Culture & Society

Ideas of India: Maternal Healthcare and Evidence-Based Decision-Making

Shruti Rajagopalan and Janhavi Nilekani discuss the ‘too little, too late’ and ‘too much, too soon’ problems in Indian obstetrics and midwifery

Indian maternal healthcare is often too little, too late or too much, too soon. Image Credit: Anindam Ghosh/EyeEm/Getty Images

Ideas of India is a podcast in which Mercatus Senior Research Fellow Shruti Rajagopalan examines the academic ideas that can propel India forward. You can subscribe to the podcast on AppleSpotifyGoogleOvercastStitcher or the podcast app of your choice.

In this episode, Shruti speaks with Janhavi Nilekani about India’s high rate of C-sections compared with vaginal births, problems with maternal healthcare, the present and future of Indian midwifery and much more. Nilekani is the founder and chair of the Aastrika Foundation, which seeks to promote a future in which every woman is treated with respect and dignity during childbirth, and the right treatment is provided at the right time. She is a development economist by training and now works in the field of maternal health. She obtained her Ph.D. in public policy from Harvard and holds a 2010 B.A., cum laude, in economics and international studies from Yale.

SHRUTI RAJAGOPALAN: Welcome to Ideas of India, where we examine the academic ideas that can propel India forward. My name is Shruti Rajagopalan, and I am a senior research fellow at the Mercatus Center at George Mason University. Today my guest is Janhavi Nilekani. She is the founder-chairperson of Aastrika Foundation, an initiative to strengthen health systems through capacity-building of healthcare workers across India. In 2021, Janhavi founded Aastrika Midwifery Centre, a birth center in Bengaluru, to provide ethical and evidence-based maternity care. She earned her Ph.D. in public policy from Harvard University and her B.A. in economics and international studies from Yale University. We spoke about the state of maternal health in India, the high rate of caesarian births, evidence-based medicine, her personal journey that led her to found Aastrika, and much more.

For a full transcript of this conversation, including helpful links of all the references mentioned, click the link in the show notes or visit Discourse Magazine DOT COM.

Hi, Janhavi. Such a pleasure to have you here. It is always so much fun to speak with you, so I’m thrilled that we are having this chance again today.

JANHAVI NILEKANI: Thank you, Shruti, for inviting me here on Ideas of India. It’s a pleasure to be here.

Birth of a Midwifery Center

RAJAGOPALAN: I want to start with what is very confusing to a lot of people and, until very recently, was confusing to me. When people hear Dr. Janhavi Nilekani and they see that you actually run Aastrika, which is a midwifery center, everyone seems to think that you’re a medical doctor, but actually what you have is a Ph.D. in development economics. I didn’t even know about this until maybe last year, when we really started talking about a whole bunch of things in health economics and policy. First of all, that is a very strange job for someone who got their Ph.D. in development economics. Can you tell us about the journey that led to Aastrika being born?

NILEKANI: Sure. Thanks. As you mentioned, I was doing a Ph.D. in public policy, training as a development economist with a focus on—other than development economics, on environmental economics. For a long time, I was very focused on air pollution. All my dissertation research is in the field of air pollution and India’s extremely heavy air pollution burden and the impacts that has on public health and what are some potential solutions to that.

While I was towards the end of my Ph.D., I was doing—well, I chose to have a child partly because, I must give Harvard this, that their parental support for grad students is superb, absolutely superb. A lot of us actually did opt to have children in our Ph.D. years while we had that backing.

I was toggling up and down between Boston and Bangalore—I mean Cambridge and Bangalore, that is. I was doing a randomized controlled trial with 1,522 bus drivers across 34 taluks in South Karnataka, looking at whether certain interventions on driving style can impact pollution emissions of local air pollutants, such as particulate matter or others. At the same time, I was visiting Harvard each semester to meet my mentors and present each semester, and so forth. I was going back and forth while I was pregnant. The difference in the quality of care between Cambridge and Bangalore was so vast, I couldn’t get over it.

I think it’s pretty well known that India still has high infant and maternal mortality rates. They are coming down. There has been tremendous progress. I want to say that up front, but at the same time, rates are still high. For example, if you take maternal mortality rates, there’s still about 103 deaths per 100,000 live births. The SDG goal for 2030 is 70. I think this is a well-known problem, but till I actually was pregnant myself, I think I hadn’t grasped how much the poor quality of maternity care goes up and down the income ladder. How even in metropolitan, cosmopolitan, really one of the most well-exposed cities like Bangalore, the quality of care in private-sector hospitals was still very poor.

I was very keen to give birth in India. We wanted my son to be an Indian citizen, plus it was a December due date, and the sun sets at 4:00 and it gets to minus 34 degrees. That was for me a downside of Cambridge, and I wasn’t really keen on that. It took me a very long time to find the kind of high-quality care I was seeking anywhere in India. Specifically, what I was looking for was nothing more or less than just looking for evidence-based medicine, for clinical care that was based on randomized controlled trials, that was based on clinical standards, that was based on the best of research evidence.

I was a researcher myself, and I was just astounded by how little clinical practice in India was related to what research said. Some very simple examples would be that if you go by research evidence or guidelines, you should have cesarean rates somewhere between 15% to 19%, maybe 25%. It’s routine in Bangalore hospitals to have C-section rates of 70%, 80% and 90%.


NILEKANI: Those are really sky-high numbers of unnecessary surgeries, which is something I didn’t really want for myself, so I spent a lot of time questing for the right place. I ended up having my son in Hyderabad at a midwifery center run by a U.S.-trained midwife who works in partnership with the—she’s Indian herself, but she lived in the U.S. for a long time—worked in partnership with the local obstetrician. I personally had a great birth experience there.

The whole experience just led me to delve more into this topic of the challenges of maternal health across India. They really vary based on your income group. The problems you have in rural India, in the public sector, in certain states, are very different from what you have in a place like Bangalore, but there is a gamut of challenges.

Somewhere, I think by the time I graduated from my Ph.D., I had made up my mind to focus on maternal health and step away for a while from air pollution, or forever as it may be. I guess that’s what led here. Aastrika has the vision that every woman in India should have access to high-quality and timely maternity care. Life-saving treatment when needed, without it tipping over into excessive treatment if not needed. And at the same time, access to respectful maternity care, that disrespect and abuse should be stamped out.

If you look at the research evidence, it’s quite horrifying how predominant disrespect, abuse, obstetric violence—physical violence in the labor room is still rampant across India. That’s one of the key targets of Aastrika Foundation, is to work on that and to reduce the widespread nature of it. I finished in 2018, May, and took six months off, which I desperately needed, and then started working on this. It officially was launched in early 2019, so it’s been about three and a half years.

RAJAGOPALAN: It’s been amazing. I’ve followed your journey with Aastrika, and I’ve luckily gotten to know a lot more, not just by reading the material that you guys put out or what’s covered in the press, but actually speaking with you.

Too Little, Too Late

RAJAGOPALAN: One of the things I wanted to pick up on, specific to your journey, is that there seems to be either very little care or too much care—I’m saying “care” in quotations—in terms of healthcare. In a sense that either women are going through unnecessary surgery, unnecessary procedures, like young women who are perfectly healthy are told to have C-sections. They can’t have an expectation that they’ll have a natural childbirth without tears, without stitches and so on. On the other hand, there is a vast majority of Indian women who get too little care. That is, they don’t get the timely intervention, which is also why mortality rates are so high relative to our stage of economic growth or development.

Can you just walk me through what that landscape looks like? What does the maternal healthcare landscape look for people who are, of course, very poor and not privileged, but also people like you, who are at the top end of that privileged ladder, where money is simply not an issue, but you still cannot find a doctor or a practice that will work with you based on very sensible, evidence-based decision-making that is actually explained to you without forcing you into any procedures?

NILEKANI: The public health world calls this the “too little, too late” or “too much, too soon” challenge in maternal health. The term was really popularized by a 2018 Lancet series talking about the landscape of maternal health globally, not just in India. One of the signature articles in that was one called “Beyond Too Little, Too Late and Too Much, Too Soon: What Could a Pathway Towards Evidence-Based Maternity Care Look Like Globally?” That is basically this idea. You see globally for sure that this dynamic is going on, but let’s stay on the topic of India.

On the one hand, “too little, too late” is the—to just delve more into it—“too little, too late” is the challenge when women have inadequate access to care. This can be a range of things. A, it can simply be not having a healthcare facility in your vicinity. That challenge has been, to a great extent, lessened now across India. Definitely, there are some remote areas, be it—it can be because of Naxalite regions or it can be because of extreme hilly regions. There are parts of Arunachal Pradesh, for example, which can be quite inaccessible depending on season and so forth. That’s one area with higher maternal mortality rates.

