayats have been asked to keep an eye out for home births in their areas and report them.
The Child Survival and Safe Motherhood Scheme introduced in 1992 introduced a three-month training course for dais, says Bandana Das, president of the Society of Midwives in India. That was discontinued in 1997 because the government decided only skilled attendants could be trusted with birth, skill being measured in degree qualifications. “But the problem is that we don’t even have a full-fledged degree qualification for midwifery. It is a component of the general nursing and midwifery degree, whereas nursing is a separate qualification in itself,” says Das.
Yet, a taste for natural birth, likely of niche proportion, is developing in India. The website of Birth India, an NGO promoting home birth and alternative reproductive healthcare, notes an “increase in midwifery, birth centres, water births and home births”, childbirth educators and lactation consultants. There is also the Bangalore Birth Network, also formed in 2007 like Birth India, which generates awareness against unnecessary clinical interventions like episiotomies and advocates natural birth practices. What might be happening gradually is that the qualified dai is becoming the luxury organic service only the affluent can afford.
“I wish she [Munmun] could have had what I had. She should have delivered here, with me and her sister and sister-in-law around her. My dai-ma is excellent,” says Baidya.
“But it was probably safer for her in the hospital, her baby is premature after all,” I say.
“Oh I don’t know, no birth is simple,” she says. “I’ve had three children and each one had its complications. What you need is a good dai, like mine. Why makes you think the hospital knows everything?”
The name of the Kolkata hospital has been withheld because permission to enter the labour room was denied. The names of doctors have been changed to protect them as some of them helped me gain undercover access to the labour room. More importantly, this story is not about individuals or even institutions, this is about systemic problems in public healthcare.
Despite repeated attempts over three months, I could not contact Sarina Bibi. The phone number she provided was switched off. There was only the one time when the call went through: This was three weeks after she gave birth. Her husband said she was at her mother’s place and recovering well.