With their examinations a few days away, trainee midwife educators at the National Midwifery Training Institute housed in Bengaluru’s Vanivilas government hospital are finishing their last few classes. Two trainees, Kiran Beelagi and Kencharaj Kammar, step out of their classroom and head towards the hospital’s Midwifery Led Care Unit (MLCU), where they have been practising what they have learned in their practical clinical training. Along the way, they are greeted affectionately by several pregnant women awaiting their check-ups. One new mother has been waiting patiently with her newborn at the MLCU, even though she has been discharged, just to thank Kiran for the care and respect shown during her birthing experience.
Such responses are not entirely unexpected as the trainees have spent the last six months at Vanivilas, Karnataka‘s largest mother and child hospital, interacting with pregnant women and even helping to deliver the children of many of them. But what makes it special and unique is that Kiran and Kencharaj are India’s first male trainee midwife educators. Both men are a part of the Nurse Practitioner Midwifery (NPM) Educator initiative launched by the Union government in November 2019. It is envisioned that midwifery educators trained at the National Midwifery Training Institutes (NMTIs) under this initiative will help set up State Midwifery Training Institutes (SMTIs) at the district/taluka level. Here, they will train Nurse Practitioners in Midwifery (NPMs) to broaden the benefits of midwifery care to the community through Midwifery Led Care Units (MLCUs) established at health facilities with high caseloads. Ultimately, this cascade model will produce around 90,000 midwives providing services in 7,000 MLCUs in the country to ensure no woman has to give birth without the quality of care she deserves.
In Karnataka, this programme is being implemented under the aegis of the NMTI established under a public-private partnership between the state government and Aastrika Foundation, a Bengaluru-based not-for-profit founded by development economist Janhavi Nilekani. The Foundation is providing financial aid and technical support to the NMTI and MLCU in collaboration with UNICEF.
After training, Kiran and Kencharaj will carry forward the programme goals to build a cadre of trained professional midwives who can provide respectful and high-quality care in the state. Since a part of their schedule includes hands-on clinical training, they have also assisted mothers give birth. “I had the privilege to facilitate the first birth at the MLCU soon after its launch in June this year. I was not nervous because I was helped by my mentors (the international midwifery educators) and other colleagues. It was a memorable experience for me also because the woman, a second-time mother, told me that she had never experienced such gentle loving and respectful care during the birthing process. Even her husband was very appreciative,” shares Kiran. So far, the two men have helped 21 mothers give birth. Kencharaj, who has facilitated 12 of these, remembers that all his skills were put to the test when he was assigned the case of a speech and hearing-impaired pregnant woman. “Fortunately, I knew a little bit of sign language that I had picked up while communicating with a relative with similar impairments. I explained to her that the semi-sitting position would be best for birthing. The lithotomy or lying down position to give childbirth would be difficult and painful for her. Only after she understood and agreed, did the process begin,” says Kencharaj.
Nandini and her husband Tanvir with Kencharaj/By Swapna Majumdar
Gaining the trust of pregnant women has been paramount for both Kiran and Kencharaj. They know that in the Indian cultural milieu, midwifery is largely perceived as a woman’s work. Pregnant women traditionally prefer female and not male midwives during birthing for reasons of privacy and propriety. “My wife warned me that it would be challenging because midwifery by men is not common. But I was prepared to meet all challenges,” shares Kencharaj. He reveals that it was difficult initially as the concept of midwifery was not clear to most women and many of them had never interacted with a male midwife. “We strictly followed the guidelines of respectful maternity care (RMC) and approached the woman accordingly. Here, the woman is the decision-making authority, not us. Permission is sought before doing anything, whether it is holding her hand or teaching her exercises. By sharing our evidence- based and scientific knowledge, we are able to gain her confidence that what we are going to do is best for her,” explains Kencharaj. It is not just the women who are counselled here. Since the MLCU allows birth companions, usually the husbands, the men are also informed about the various birthing options available. The two male trainees are able to establish a bond with the couple by engaging the husbands and making them active participants in activities like exercises, dancing and massages that facilitate the birthing process. According to Ashwini, a midwifery educator at NMTI, as this is done in the company of other female trainees and the international midwifery educator, it helps to normalise the presence of male midwives.