By and large, including in the poorer geographies of India, there is access to—healthcare facilities do exist. But a second challenge is, even if the facility does exist, A, is it staffed? The development economics literature has an abundant research on—the degree of absenteeism among doctors and nurses is very high. Rema Hanna and several others [Banerjee, Glennerster and Duflo] had a paper way back in 2007, ’09, around then, talking about this. In the very randomized-controlled-trial literature of development economics, there have been numerous interventions trying to do nothing but reduce absenteeism among teachers and healthcare workers in India. The absenteeism is extremely high.

Now, let’s say the facility’s there, the staff is there. The quality of training that is received is not necessarily sufficient. You may not be getting a very high quality of healthcare even if people are physically present. That’s on the skill side. Over and above that, do you have enough drugs? Other than human resources, do you have the other things you need to ensure life-saving care?

Just to go—I guess I’m going a little deep. There’s this geographic insights at That’s a really fascinating geographic tracker, which compares at the district level data from NFHS-4 and NFHS-5. And just staying on C-sections because the data quality is very good there, let’s say, at a population level, somewhere between 10% and 19% seems to be an appropriate cesarean rate. More than that is probably excessive. Less than that is insufficient. What you do see is, there are several districts—I think there were about 70 between NFHS-4 and NFHS-5—where the number of cesareans in that district actually dropped between 2015-16 at NFHS-4 and then the 2019-20 in NFHS-5.

This really tells you that most likely, from everything we know, these would have been districts where the district hospital five years ago happened to have both an obstetrician and an anesthetist. But in the next NFHS-5, at least one of those people, that post was no longer filled, and then they no longer had the ability to do surgery. There are districts in this country which do not have the ability to give emergency care. They may have a hospital, but unless it is staffed by obstetricians and anesthesiologists, you can’t do emergency C-sections.

The government of India’s own data says that 34% of rural obstetrician posts—only 34% were filled in 2016. That’s the extent to which it’s very hard to get specialists to go and work in obscure parts of the country. Then, even after all of this—let’s say you’ve sorted most of these things, and there is an emergency facility in the district and so forth—you do run into this challenge where referral pathways are inadequate.

Let’s say there’s an auxiliary nurse midwife, an ANM, in a rural primary healthcare center in Bihar, also who’s skilled enough to appropriately identify that this woman needs to be referred to a tertiary center, but still may not have the ability to actually move that person, that lady, from the PHC to the staffed emergency center in the vicinity. All of these cover what is called “too little, too late,” and all of them are still unfortunately very widespread.

The other challenge, generally talking about prevalence, typically “too little, too late” is relatively more prevalent in the public sector than the private. It is, of course, more prevalent among poorer socioeconomic segments rather than the wealthier. There are certain states where it’s still widespread.

Too Much, Too Soon

NILEKANI: The opposite challenge is what is called “too much, too soon,” which is an excessive amount of—literally too much intervention too soon, before it’s needed, where heavy-duty interventions—I’m not talking about mild ones, like full-blown cesareans, augmentations, inductions, episiotomies, a whole gamut of medical interventions, which do carry dramatic morbidity. I mean, they have side effects for women, substantial ones.

These have also become extremely prevalent in many parts of the country. I think the scale of it is sometimes shocking. As I’ve been mentioning, 10% to 19% also seems to be the range for population level of good outcomes in terms of cesarean rates. For example, Scandinavia, the Netherlands, many of those countries have cesarean rates between 15% and 20%. They seem to have the best maternal and neonatal health outcomes.

The United States, I believe, peaked at 32% nationwide in cesarean rates, and it’s on a slightly downward trend or stable at the moment. The U.K. has very recently climbed in the low 30s. It used to be in the high 20s. In comparison, Telangana has a statewide cesarean rate of 61%. You’re talking about doubling the C-sections compared to the United States. And this is across rural/urban, private/public, across the state of Telangana.

There are three states in India—Telangana, West Bengal and Jammu and Kashmir—where, based on NFHS-5 data, C-section rates in the private sector are more than 80%. That’s just a sky-high rate of unnecessary surgery. C-sections are the most common surgery worldwide, and I think there are very few other surgeries which have become this normalized, where it is so much seen as a choice. Almost like, “Are you going for this dress or that dress?” In a very casual way, without either at a social level or at a medical level understanding that at any point, any human going to any surgery faces substantial surgery-related risks.

That understanding seems to have almost vanished from India’s urban landscape in a span of a few years, barely a generation. India basically sees all of this. Sometimes in the same birth, you will have both “too little, too late,” where you have inadequate access to respectful maternity care, and “too much, too soon,” which can be completely unnecessary intervention. That’s a very high-level picture.

The other major challenge we see across India is that disrespect and abuse is rampant. I talked already about the physical abuse that you may see in certain settings. Even in the urban private healthcare space, there is a lot of non-consented care where people don’t have appropriate informed consent before something like a surgery is done. That is a type of abuse. I’m not saying it’s the same as slapping somebody in labor, which also happens in other segments of society.

RAJAGOPALAN: Happens shockingly often, relative to what one would imagine, especially what men would imagine. Yes.

NILEKANI: Yes. Some of the reporting on this, if you read, in the same public hospitals you will see far more abuse in the labor room than in, say, an orthopedics department. Even among the wealthy, surgeries done, be it for profit or convenience or whatever, is inflicting side effects and physical harm on somebody for reasons that are not in that person’s best interest. It’s certainly not appropriate care, if nothing else.

RAJAGOPALAN: Yes, and the other thing is, when this is happening during childbirth, a lot of the consent seems to vanish out of the window, especially because they think, “Oh, the woman is in too much pain,” or she’s not capable of giving consent, or they’ll just ask a random family member. Or even if the mother says that, “No, I do want to have a natural childbirth,” they will give all kinds of incorrect information or throw terrifying statistics in that moment and say, “You’re harming your baby, and you must do this procedure.”

There’s also a lot of complicated consent issues, even if there is no abuse in the more wealthy or elite sectors. Women are literally pushed into things that they really don’t wish to do.

NILEKANI: A lot of what I call fear-based consent rather than truly informed consent.

Pregnancy Experience

NILEKANI: This is what I found so challenging in my own pregnancy because Harvard’s IRB was making me go through insane amounts of informed consent to ask drivers about their driving practices, in comparison to which I was not receiving any informed consent for major medical issues.

RAJAGOPALAN: That’s actually so interesting that you say that, because the review board, when you do an RCT or any kind of survey and so on, it’s a very high bar, as it should be. Like you said, this is about, “Are you using CNG, diesel, gasoline?” decisions, or “What route are you driving?” Whereas when it comes to, “Hey, I want to have natural childbirth. I want to make sure that there is no tearing, there is no stitching, there is no unnecessary C-section,” people are just not giving you the information that you deserve.

This is entirely not even about you running this survey with other pregnant women. This is literally happening to you. What were some of the strange things that you encountered during your pregnancy?

NILEKANI: Oh, wow.

RAJAGOPALAN: The reason I asked is, I think your personal story illuminated a lot to me. Because of all the people that I imagine having difficulty in getting excellent care when it comes to childbirth and maternal health, Janhavi Nilekani is not someone who comes to mind struggling with the appropriate level of care—not “too little, too late” or “too much, too soon.”

Your personal story is actually quite informative on what the landscape looks like in India, especially in the private sector, even for the most privileged and elite. Women cannot buy their way out of this problem. This is a systemic problem at the entire market/government system level in India. I think that’s one of the reasons it’s so illuminating.

NILEKANI: I think, to some extent, the fact that I was a Ph.D. student at Harvard and had full health insurance, I always had the backup of giving birth in Cambridge. You know how we talk about, people have bargaining power if they have exit options. Gary Becker has written a lot about that in the context of marriage. That’s a common framework in economics. And fundamentally, by always having the option to walk out to the U.S., that gave me power that the average Indian urban woman does not have.

Yes, it’s shocking how much I myself had to struggle and strive for one birth, though I personally am not a believer of natural childbirth, I would say. That’s maybe because the way the word is used liberally, a “natural” childbirth, people use it to refer to non-intervened births, and a lot of people genuinely want that. I was never one of those. What I was looking for was an evidence-based birth. What I wanted was interventions which science and research and meta-analysis show that the benefits outweigh the harm. I did not want interventions where the harms outweighed benefits. It was as straightforward as that, which was nearly very hard to get.

Even in the U.S., evidence-based practice in maternity care is not where one wishes it should be. For example, there’s a lot of lag between when, say, the American College of Obstetricians, ACOG, will put out a protocol and it being adopted nationwide. All these lags are there, but that’s the normal scheme of how long it takes to disseminate best practices. In India, it was far more dramatic than that.

