Nine Months of Gestating Fieldwork Research: Experiences and Desires for Birth Companion Support.

By Julie Fleur Morel

The first time I went to India was in 2017. It was the fall semester of my third year of college, and I’d chosen the program because it was the only non-European country that emphasized a focus on community approaches to public health. After several months of connecting with different organizations and lecturers, it was time to declare what I would study for my one-month independent field research project. I knew I wanted to speak with and learn from traditional birth attendants that guide rural families through their reproductive lives, so I spent one month solo in the field around Udaipur interviewing elders who had welcomed hundreds of babies in their hands – elders removed from formal medical knowledge but relying on generations of innate wisdom and community caretaking that bolstered families’ wellbeing. At a mere 20 years old, it felt like I was in way over my head (because in many ways, I was), but choosing to focus my learning around traditional birth attendants and people’s birth stories at that time is what brought me back five years later – this time with nine months of research instead of one, and with a much deeper understanding of Hindi and birth contexts.

As someone who had spent the previous five years deep in birth nerd mode, this time around I was particularly interested in understanding what low-income women’s support networks looked like during the perinatal period. Undoubtedly, we know that women in childbirth have historically been accompanied and supported throughout delivery by various family members and community members, and this has always been thought of as something beneficial to the birthing process. In the United States, today this often takes the form of a doula – a non-clinical but fully-trained emotional and physical support person providing guidance throughout pregnancy, birth, and postpartum. And although this title of “doula” does not exist in most of the world, its principles are woven into the fabric of nearly every society. In India, in particular, this care-taking support role is variably held by family members such as mothers-in-law or sisters, or by community members such as community health workers, accredited social health activists, and traditional birth attendants.

A newly postpartum mother, her baby, and her own mother who was her birth companion and a previous traditional birth attendant

A newly postpartum mother and her baby, who she gave birth to while on the way to the hospital from her local village

And so, motivated by recent studies that confirm what generations have known all along – that birth outcomes are positively swayed by the presence of a non-clinical support person – I was interested in hearing people’s perspectives on the value of receiving support from multiple sources in an Indian cultural context. Although Indian institutional structures have reflected this only minimally with the prioritization of medicalization, Indian social structures have always reflected diversification of support within strong familial and community networks. My research intention, then, was to seek to explore this deep-seated practice and suggest possibilities of expanding and further legitimizing it.

Situated in North India, my conversations with people aimed to understand women’s own experiences and perceptions of the specific support actions they receive from non-medical companions during childbirth, and to compare this with the perspectives of healthcare providers across delivery settings. By interviewing folks from urban Janta Mazdoor Colony in Delhi and from rural Bahraich in Uttar Pradesh, my research intended to uncover (1) how women attribute support actions as contributing to a positive or negative childbirth experience, (2) women’s expressed needs and desires from relationships with a birth companion, and (3) healthcare providers’ perspectives on the presence of birth companions in the delivery room.

Over my nine months of research (the perfect stretch of gestating my own little project baby), I was able to sit down with 23 mothers aged 18-35 years who were less than 6 months postpartum, 11 health professionals who attend birth in public health facilities, and 8 traditional birth attendants who primarily have attended home births.

Sitting with postpartum mothers in their homes in Delhi, as we spoke about their birth experiences and lack of birth companionship in hospitals

Heartbreakingly, I found that despite international and local scholarship and large public health bodies declaring the importance of birth companionship, women birthing in government hospitals in Delhi were largely withheld this right and forced to birth alone. However, in contrast, all but one of the women interviewed who delivered vaginally in rural Bahraich District were allowed to have a birth companion with them in the labor and delivery rooms. Women who were permitted the presence of a birth companion noted a myriad of positive support actions during labor and delivery, including an array of physical, emotional, educational, spiritual, logistical, and advocacy support, and women largely expressed that this significantly affected their birthing experiences for the better. Women who were prohibited the presence of a birth companion, on the other hand, often reported experiences of significant birth trauma (emotional and physical) and expressed that they wished a family member had been present with them at the time, potentially pointing out the importance of companionship in environments where health facility conditions or staff behavior may not be as favorable. While women named some aspects of birth companionship that may contribute to a negative childbirth experience – such as receiving too many instructions or being told to keep quiet while in pain – women reported an overwhelming number of support actions as positively contributing to their experience.

Examples of support from birth companionship were varied, and all held true to uplifting community with love. Women shared examples of physical support such as oil massage of the legs, feet, and hands, hand holding, pressing of the head to alleviate headache, pressing of the legs and feet, holding her up as they walked around together; emotional support such as giving courage through words like “don’t worry, it will happen,” sharing smiles and warm energy; educational support such as guiding her how to breathe and push in order to reduce pain and aid with contractions, showing her how she can hold her own thighs up to make more room for the baby to come out, encouraging her to maintain her energy in various ways; spiritual support such as praying and asking her to remember God; advocacy support such as talking to the doctors on her behalf, convincing them to avoid referral to a bigger and more expensive hospital for cesarean section and to try harder for a vaginal delivery, controlling who else is present in the birth space and sending out other family members who are “useless or causing disturbance,” and acting as a witness to watch out for the exchanging of babies that sometimes happens; and logistical support such as providing food and water and chai, carrying newborn clothes and blankets, and providing a change of clothing.