When 26-year-old Nandini was referred to the MLCU as she was in a latent stage of labour and needed help to induce contractions, it was Kencharaj, who took up the responsibility. He guided Nandini and her husband Tanvir. “All exercises were done in front of me and then taught to me so that I could help my wife. Although he was the only male midwife there, neither of us felt uncomfortable because he was so respectful. He took our permission for everything,” shares Tanvir.
It was this care and respect that prompted Nandini to keep coming to the MLCU the three days it took to induce contractions. “When I spent time with him learning the exercises, it felt like I was with my mother. I felt protected. I wish there were more like him,” says Nandini. For Nandini’s wish to come true, there needs to be more male midwife trainee educators at the five NMTIs in the country. Except for Karnataka, no other state NMTI has selected men to train as midwife educators. Telangana missed the opportunity of becoming the first state to train men even though it started the country’s first NMTI at the well-known Fernandez Hospital in Hyderabad.
Despite being selected by the Karnataka government for training there, Kiran and Kencharaj were sent back by Fernandez Hospital as it felt men would not fit the bill. It is only when Karnataka got its own NMTI in 2022, that the two government nursing officers were able to fulfil their dream.
They were lucky to get support from Dr Rajkumar, the dynamic Deputy Director of Maternal Health at the Karnataka Health and Family Welfare Department. An obstetrician himself, Dr Rajkumar was keen that meritorious male nurses be given equal opportunity. “They were selected after a rigorous test. But Fernandez Hospital had reservations about training men as midwife educators. So when we started the NMTI, they were given the chance. We didn’t want to waste their talent. Our main selection consideration was skill and not gender,” he contends.
The presence of two men among 29 women trainees did not lead to any changes in the way the training was conducted at the NMTI. “We didn’t have to tweak the curriculum or do anything differently for them. Midwives, whether men or women, must have the same set of skills since they do the same work,” says Sarah Coxon, the NMTI international midwifery educator (IME) from the United Kingdom and director of midwifery initiatives, Aastrika Foundation.
For Dr Savita, Medical Superintendent (OBGYN) at Vanivilas Hospital, it is a matter of pride that they are the first to train male midwifery educators. “I have received good feedback from the women they have interacted with. My patients are getting good care and that is what I want. I am really happy that we could start the NPM programme here and establish a midwifery-led care unit as there is evidence that 87% of maternal health care during childbirth can be managed effectively by professional midwives. Considering that Vanivilas has over 18,000 births every year, they can help in reducing the burden on our doctors,” she states.
It was not so easy in the beginning to convince pregnant women that the trainee midwife educators at the MLCU were just as capable of conducting childbirth as the obstetricians and gynaecologists at the hospital. Dr Savita helped overcome this challenge by allotting them space within the antenatal ward so that they could establish their credentials and explain how the MLCU conducted births. This helped in familiarising the NMTI trainees with the pregnant women before they came for their deliveries. It also presented an opportunity to create awareness about midwifery and the advantages of natural birth for women with no medical complications. Doctors were also advised that low-risk pregnancies could be referred to the MLCU.
When women saw yoga mats, birthing balls, beds, and a lot of open walking space to allow for mobility during labour at the MLCU, they were surprised. “When I had my first child at Vanivilas seven years ago, there was nothing like this. I never knew that doing exercises could help and I had never seen birthing balls. Also, this time I got so much care. Everything was explained to me and my consent was taken before anything was done,” recalls Nandini. Having the choice of midwifery care, during pregnancy and childbirth has now become possible for the hundreds of women who travel as far as 200kms to give birth at Vanivilas Hospital. The word is getting around that women can have a say in the way they want to give birth. Additionally, workshops conducted by the NMTI trainees and trainers to sensitise the non-medical staff like security guards, and members of the sanitation and housekeeping department dealing with pregnant and lactating women, about respectful maternity care is helping women feel respected and cared for right from the moment they step into the hospital. “This is just the beginning. We hope to transform the birthing experience of many more women with the midwifery model of care,” claims Janhavi.
Swapna Majumdar is an independent journalist writing on development and gender.