Bangalore is a city with 60%, 70%, 80% cesarean rates, if not sometimes higher in private hospitals. First, I had a really hard time finding doctors who were even willing to try for a vaginal birth. Again, I’m not in any way an ideologue. All I wanted was, a cesarean should be only done if there was a cause for it and not done unnecessarily. That was all I was seeking.

I did find a handful who were willing to try for normal deliveries, but they really didn’t follow other evidence-based practices which are recommended world over. Some very simple examples: Be it the WHO or the ACOG or RCOG or FIGO, guidelines all over the world have shown that routine episiotomies are harmful. Episiotomies are a surgical cut to the perineum to enlarge the opening, the vaginal opening for childbirth.

In India, they are done at the rate of 85% or more of first-time mothers—pretty much universal. Published research in some tertiary hospitals says 85%. But if you speak to—colloquially, I don’t know any—anecdotally, every place, at least in Bangalore, seems to be at 100%. I could not find any hospital who would agree to follow global protocols on this.

I did argue a lot with my obstetrician, saying, “Look, here are these RCTs. Here are these systemic reviews. Here’s this meta-analysis. Evidence from every corner, guidelines from every corner says this is a harmful practice because it tends to cause tearing. It tends to cause slow recoveries. Generally, the harms far outweigh any benefits.”

She said, “Janhavi, but all this research was done on white women, and you are Indian.” That threw me, and I think for a few minutes, I reacted in a completely Ph.D. student way of being pulled up in front of—Cambridge’s development economics place is stressful. It is filled with potential Nobel prizewinners pulling you up. I went straight into the external validity of the research and reacted in a very sincere, “Okay, let me go vet the quality of this research” manner.

Then eventually I realized they were also doing things like shaving and enemas in a way. They were doing a lot of things which are almost 30 or 40 years behind protocols. There was a moment when I said, “Okay, I call it quits. I can’t keep striving and struggling to get Bangalore to be more evidence-based. I have to exit this market.” I literally walked out of Bangalore’s private healthcare market and flew to Hyderabad to have this child.

RAJAGOPALAN: How did that go with everyone around you?

NILEKANI: It was the childbirth version of an elopement. [laughs] Everybody thought it was crazy. It is a bit crazy if you think about it. I was approaching it from three angles. One was, I was sufficiently decent at understanding or interpreting research to be able to understand research to know what worked or didn’t work. I think what being an economist student at the time gave me was some understanding of incentive structure. My mother, for example, was strongly advocating that we should stay in Bangalore and then negotiate with a system to try and do a one-on-one case exemption, exception, which could have worked.

But the whole time, I kept feeling it is nearly impossible to change the incentives of any institution. Systems are geared around all the actors in it having some incentive alignment to what they’re used to doing. That was one of my biggest takeaways from economics, that aligning the incentives of people is very hard, and changing the incentives that they already have for one of exemptions is even harder.

Finally, I felt I really needed to go to a place where all the institutional actors were aligned towards the same outcome I wanted of evidence-based medicine. That’s what I ended up doing. There’s a big culture in India of doctors often treated as gods. There’s a big culture of not questioning what doctors say. It’s changing now, sometimes in bad ways, with a lot of acrimony between doctors and patients, and you hear stories of physical abuse of doctors after bad client outcome. There have been very bad stories in that direction as well.

But still, by and large, there’s a huge hesitancy at any segment of society to question what the doctor says. There’s a presumption that the medical professional knows better. If at a system level you’re seeing such bad outcomes—and obviously at the individual level they’re taking numerous bad clinical decisions. You wouldn’t get such bad statistics at city levels otherwise.

RAJAGOPALAN: No, and I think of course this is particularly acute in the case of maternal health, but recently—I’ve had long COVID since August, and I’ve realized this is also true for that. In India, they are prescribing steroids willy-nilly, and pretty high dosage of steroids. Now, of course, you know long COVID comes with very bronchitis kind of symptoms, a lot of lung issues, a lot of coughing. There is a lot of relief when you give a harsh dose or a strong dose of steroids, and the coughing or the inflammation can reduce.

On the other hand, there are a lot of people, especially the elderly, where if you give a very high dosage of steroids, which is “too much, too soon,” it’s going to suppress all the other symptoms. It’s suppressing things like pneumonia. They actually weren’t suffering from bronchitis. It was something else, and now that got completely suppressed, which means they couldn’t intervene for things like pneumonia until it was almost too late because a medication was too strong, too soon. Once again, just rampant abuse of antibiotics—again, too much, too soon, which is of course a public bad at this point because it has this huge externality in terms of antibiotic resistance.

Incentives in Maternal Healthcare

RAJAGOPALAN: I can see what you’re seeing in terms of incentives, but can you also spell it out in the case of maternal health specifically? What are the incentives? Is it that C-sections are easy to schedule? These doctors are super busy, which means they can do six or seven a day. Whereas when it comes to a regular childbirth, we don’t know how many hours the woman’s going to be in labor, we don’t know what kind of staff you need. You might need more trained nurses, you might need someone who’s a trained anesthetist, a doctor who can be there on call the whole time.

Is it simply a question of convenience and cost? Is it a question of supply? What are the incentives that make this problem so problematic, especially in urban centers in the private sector?

NILEKANI: It’s pretty multifaceted. There are a whole range of issues going on. I’m not going to talk about the public sector at all at this point for this, but I’m going to look at the entire private sector, including many of the smaller nursing homes, which are often a single doctor who lives in a flat above a nursing home, because a lot of cesarean rate is driven by that. It’s not only your big chain hospitals, but a lot of individual nursing homes as well.

Looking at private-sector urban maternity care, one straightforwardly is cost. A lot of places charge substantially more for a cesarean section, and hence it is in the hospitals’ incentive to do more cesarean sections. Of course, they’re making more revenue per procedure. That’s one.

More important than that, I feel a second but ultimately more important factor is that cesareans are much more cost-efficient. They are much more cost-efficient. You do them back to back. You can fit—

RAJAGOPALAN: For the healthcare community, not the patients.

NILEKANI: That’s true. On the supply side, the first factor, I feel, is that straightforwardly, cesareans are often billed at higher rates. Any particular cesarean procedure is more revenue-raising than vaginal birth. A second factor from the supply side, again, is that it’s a lot more cost-effective to do cesareans. In a sense, they take much, much, much less time. It takes an hour to do a cesarean. A normal childbirth for a first-time mother, 8 to 24 hours is considered normal.

The big challenge that hospitals have is that if you want to safely do vaginal births, you need to have a reasonable amount of ability to do an emergency cesarean all the time, 24/7. That is very cost-ineffective unless you’re in a large-volume center. If you’re going to keep an obstetrician on standby 24/7, a neonatologist on standby 24/7, an anesthetic team on standby 24/7 in case any particular birth becomes an emergency cesarean, your human resource cost and what you’re paying out in an extremely expensive, high-human-capital employee is much higher than if they’re all there on a day shift during which you’re largely finishing off cesarean births.

You’ll often see a pattern where—I haven’t seen data on it, but my guess is the by-day, time-of-day pattern in Indian births is very, very high where even the vaginal births, which are happening in urban India, are typically happening because they happen to happen in the daytime. If the birth does not take place by 8:00 or 9:00, it’s usually converted to a cesarean. People aren’t keeping the hospital staffed in an emergency-ready state at night. That itself is shaving off tons and tons and tons of costs.

Part of the reason is that it has become—now jumping to a demand-side factor, is that cesareans have become normalized. “Too much, too soon” is normalized in India. You’re completely right. It’s not only about C-sections, be it about unnecessary hysterectomies or knee surgeries, but I think antibiotics is the biggest one. If you just stop for a moment on COVID—you mentioned long COVID, and I really hope you recover quickly. But COVID treatment itself was insanely overdosed, where global guidelines said, asymptomatic COVID, don’t do anything much or just treat it like you take your paracetamols, you take your Nyquil equivalents—

RAJAGOPALAN: Fluids, rest.

NILEKANI: —your fluids, rest. In India, official guidelines often said, “Take ivermectin, take antibiotics.” The amount of huge dosing that happened for the millions and millions of people who had COVID, that was very in-your-face, the extent which India has normalized “too much, too soon” across healthcare. Including things like a fever and so on—it’s so routine to have people, “Okay, I went to the hospital, I got a drip. Now I’m okay.”

Well, there’s a placebo effect in all of that, but essentially, there’s a cultural expectation of aggressive treatment for everything. Perhaps a cultural, well, lack of understanding, of appreciation of how much the body can actually recover if you just give it a little time to recover. That’s certainly a big factor.