A newly postpartum mother and her community support network that uplifted her during birth and beyond

While traditional birth attendants interviewed for this study spoke positively about the presence of birth companions, most health facility staff interviewed (doctors and nurses) were hesitant about this involvement due to overcrowded hospital conditions, aggravations of being questioned about their medical procedures and authority, and concerns of family members disturbing their work and being unable to witness their loved ones in pain. Overall, there was also a general lack of clarity about what support these birth companions actually provide to mothers. While some health facility staff understood the importance of having a birth companion for psychological support and had made policy adjustments pre-Covid with programs such as the LaQshya Initiative, change is slow. Seeing as traditional birth attendants are able to perceive birth companions as necessary members for both the mother in labor as well as for their own personal workflow, these sentiments of collaboration and collectivity are models for how health facility staff might be able to reframe their perspectives.

Interestingly, this struck a similar chord to how doulas and traditional birth workers are perceived in the United States. While midwives or homebirth professionals tend to appreciate the support contributed by the doula and can understand the value added in facilitating a calm encouraging environment, health facility staff within the medical industrial complex often have a hard time working alongside these birth companions if they are in any way challenging authority or “getting in the way.” As a full-spectrum doula myself, it was difficult to witness families’ and traditional birth attendants’ frustrations, as well as postpartum peoples’ regrets, that not more could be done to uplift the birthing dyad and promote the most supportive birth outcomes possible. Seemingly this thread trails across the world, but I have hope that with more conversations prioritizing the innate wisdom of traditional knowledge and community approaches to care, we can return to a society that centers families, shared decision-making, and emotional health alongside physical health.

From left to right: Speaking with a traditional birth attendant who primarily used to attend home births, spending the day with a local auxiliary nurse midwife (ANM) that works primarily in the hospital, and taking a walk with an accredited social health activist (ASHA) through the village

Allowing my research to unfold in the ways that it has over this grant period has been an immense lesson in flexibility and patience. From initially attempting to propose research on an incredibly broad topic, to then being pushed and encouraged to hone in on a very specifically tangible anchor; from waiting around listlessly for IRB approval after months of literature review to then suddenly hitting the ground running with three interviews a day and ten-hour transcription sessions; from understanding a mere lick of Hindi to then being able to conduct one-hour interviews in rural villages by myself – I am immensely grateful for the ways in which my professional and personal limits were gently pushed at with confidence.

From left to right: My translator in Bahraich, my self-introduction to participants in Hindi, my translators in Delhi

Though undoubtedly challenging, this time has affirmed my love for working on the ground with folks and has sustained my excitement for continuing into the field of public and perinatal health as a doula and midwife in the coming years. Being able to connect on a personal and professional level with my affiliate and advisor, with my NGO partners, with a plentitude of interview participants, with my fellow Fulbright student-researchers, with new local friends, with old connections from prior visits, and with novel budding partnerships, has been immeasurably beautiful. Dedicating time to supplementing my research by connecting with these social networks, traveling amidst boundless natural and human beauty across the Indian subcontinent, engaging with local festivals and weekly yoga classes, and gorging myself with some of the best food of my life, this grant has reignited an inspiration much-awaited in a “post-covid” world. I am in deep gratitude for the many stories and experiences that have been shared with me across this period.

I recall spending a large portion of my time as a Fulbrighter wondering what in the world I was doing on this grant, what the greater meaning and implication of it was, what my place was in these spaces where folks with very little means were welcoming me inside their homes for hot chai – and I am still trying to figure that all out. I likely always will be. But I do know that the kindness and openness with which I was met was like a balm of love that seeped in every direction. Sitting in these women’s bedrooms and hearing these people’s most intimate birth stories and their experiences witnessing birth around them has affirmed the deep beauty of community-oriented care and my excitement for open discussion around this. To commune with newly postpartum moms and their sleepy babes, to sit for hours without a word of English because I could manage to follow most of the Hindi I’d learned, to share laughter and tears together – it has been an utmost privilege.

From left to right: CHSJ community space in urban Delhi, and DEHAT community space region in rural Bahraich

I am grateful to all of the women, family members, community health workers, and health facility workers who shared their time and experiences so generously to be a part of this experience. I thank my NGO partner mentors Shreeti Shakya and Sandhya Gautam at CHSJ, and Divyanshu Chaturvedi at DEHAT, for guiding me in this study and providing continuous encouragement, and I am deeply grateful to my in-person translators, Niharika Singh, Kashaf Yusuf Zai, and Shreeti Shakya, who seamlessly integrated my hopes for this project into reality. As I continue to engage with this work even post-Fulbright, I am incredibly grateful to Dr. Devaki Nambiar from The George Institute for Global Health for supplying me with constant feedback and support in the proposal stages of this research and beyond, and to the Fulbright United States India Educational Foundation for funding this grant. And lastly, to thank my origin story of this work in particular, I thank my study abroad mentors in Delhi – Archna Merh, Goutam Merh, and Azim Khan from SIT India – who have continued to partner my love for this work, even half a decade later.

Accredited social health activist (ASHA) community health worker guiding us through the village in Bahraich to meet new mothers

A note on language: The use of the term “women” in my work encompasses the gender identities of participants that I connected with during this research. Women are not the only people that can be pregnant, labor, and give birth, and it is critical to acknowledge gender expansiveness within perinatal fields that too often marginalize birthing people of other gender identities.