C-Sections vs. Vaginal Births

NILEKANI: As cesareans have become normalized, the fear around vaginal births has gone up a lot. There’s a perception that cesareans are safer. If you actually look at science, if you look at long-term and short-term health effects, morbidity, even mortality risks are considered higher with high levels of cesareans—for mothers, that is. Somehow there’s a public perception that C-sections are the safer way to give birth. Even trying for vaginal delivery is risky.

Coming to a more landscape thing, one challenge is that the medical-legal lawsuit landscape is unbalanced. People are very often sued for the cesareans they didn’t do but are never sued for the cesarean which caused any number of downstream side effects. As an example, you hear of multiple people losing—suppose you have one cesarean. One of the biggest side effects is that you are considered high-risk for your remaining reproductive future. Every pregnancy becomes more high-risk. The most cesareans you have, each cesarean makes the next pregnancy even more complicated.

RAJAGOPALAN: Also, the more cesareans you have, the more you need, which also is skewing the incentive structure. Right now, this is—

NILEKANI: The more you need, and now the more dangerous the surgery is. The more dangerous the surgery is. You have ectopic pregnancies, you have adhesions in the abdomen, you have higher rates of bleeding. A lot of things start to escalate.

One of the attitudes that’s there in India is that, “Oh, nobody has more than one or two children anyway, so it doesn’t matter if we do cesareans for everybody.” Now, it is true that total fertility rates in India are actually very low. The parts of India with high C-section rates actually have very low fertility rates. But India is still a country with an infant mortality rate—around three of every 100 Indian children are still dying before the age of one.

In a way, it’s scandalous to be impacting a woman’s future reproductive lifetime without having that higher degree of assurance that this child is going to survive. I personally know of at least three to four women who had a cesarean with their first child, the first child passed away, and are now looking for two living children. They’re not looking for two pregnancies over the course of a lifetime. Now each pregnancy has now become high-risk. Once you’ve had a cesarean, if you try for a vaginal birth after cesarean, that is considered—that’s relatively risky. Even in the U.S., the rates of VBAC [vaginal birth after cesarean] aren’t very high because the uterus can rupture during second birth.

Now, suppose there are these ruptures, and this second-pregnancy child passes away or has long-term issues. In India, the landscape is you will always sue or go after the doctor who dared to try a VBAC, but you would never go and sue the doctor who probably did an unnecessary cesarean the first time, making you high-risk in this pregnancy. It’s completely skewed. That is definitely a huge factor.

To some extent, I think there’s a fair amount of skill erosion. The more and more vaginal births have become rare, the less and less practice people have with vaginal births. The healthcare system is forgetting how to do complicated vaginal births. They can still handle the ones where the baby just comes out, but the moment there’s the slightest degree of complexity, these births are being done as cesareans. The ability to do a complicated vaginal birth is rapidly eroding in India.

RAJAGOPALAN: This is where the midwifery skill becomes so important relative to the skill of just surgeons and OB-GYNs and the entire surgical team and surgical staff, right? There is a very particular skill that is eroding, and other kinds of skills are not eroding.

NILEKANI: Surgical skills are definitely not eroding, but obstetricians are the ones I think who are losing the skills to do complicated vaginal births. Actual professional midwives are barely present in India. There’s an effort now to introduce midwifery, but it’s very nascent. Obstetricians even 20 years ago weren’t doing cesareans at this extent. What they trained for in the ’90s and what they’re practicing now, of that generation of obstetricians, there would be a skill erosion because a lot of the births you would’ve done vaginally in the ’90s, you’re no longer even trying.

I recently met an anesthetist who was at a big medical college in Uttar Pradesh. Even in such places, the substantial majority of births are cesareans because all the students want to learn surgery. They don’t want to learn how to do vaginal births. These are in public hospitals in UP. Sooner or later, everyone is going to get cesareans; it’s not just about South India anymore. All of these are coming together to create this challenge in India.

Midwifery Globally and in India

RAJAGOPALAN: What is the difference between the very traditional midwifery skill in India—there is a network of anganwadi centers, and there is a homegrown traditional midwife and midwife knowledge which works pretty well, except in cases which are really, really complicated. That has been the traditional trajectory of Indian midwifery. There is also a global protocol and standard and training for midwives. What is the difference between these two, and what is the gap between these two?

NILEKANI: Okay. If one looks over millennia, then, of course, we have always had a traditional culture of daees [midwives]. Every society before the rise of modern medicine had a traditional culture of a village woman, a village midwife, a daee in Indian languages, and so forth. In the modern public health language, they’re called traditional birth attendants who are following more traditional practices.

I personally feel that—I wouldn’t say that historically they’ve really had many good outcomes. The very fact that India’s infant and maternal mortality rates were so high even two generations ago, they weren’t delivering that good outcomes, in my view. I think it’s a good thing that modern standardized medicine has come in. I’m not advocating for a return to the home births or to traditional midwives or anything of the sort.

What happened in India is, rather than strengthening midwives, more or less traditional practices have been stamped out in favor of a more medicalized and obstetrician-heavy model. In a way, we follow the U.S. in this. Europe has managed to sustain a tradition of midwifery over centuries and strengthen them so that nowadays there are actually excellent outcomes, the best in the world. In fact, European midwives can lay claim to literally having the best maternal and neonatal health outcomes globally.

In India, what happened is pretty much they have already been stamped out in favor of obstetricians and various nursing cadres. India has a ANM cadre for auxiliary nurse midwives, a GNM cadre of general nurse midwives. These are all varieties of nurses with some extent of midwifery training, not very much. More recently, from 2018 onwards, there’s been an effort from the central government and NGOs like ourselves, as well as state government, to bring in what are being called professional midwives, a nurse practitioner in midwifery.

The idea is that an Indian nurse who has finished a B.Sc. nursing or equivalent and has some labor room experience would then go ahead and do 18 months to two years of master’s-level postgraduate specializing in midwifery to become a professional midwife. Aastrika Foundation is very involved in that effort. We just recently signed an MOU with the government of Karnataka to establish a national midwifery training institute in Bangalore at Vanivilas Hospital, for example. In general, we are strong advocates and proponents of an effort to bring in a cadre of professional midwives.

Professional midwives are trained to what—the International Confederation of Midwives, the ICM, has set certain global standards for midwives. I think there is, I would say, a vast difference from a more traditional knowledge, and this is very regulated. This is very working in sync with obstetricians with a very clear idea of when to refer and when to not. Fairly clear triage guidelines, very clear ideas of who falls under the scope of practice of a midwife and who needs to be referred to an obstetrician.

European-style professional midwifery is very Western in its approach. I would say it’s part of a very modern style of medicine. It has shown remarkably strong impacts globally. If you look at, say, for example, data on some of these—this was also in the Lancet 2014 series on midwifery—83% of newborn and family planning and care around childbirth can be delivered by skilled midwives. That just frees up—if you can train sufficient midwives, you just have a much better supply of human capital to cope with the sheer scale of maternal health needs globally.

Modern Midwifery

RAJAGOPALAN: This is super helpful, actually, because a lot of times when we think about, “Oh, the doctors are doing too much, too soon,” there’s this other mindset in India, which is, “Oh, we must go back to traditional medicine and Ayurveda,” and all these other things. Basically, what you’re saying is, there is traditional medicine, and there’s a certain traditional skill, but it’s not “C-sections or we go back to 200 years ago when mortality rates were ridiculously high.”

There is something in the middle, which is the appropriate level of intervention, which follows the standard guidelines of Western medicine: interventions that are fully compatible with everything else that’s happening in hospitals, but they are just trained better and skilled better to know when to act and when not to act.

Basically, it’s not that Indian midwives aren’t good enough. It’s just that they have not been trained at all in any midwifery which is compatible with Western medicine that is happening, at whether it’s public hospitals, private hospitals, primary healthcare centers and so on, so forth.

NILEKANI: No, precisely. You hit the nail on the head, Shruti. The thing about modern midwifery is yes, sure, it’s arisen out of western medicine. That’s one thing, but fundamentally, what I love so much about it is, it is scientific. I think I’m just too much that—some passion carried me through endless years of that Ph.D. is the belief that research pushes the Pareto frontier. It reduces tradeoffs. The whole process of research and evidence generation is to expand what is possible with scarce resources. The thing is that this modern midwifery that I talk about, professional midwifery, is from that tradition. What you do has to be based on science.

I completely agree with you that in India, there’s a strong tradition of focusing on natural methods or complementary medicine, including the whole AYUSH ministry and Ayurvedic medicine. Something I personally find sad in Ayurveda, all knowledge we have, there seems to be so much abundant promise in Ayurveda. I mean, most modern pharmaceutical medicines are often very much derived from plant-based knowledge or other traditional facts.

Though there seems to be so much practice in Ayurveda and the medicine itself seems to hold a lot of promise, it’s not being evaluated as per modern standards. There isn’t that research into which Ayurvedic medicines work, don’t work, double-blinded, placebo-controlled trials. If they’re existent, I haven’t really come across many of them.

RAJAGOPALAN: No, I know exactly what you mean. What you mean by scientific is not necessarily Western. You don’t even mean that it’s perfect. What you really mean is that it has gone through some evaluation, and it’s not based on the discretion of the person performing it. It is not based on the experience and practice of the individual. It is based on the experience and practice of a community which has vetted that particular process.

I think there is another confusion about what is scientific. Ayurvedic medicine can be scientific. You can have trials on whether some of these concoctions which help you get over the flu a little bit quicker or which relieve certain gastric problems actually work better than all your allopathic medication, but we just don’t know. Do they work? Do they work better in certain contexts and certain doses? This seems to be almost a question of testing and manualizing. Is that a problem, or is that the problem?

NILEKANI: I think it’s the problem. You cannot possibly say Ayurveda needs more R&D. It has 5,000 years of R&D behind it. What it doesn’t have is, it’s not been put under the scrutiny of, when I say “modern science,” modern scientific ability to evaluate. Forget about the medical science.

RAJAGOPALAN: It’s the evaluation.

NILEKANI: It’s the evaluation which is lacking. I personally know a lot of people who’ve genuinely benefited from Ayurveda. I grew up in quite a tradition of it, and at least for small ailments, I’ve found it quite helpful as a child. But there just isn’t that rigor of—everything can’t be cultural. When John Snow studied the cholera epidemic and figured out who was first—it was a difference-in-difference model, pretty much. The reason that has become mainstream worldwide is because it works. Maths arose from the Asian subcontinent, but it spread worldwide.

Humanity has arrived at certain processes of evaluation because the processes of evaluation work, not because of cultural things. It’s unfortunate to me that Ayurveda hasn’t really come under that level of trials, which could make it mainstream and used globally. Something interesting is that, specifically in maternal health, it’s amazing to me how much Chinese medicine actually has been evaluated in randomized controlled trials.

This is going slightly off track, but one of the things I did after, or Aastrika did, is launch a private-sector birth center in Bangalore, as an effort to act as an implementation lab, as a practice site, as a mini research and teaching hospital even.

RAJAGOPALAN: Also training. I mean, you learn from that, and that informs the huge training programs you guys do.

NILEKANI: Exactly. We do a lot of small-scale trainings in-house, and then we scale them up across large programs. Because of that, because we do a lot of—because we have set up this internal hospital and we do a lot of hands-on work with clients, I’m pretty much the in-house researcher. If doctors want something from me, I go look up some RCT and send them a WhatsApp summary of it. I spend a lot of time looking at all of this research. And acupressure, acupuncture for induction has been under RCTs, for pain relief has been under RCTs. It’s just the quality to which you can trust that is substantially higher because of this rigor.

Effects of Privilege

RAJAGOPALAN: The other thing I find interesting is culturally, we are an interesting lot. I’m talking about families like yours and mine: urban, English-speaking, have basic understanding of Western medicine. Our mothers know when to give you some Kashayam concoction for whatever is going on in our life, and our mothers know when to take you to the doctor.

It seems like that is also precisely the problem because we don’t know what is enough and what is too much and what is too soon, and when we are going to the doctor too soon—you should have just continued that Kashayam for the flu—and when a Kashayam simply does not work in this context. You really need to get a CAT scan or an ultrasound.

Because we have resources, our families don’t fall in the category of erring on one extreme or the other. For most other people without the same means and without the same education, that is exactly the hole they fall into. They fall just through the cracks because there is one kind of medicine that they’re most familiar with, for which they have ingredients at home, for which their neighbors can advise them. Each family has its own recipe, but it’s not put under any trial or test.

There’s another kind that they’re completely unfamiliar with, where they just go with what the doctor is saying without any questioning because they don’t know how to question the doctor. There is a rare example of someone who is a development economist and who’s studying in the lap of, the birthplace of this RCT, impact-evaluation situation, who can then say, “Hey, whatever is happening in my life, I need to have that at a certain level of evidence-based reasoning,” or something like that. Which is what makes your story so unique, but it also makes everyone else’s story so tragic, right?

NILEKANI: No, it is depressing. I mean, think how many things I needed. I needed the wealth to go to Hyderabad, or at least the financial stability, and the independence from family.

RAJAGOPALAN: Agency to make decisions within your own marriage, within your parents, in-laws, everyone.

NILEKANI: Empowerment. The ability, as you said, to understand any science. It just took so much, and still I almost gave up because it was too hard.

RAJAGOPALAN: It was for such a small thing. In the larger scheme of things, it was just about, “I would like to control what people do to my body when it’s an emergency or a complicated situation in a way that I don’t suffer and I have a healthy childbirth.” It feels like this is not a tall ask at our level of economic development and our level of privilege, but this seems to be like all of India’s falling through the cracks on this one.

NILEKANI: That’s something that really shocked me. I completely understand that, just like with so much else that happens in India, there’s huge inequalities. I did not expect that at the highest levels of privilege, you still can’t get good healthcare in Bangalore. That, I was unprepared for.

The Problem of Female Agency

RAJAGOPALAN: How much of this has to do with the fact that this is a women’s issue versus men? We’ve talked about how virtually all medicine in India has some element of “too little, too late,” or “too much, too soon.” A lot of the stories in maternal health make it seem like this is a women-only problem. Especially when it comes to childbirth versus other women’s health issues, it feels like in this instance it’s okay for the entire family to be involved, when it comes to fertility and childbirth, in a way that it is absolutely not in any other medical decision. To me it feels like this is a very female empowerment/agency problem. You can tell us more about this.

NILEKANI: I completely agree on this. Again, it’s true at all levels of society. Certainly, I had mentioned it earlier, but Sohini Chattopadhyay wrote a really good exercise of undercover reporting from a public hospital.

RAJAGOPALAN: It’s gut-wrenching. To the listeners, we link to it in the transcript, but read at your own peril and don’t—

NILEKANI: Trauma warning, a trigger warning.

RAJAGOPALAN: Oh my God. It really is.

NILEKANI: It is quite gut-wrenching, but it’s accurate. It’s accurate for many settings. That’s one which is very well-described. A point she makes in that, or one of the doctors she highlights made in that, was that the care that women in the labor room receive is far more abusive than what, say, men in the orthopedics department receive. Yes, healthcare is bad, but women’s disempowerment is definitely making it worse, there is no doubt, at that socioeconomic group.

Because of Aastrika Midwifery Center, our hospital that we’re running in South Bangalore, I feel like I’ve interacted way more with way more people from many segments of society in the last year than I had before. The choice of doctor is seen as a family decision, not the mother. There’s no—even at the most wealthy segments of society, there is no underlying belief that a woman has a right to choose over her own body. That pretty much doesn’t exist. In Chennai, apparently it’s your mother-in-law who chooses the hospital. In Bangalore, I would say it seems—I’ve heard this from multiple friends in Chennai. I don’t know, Shruti, would you know more?

RAJAGOPALAN: I have no idea. I don’t have children. I have spent the last 15 years outside, in the U.S. And I have heard horror stories in India, very few in our socioeconomic level. Most of the horror stories come from the woman who’s working in my parents’ home and those sorts of things. They’ve literally given birth waiting in the hallway at one of the government hospitals. Like, a bucket was used. Some really terrifying things that I don’t have the stomach for.

I will say one thing, even among my friends: One, there was a lot of intervention of the whole family, and when the woman wanted to say, “I want things done a certain way,” it’s like, “You’re difficult. You’re hormonal.” There’s a lot of that going on. “You’re unreasonable.”

NILEKANI: “You’re uncooperative.”

RAJAGOPALAN: Uncooperative, unreasonable, all the favorite words for women like us. The second is, none of them had a pleasant experience, none of them. Sometimes it was unpleasant because of the way it was induced. I have heard of women literally getting scolded and screamed by the nurse after they’ve given birth on how they don’t know how to breastfeed. Breastfeeding is not easy. It is apparently the most natural thing, but apparently it is not because it’s not easy, and it doesn’t come naturally to all babies and all mothers.

Women are just getting yelled and screamed at, even at our socioeconomic level, when you have just gone through a really painful and traumatic childbirth experience. I don’t know anyone who’s had a good experience, let me put it that way, which is frankly shocking to me because most of my friends are extremely privileged.

NILEKANI: Definitely. I think when I had a very positive birth experience, all my social circles were shocked. They were just shocked that I actually had a positive birth experience. Forget about whether it’s a vaginal birth or a cesarean—that you had a positive time, you feel you’re respected, you feel you’re part of what has to say. You feel that things are being done for the right reason.

At our hospital, one of the things we tell clients is that we’re trying. First of all, we’re not a natural childbirth center. There are certain interventions like vaccines which we advocate for everybody. Leaving aside that, we try hard. You shouldn’t go away feeling as something was done to you. You should go away feeling something was done with you and for you. It’s very hard to implement. Oh my God, my hair is going white because the healthcare system is not set up like this at all.

Even to find people who are willing to change their methods so much is very, very hard. Definitely, I think there’s the premise that giving birth is a family decision. Where which hospital you’ll go, how you’ll go about it, it is something where it’s not even about interference. There’s no expectation that it should be perceived as interference. There’s no thought at all that this is an individual choice in the first place. An added thing is that families are extremely focused on the grandchild versus the daughter or daughter-in-law, which is definitely coming from Indian women’s disempowerment. If at any point the doctor says—

RAJAGOPALAN: And also, you know, the fear of infant mortality from time immemorial. You’ve heard stories of your grandmother or your great-grandmother having miscarriages, and not enough babies survived. There is some family—institutional or family memory which is persisting, and lot of fear-mongering there. The fact that women are—it’s the worst combination of the two things somehow.

NILEKANI: Generally, if the doctor says there may be even some small and marginal benefit to the newborn at the expense of substantial morbidity to the mother, the people pick the child. A big attitude that being a mother is to sacrifice.

RAJAGOPALAN: Even from that stage. Even before the baby’s born, the sacrifices began.

NILEKANI: Prenatally also.

‘Expecting Better’

NILEKANI: Emily Oster is one of—I’m a huge fan. I’m very grateful to her also. She might listen to your podcast, for all I know. Maybe I should one day thank her by email. She’d written “Expecting Better” in 2013, and I—

RAJAGOPALAN: Yes, which is a wonderful, wonderful book. I have given it to every friend of mine who’s expecting a baby, exactly for the reasons you mentioned.

NILEKANI: Her follow-ups were good too. Even her column is good, ParentData. I watch it quite closely. A lot of her COVID stuff was good, too. In general, she’s great at translating evidence into actionable things for, I would not say the common person, but at least reasonably well-educated adults.

In my life, the thing is, what I was really trying to avoid was a routine episiotomy. Nobody supported that. Every doctor thought I was being crazy, plus this research is on white women and so forth. Even among my family and friends, everybody thought this was just too much trouble to go to Hyderbad for it. There was very verbal attitude. “We all went through episiotomies, we got over it, it’s not such a big deal. Are you really going to go to Hyderbad just for that,” et cetera.

I must say, maybe the only thing which gave me some internal conviction—I had a lot of internal conviction, but maybe the only external support I got was actually from “Expecting Better.” Because there’s a page where Emily writes of the research around episiotomies and how there’s such an abundance of evidence and such a vast literature on its harms. She actually wrote that if you come across a doctor who is still promoting an episiotomy, then I personally would go and run in the other direction, because it means they haven’t looked at the medical research in 20 years.

Though it was actually very difficult to go to Hyderabad. It was—just logistically was a pain. I had never been there until I was pregnant. The whole thing was pure medical tourism. That was a very motivating paragraph. In the end, I did go and run away from the doctor because—and it helped to just have somebody voice that, that I was not crazy. All I was trying to do was something—just somebody else writing even in a book that I am not being crazy was hugely validating. I am very grateful to her. I don’t know how I got onto that.

RAJAGOPALAN: We were talking about how the entire system in a particular way is stacked against women, or is it really stacked against women, or is this just generally a healthcare problem in India?

I think it’s quite clear that women are in a particular intersection of lacking agency even within their families. Then there is a question of falling through the gaps when it comes to medical advice. Not knowing what questions to ask the doctor, thinking they’re God, believing what they’re saying. Simply not maybe having the ability to navigate that healthcare system.

These two things put together, and with the added fear of, oh my God, the fear of something bad happening to the child, which at this point belongs to the whole family and not just the woman—that just compounds this entire situation and turns it into something else.

A Supply-Side Shortage?

RAJAGOPALAN: How much of this is a problem of scarcity? In a sense, India has—in terms of per capita doctors, per capita hospital beds, per capita OB-GYNs, everything, India’s very, very low on healthcare capacity. We’ve of course experienced the worst of it during COVID because even basic things were not available. It was a horror story that unfolded.

But we also know that India is one of the youngest countries in the world. Our population, it’s growing. At this point it’s at replacement rate, but that’s still 2.1, 2.2 births that are taking place per woman. Given a population of that size, we know we need a lot more maternal health infrastructure. We don’t have enough time, we don’t have the resources, we can’t have a midnight emergency room running and so on. How much of this is just simple supply-side shortage?

NILEKANI: Not much, because this whole thing is geographically extremely disbalanced.

RAJAGOPALAN: That’s true.

NILEKANI: I agree that India’s TFR, total fertility rate, is 2.1-ish, replacement level. Other than some two states which are above replacement, the rest are below replacement. There literally are just a handful of states above, but they’re high-population states. The whole average is being skewed by that. All of South India is below replacement level of fertility. Goa is at 1.3 and has an extremely high cesarean rate.

Moreover, to the extent that we have obstetricians, they’re all clustered in the cities. The places with the most supply of healthcare staffing is doing the most cesareans to save time, though it is not necessary. There are different problems in different geographies. India’s a land of 30 nations, roughly.

RAJAGOPALAN: Yes. It’s basically, we do have shortage, right?

NILEKANI: In some places.

RAJAGOPALAN: But the places where we have shortage is not the same place where too many C-sections are being scheduled.

NILEKANI: Exactly.

RAJAGOPALAN: That is happening for a completely different reason. Part of it could be that we are still short of enough OB-GYNs and enough training and stuff like that, but that’s not the reason. It’s an incentive problem, which is completely different, and the revenue model, basically.

NILEKANI: These are incentive problems. Take it as simple as that. All of Bangalore practices single-consultant models. It’s a rarity to find a group practice, which means that each doctor is their own entrepreneur as a consultant. Or even if they’re full-time, they may be occasionally salaried, but by and large it’s fee for service. They’re their own entrepreneur. They take on their clients. As they get clients, they—clients expect them to be present at deliveries. And therefore, to have any semblance of a life, they have—they do a lot of cesareans. But that is completely incentives. All you need is group practices of three doctors each to cover 24/7 shifts, and you wouldn’t be doing so many cesareans.

RAJAGOPALAN: Which is what happens in the U.S.

NILEKANI: Everybody’s competing in the same daytime hours there too. I really think, at least in South India or in most states, it is not a supply issue.

RAJAGOPALAN: Is it a supply issue when it comes to nurses and skilling of nurses, skilling of midwives, upgrading, and investing in that human capital?

NILEKANI: There’s a huge shortage of quality, but I don’t think the shortage of personnel is that high, at least not in the places where there are a lot of cesareans. This is a shortage of skill. They’re not good at doing vaginal births, which are complicated.

RAJAGOPALAN: Yes. And this is true across the board, at every level.

NILEKANI: That is true. All the same, we have statistics on stuff like this as well. Take it like the WHO will look at doctor capacity and so on. The big problems in India is either capacity at a high level is too low, but what capacity exists is very clustered in some places. They’re the same places you’re doing surgeries for everybody. And it’s just nonexistent in some parts of the country.

RAJAGOPALAN: That’s why you have “too much, too soon.”


The Aastrika Model

RAJAGOPALAN: Now, in terms of what interventions you are trying to bring in. It’s great to know both your personal story and how you approach this as an academic and now as an entrepreneur. What exactly does Aastrika do? I think I’ll start there, and then we’ll get into why you do what you do.

NILEKANI: Great. Aastrika consists of Aastrika Foundation and then this hospital, Aastrika Midwifery Center, which we spun off as a private-sector institution. Basically the foundation, as I mentioned earlier, is trying to ensure that every Indian woman has access to high-quality, respectful and timely maternity care. Essentially tackling on all three, we’re working on all three challenges: that disrespect and abuse needs to be stamped out, that “too little, too late” needs to be stamped out and “too much, too soon” needs to be curbed.


NILEKANI: We really do three things. One, we work on health systems strengthening, specifically of human resources. We run Aastrika Sphere, which is a learning institution or a learning platform for both online courses as well as now, post-COVID, we’ve been able to expand properly to offline courses.

For example, when it comes to online courses, we run a digital platform, Aastrika Sphere digital, so to speak, where we partner with public health institutions across the country and across the world, in a way—with Maternity Foundation out of Denmark, or Jhpiego, or the National Quality of Care Network.

There are a whole range of partners that we have—the White Ribbon Alliance, India, numerous others, I’m missing some—to create courses for healthcare workers, mostly nurses and ASHA workers, and to roll them out nationwide. Currently we have about 8,000 learners across the country, but that number continues to grow. We’ve signed an MOU with NHSRC, the head Central Health Ministry, to digitize all the courses that exist for ASHA workers and bring all of them online.

What we’re trying to do through Aastrika Sphere is increase capacity, increase the healthcare systems capacity on the supply side through theoretical learning, both online and offline. We’re venturing more and more into simulation learning, on ground I mean, as well as proper classroom training, like physical old-school classroom training, and clinical training as well—for example, working in hospitals in Bangalore and so forth. A whole range of human capacity-building in the maternal healthcare space. That’s one major thing.

The second major program we have is to invest in a professional cadre of midwives. Under this, we are doing several things. One is, we are partnering with the government of Karnataka to launch a national midwifery training institute at Vanivilas in Bangalore, where European midwives will train Indian midwifery faculty, who tomorrow will train a cadre of midwives in the state.

Secondly, the midwifery program is also creating a lot of learning content on Aastrika Sphere to try and scale—eventually we would want to be able to train midwives other than with this government program, but to directly train midwives as well. We set up this private-sector hospital also broadly under this midwifery thing to have a site to train midwives, a site to practice with midwives. A place to see how you can have interdisciplinary care with midwives and obstetricians.

Then, finally, we increasingly want to work on advocacy work, on demand generation for high-quality care. One of the problems in India is that women at every socioeconomic level have normalized atrocious maternity care. Even the wealthiest and most privileged do not—as you said, you don’t know anybody who’s had a positive birth experience. You assume it is not possible. Then you go along with it. Unless at least the elite stand up and demand high-quality care, the supply side of any system will not respond.

Demand generation for high-quality care through advocacy work is another vertical that we have not too much ventured into yet, but is definitely in our medium-term plans. Between these three pillars largely, we really hope to make a sizable dent, both in terms of lowering infant and maternal mortality rates, as well as on stemming this epidemic of over-intervention, at least contributing to stemming it somewhat.

The Professional Midwife Shortage

RAJAGOPALAN: Can you give us a good way to think about how many midwives does India need at the skill level that you want them to be at, and also continuously training? How many midwives are we short of?

NILEKANI: Professional midwives?


NILEKANI: I believe that we need 150,000. I’ll give you the why I’m saying that. The government did an in-depth calculation—there’s a guidance note from the Indian Nursing Council—a complex calculation why you need 83,000 midwives only to staff the high-caseload public health facilities.


NILEKANI: Then when you also count the low-caseload public health facilities, as well as the entire private sector and those people who are still giving birth at home, to cover the entire population, for every woman to have access to midwifery care, you need 150,000 ballpark.

RAJAGOPALAN: So we have only 300 trained midwives, not traditional knowledge, but trained at global standards, familiar with Western medicine and so on, and we need 150,000. Now, how can your model scale?

I think in India everything needs to scale. In particular, I feel like, relative to what is happening with doctors and healthcare centers and a whole other infrastructure, on the one hand it feels like training midwives is quite easily scalable. But on the other hand, I have no idea what the difficulty is, especially at the level of skill that you are expecting from professional midwives.

NILEKANI: When I talk of Aastrika Sphere, a lot of our training programs around training of nurses are designed for scale. In fact, that entire program called Aastrika Sphere is designed to scale up. The digital platform, for example, is built on the technology behind Diksha, which has been used now in India to train 13 million teachers. Tech-wise, it’s already designed for scale. Even in terms of ability to reach people, we are working hard on partnering with central and state governments to directly innovate.

The government already runs a lot of training programs. What we’re trying to do to great extent is to improve access to them, to digitize them, to have them available, self-based on a mobile phone in your home. I think the ability to upscale nurses is quite scalable, and already people have been working on it for decades. There are numerous public health NGOs working on it. In a way it is working. At the end of the day, mortality rates are falling for everything. It’s not like this is all not working at all. I think that is scalable. That continues to scale.

Scaling midwifery, I think, is very hard. We are very, very far. I don’t think we can achieve 150,000 midwives. I don’t even know if there’s demand in India for that. Plenty and plenty of people are still fine with the very obstetrician-heavy model. Currently, it should be reasonable to scale up to at least a few thousand midwives, which itself is enough to make a sizable dent. We’re going from nobody to a sizable dent.

The way the central government’s program works is that there is a network of institutions, medical colleges, public medical colleges, which have been accepted as sites for national midwifery training institutes. We are working with one in Karnataka. The Bill & Melinda Gates Foundation is funding, UNICEF, WHO. There are various international and prestigious and other partners and foundations who are adopting, taking on one, one, one NMTI each. If each NMTI over a couple of batches, let’s say you could get to a pool of 200 or 300 midwifery faculty in five years easily.

I think if they can set up even 30 or 40 midwifery college programs, over a decade you would get several thousand if not 150,000. But you can actually train several thousand midwives, which is enough to make a sizable dent. I think this cascade training model, especially since there’s a lot of buy-in from the central government, state governments, as well as public health NGOs—there’s a whole coalition of partners working on it, to some extent—I think it is doable.

Better Care at Lower Cost?

RAJAGOPALAN: It’s not often that the cheaper model is actually the better care model. This is one of those unique situations where, in terms of public health investment and also private payment for maternal health, this is much, much more affordable. And at the same time, it seems to be a far higher level of care in 85%, 90% of the cases, where it’s not a very, very complicated childbirth. I feel like there’s clearly a market for it, should the pool of trained personnel actually grow and keep up with demand, and there is some demand-side advocacy that goes along with it.

NILEKANI: Women have to demand. I think it is only cost-effective in high-volume centers. If you have to staff—like, our place is really not cost-effective at the moment because it’s very small. If you have to have 24/7 staffing of anesthetists, neonatal nurses, obstetricians, and yet you want 80%, 90% of women to give birth with a midwife, you actually need very high volumes to ensure that your high-human-capital medical staff is doing something.

RAJAGOPALAN: That’s my prediction. My prediction is you’re going to be running a full-fledged hospital very, very soon, the rate at which you’re going. Because you’re the kind of person who—

NILEKANI: What we need is to train as many midwives as we do. We need to have the volumes to do training.

RAJAGOPALAN: One is volume, and also you’re the kind of person who wants to almost personally test and follow through on each of the challenges that you’re facing. My prediction is, this is going to end with a full, really large maternal health, and maybe more fully enormous hospital that you’re going to eventually end up running. I think you’re the right person to do it. I’m not too worried about that.

Feedback Loops for Maternal Health

RAJAGOPALAN: One question I have is also what—you have the foundation, and you have the center. It’s a birthing site. I see pictures on Instagram that you post, women having these great birthing experience, so on. It almost feels like you’ve tried to complete this feedback loop.

There’s a difference between academic literature that we read—and there is some stuff that we can get from it, but there’s also a wealth of context and knowledge that one can get from anecdotal evidence. Women coming and telling you horror story after horror story. Actually understanding how women’s agency works once they enter a maternal health center and so on. Can you tell me a little bit more about how this feedback loop has worked for Aastrika Foundation and the birthing center?

It’s literally like you’re on call all the time I have seen you. We’ve been together in situations where you’re like, “I’m getting a call from the hospital,” things like that. You’re one of those people who’s always on it. What is the feedback loop that’s coming in from running what is a very personally and professionally very costly endeavor?

NILEKANI: It honestly is personally and professionally costly. I like how you brought all that into the podcast. It is very true. We keep hiring people, but some way any new venture is fraught with challenge for the leadership that is trying to found it. That is the story of my life at the moment. I think we’re getting a huge amount of learning from it. In that sense, basically Aastrika Foundation launched this hospital. It’s structured in the private sector, but it is a product of our NGO. It was set up to fulfill our NGO’s larger aims.

We have already, in just over a year, actually found ample return. It’s certainly not financially very profitable. It’s not at all, but highly loss-making. I meant in terms of social return and why an NGO would say this is something we’re going to do at all. One is, I think it just says no matter—there are numerous sources of evidence, of course. We as a foundation, I must say we look at secondary research, we look at primary research, we have done surveys, we have done all of that. But running a place and getting firsthand experience day after day, as you said, is a form of evidence, and it’s been hugely valuable.

One thing is, I think without leaping into it, we did not have a very clear sense of quite how vast a gap has to be bridged in terms of skill-building of nurses and midwives. It’s when you try and hire a few after interviewing gazillions and gazillions, you really realize the state of the market and what is the extent of skill-building that is actually necessary. The rarity of talent even among healthcare providers who are willing to practice as per international evidence-based protocol. A lot of what our hospital is trying to do is bring European or international quality of care to Bangalore.

There’s nothing magical about what we are trying to do. What’s innovative is trying to do it in a developing country where it’s really not the norm. Even in terms of what is the situation with doctors, why are there—a lot of this day-to-day immersion is where I feel confident giving certain reasons why cesareans are happening. It’s from having immersed myself sufficiently in this space.

Cultural Factors

NILEKANI: One of the things that sure took me aback is, I was not prepared for how many families are so ready to have cesarean births and so on.

RAJAGOPALAN: [laughs] You schedule it on a good day, nice astrological day and so on. Good time of day. Avoid Rahu Kalam.

NILEKANI: Even normal births, we sometimes get pressure—“Can’t it happen before 7:00? After that it is Rahu Kalam,” or whatever.


Until recently I was like, is that really fair, astrology-wise? Shouldn’t it be as per the stars? I don’t know, if you’re engineering it, is it quite the same in terms of fate? Then I realized, even in the Mahabharata, Bhima waited to pass away at an auspicious time. We have an age-old culture of trying to time life and death. That is actually a big factor behind cesareans in India. It is a substantial demand-side factor for it.

I think doing it on the ground has taught us how hard it is, how much time it’s going to take, but it’s also hugely gratifying that change is possible. At some level, no matter how many MOUs you sign with state governments or central governments or partners and so on—we are doing fantastic work at Aastrika Foundation. Still, in general, the pace of change in any NGO can be a little slow. That is the nature of the work, to keep going after it till you achieve.

Any NGO works like that. But having a hospital, at least we know where these 57 women almost all have genuinely had positive birthing experience. That is an achievement, and that is a motivator for the entire foundation team as well. That at least we tried, that what we are doing works here, and hence we have confidence to advocate it elsewhere. We were very keen on not just talking. It was actually important to us to walk the talk. This whole hospital is an effort to do that.

RAJAGOPALAN: At a very basic level, this whole exoticizing Indian women—I was having this conversation with Ashwini Deshpande, and she was telling me, this female labor force participation problem—we’ve walked away from demand and supply forces. We made it an exotic Indian culture thing, in a lot of the literature. It’s the same answer that you got. “All these RCTs are on white women, and they’re on Danish women and Swedish women. Does it really apply to us?” We’re like some exotic species for whom nothing works.

I think the 57 births, at the very least, you know that you can have this kind of—the appropriate level of intervention in an evidence-based world also works for Indian women. We are not bizarre creatures. I’m not saying culture doesn’t matter or context doesn’t matter. Indian women’s agency problems, family problems, all of these things are huge, Rahu Kalam being an issue for C-sections. Of course culture matters. On the other hand, we are not from Mars. A lot of the standard stuff, medical interventions or lack thereof, will also work on us the same way that they work on other people.

NILEKANI: At the time, I think I was just bewildered. Over the last six, seven years—it’s been more than six years since that episode. I’ve always looked back and said, what is your Bayesian prior? Why would you start with the premise that Indian women are not women? How would you begin there? Obviously first you’re women; then you worry about ethnicity. It cannot be that research done on the human body is going to vary that much by culture. It’s a very strange premise to start from. But you’re right, that is happening in multiple fields, not only in medicine.

RAJAGOPALAN: I can see it creeping in in economics. I have sympathy for researchers and writers especially, people who are writing in newspapers and on Twitter and so on. You want to be culturally sensitive. I get the line that people are trying to walk. But at the same time, all humans are rational, like homo economicus is applied across the board. As an economist, I’m often offended by what Ashwini was saying, this turning us into exotic creatures and so on. Actually, I follow Aastrika on social media and things like that. I really like seeing the happy, positive stories, just at that level.

Limits on Evidence-Based Decision-Making

RAJAGOPALAN: The other question I have is, it’s great that you are marrying the global literature on this—the randomized control trials, the medical control treatment, very, very strong trials that you have in Europe and the United States and so on—marrying it with how we can introduce it in the Indian context, which has all these capacity problems at every level, cultural issues, agency issues. I also want to ask you the flip side. What are the limits to evidence-based decision-making that you find now that you work in this space?

I’m not just asking from an external-validity point of view, which is, is that particular study valid here? But just more generally. Because you come from, again, such a strong background and prior in using evidence-based decision-making, not just at the policy level but also at the individual level, so much so that you went looking for it in your own childbirth story, and you eloped to Hyderabad and lived happily ever after, all of those things. Are there limits to that? Is there a role for experimentation in maternal health in a way that may almost run contrary to what the evidence-based literature is teaching us and so on?

NILEKANI: I don’t know if I lived happily ever after. I went on to worrying about evidence-based parenting and school pedagogies, and is there evidence to support any particular style of teaching reading and so forth. Again, I’m going to go to Emily Oster here, but when you’re taking decisions, yes, data is critical. But, at least when we talk about individuals, preferences are hugely important. At the end of the day, if a woman wants to take a choice which is not evidence-based, I think as a healthcare provider at the hospital level, of course, I’m still going to recommend against.

But I think at some level, I do believe that as women, our right to bodily autonomy and informed consent triumphs the need to take evidence-based decisions. Now, obviously, being a sensible hospital, if somebody really opts for something which I find is risky, we would make them sign informed refusals. People have a right to both informed consent and informed refusal, because unless you have the right to refuse in an informed way, your consent is meaningless. This is not exactly what you asked, I think, but where people have strong preferences, that needs to be taken into account in any decision-making metric.

So much of what we’re talking about, there isn’t evidence. There just isn’t. That’s going to be true globally. I’m not even suggesting these are priority areas for research. At least the big-picture questions, there’s research evidence, and a lot of—for all that I’m so intellectual and so hung up on all of this evidence generation, so on, which I am—when it comes to things like parenting, or even birthing, to a little extent you have to feel your way through it. One of the things I’ve learned to appreciate is somewhat more trust in physicality. It’s helped me, I guess. [crosstalk]

RAJAGOPALAN: Your instincts, right?

NILEKANI: Yes, to trust instinct and intuition somewhat, especially with parenting. Because very often, you, just by being there all the time with your child, are picking up a lot of things. A book will not know as much about your child as you do. You have to have some ability to trust your own judgment, at least some course of time, if not the day you give birth.

Also, I think that where there isn’t—not talking clinically, and where there isn’t evidence and so forth—I think I mentioned to you before in some of our personal chats that I’m a huge, huge fan of Richard Zeckhauser. I took his class in Harvard. He writes a lot. He’s taught a lot about decision-making under uncertainty. Dan Levy has published a book about his maxims called “Maxims for Thinking Analytically,” which I highly recommend, especially to your audience of young people, folks interested in economics.

A lot of that is, how do you go about thinking when there isn’t that much data? I think I try to follow that a lot. If there is strong evidence, great. If there isn’t, then you still need to take a decision. A lack of decision, by the way, is a decision. Which for—many people behave as though if you just don’t decide, you’re not implicitly making a choice, but you are.

Uncertainty and Subjective Knowledge

RAJAGOPALAN: You’ve touched on two very important things. I think one is just subjective knowledge. You know your body better than the next person, you know your child better than the neighbor and the schoolteacher and so on. I think we under-emphasize that.

I think this also links back to women’s autonomy, in a sense. At one level, the mother is this glorified figure, almost godlike, and on the other hand her voice is the one that matters the least when it comes to these things, though she knows best. I think there’s this—the importance of subjective knowledge, and the importance of uncertainty and decision-making under uncertainty at the individual level.

You’ve absolutely hit the nail on the head. When you’re picking a doctor, yes, you go check their credentials, you ask a bunch of questions and so on. But past a point, it’s instinct. Now we’ve reduced it to bedside manner. That’s the term that we use. “This person has better bedside manner, so I felt more comfortable.” That’s really just what it is. You feel you will be able to do better with this particular healthcare practitioner, or in that particular circumstance, or in a particular school. In some sense, the research doesn’t capture the value of that, or how much of that happens in our daily life.

This has been hugely illuminating. Every time I speak with you, I feel like I learn 50 new things. It’s always just so lovely to speak with you and so lovely to watch what Aastrika is doing. Thank you so much for doing this. I hope you come back and we’ll chat more about a whole bunch of other things, because I know you know so much more about healthcare policy. This conversation was very focused on what you’re doing day to day with the foundation and the hospital.

NILEKANI: Thank you so much. It’s been a total pleasure. Though we’ve spoken multiple times before, this was still great fun. We wandered into all kinds of new ground. I always love our conversations because it gives me an opportunity to dip back into the waters of economics. My day-to-day life has a lot of meetings and administrative work, so it’s always fun to get back into intellectual geeking out. Thank you so much for having me, Shruti.

RAJAGOPALAN: Always a pleasure.

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