India Needs More Research on Aftereffects of Pregnancy and Childbirth

Asha Mahtta was carrying her second child in 1997 when she found that she had developed diabetes. Mahtta now suspects that she may have had it since her first pregnancy three years earlier. “There was simply no information or awareness about gestational diabetes at the time. The doctors neither told us what tests they were conducting nor their results,” she said.

She has been living with diabetes for the last 26 years, a condition she didn’t know was in any way associated with pregnancy. Then in 2013, another shock came her way: diabetic retinopathy.

“I was getting tested regularly for any complications since my diabetes was diagnosed. When we relocated from Aligarh to Jammu in 2013, the doctors were surprised that I was unaware of my retinopathy, which had been present for quite some time by then. This came as a shock to me also because I’d done everything right and yet the doctors in Aligarh didn’t detect it,” Mahtta said over a phone call.

Mahtta’s experience isn’t an isolated incident. Hundreds of women are taking to social media to post about permanent changes to their bodies after pregnancy and childbirth. Their changes range from gestational diabetes (GD), separation of abdominal muscles, a permanently enlarged ribcage, and loss of bladder control to undiagnosed thyroid problems wrongly attributed to postpartum depression.

For many women, these problems are temporary and resolve themselves within six weeks after the child is born, but for others, they can turn out to be lifelong conditions which can affect the quality of life as well as their mental well-being.

However, other than anecdotal evidence and a few articles calling these conditions ‘medical mysteries, there is hardly any dedicated research available on the permanent aftereffects of pregnancy and childbirth.

“Postnatal or post-pregnancy care is not something that people are aware of and not much research has gone into this. From the family’s point of view, pregnancy is very important. But once the baby is born, it’s usually the baby who gets the importance and the mother just recedes into the background even if she had faced complications while carrying the baby,” explained Dr. Anne Cherian, community health obstetrician at Christian Medical College (CMC) in Vellore.

“That is one of the reasons why there’s a lot of research that goes into pregnancy and improving pregnancy outcomes but not much about post-pregnancy outcomes,” she added.

The curious case of gestational diabetes

According to a 2015 study published in the Indian Journal of Endocrinology and Metabolism, about 40 lakh women are said to be affected by GD in India today.

Another recent study, done by Chennai-based Diabetes in Pregnancy Study Group India (DIPSI), found that nearly half of all women with GD go on to develop type 2 diabetes resulting in a chronic disease after pregnancy.

The DIPSI report estimates the prevalence rate of GD in India to be between 10-14%. However, the 2015 study mentions that prevalence rates can be as high as 35-41% in some states like Punjab and Uttar Pradesh depending on factors like age and socioeconomic status of women.

Also read: Postpartum Depression: Is Motherhood for Indian Women as Blissful as it Should Be?

Dr Kundavi Shankar, who heads the gynecology department at the Madras Medical Mission Hospital, said that GD not only poses a risk to maternal health but also contributes to the likelihood of the child born out of such a pregnancy developing type 2 diabetes later in life.

“If the mother has a family history of diabetes, then she is all the more likely to develop GD. This can cause several complications during pregnancy,” she added.

Who has access to vital information?

Women often develop urinary incontinence or loss of bladder control during pregnancy which usually takes up to a year to resolve after childbirth. But for many, this can become a lifelong problem, according to Mumbai-based Dr Sylvia Norohna, who specialises in high-risk pregnancies.

She said that incontinence can be attributed to pelvic floor dysfunction or weakening of the pelvic muscles. While the incidence of incontinence is quite high, it is hard to put a number to how many women experience it because of the lack of data on this, she added.

“The constant dribbling of urine due to incontinence can lead to skin rashes and vaginal changes. You can also develop a persistent unpleasant smell. This is not just bad for the woman’s body but it can also lead to social ostracisation and affect their overall well-being,” Dr Tanaya Narendra, the author of ‘Everything Nobody Tells You About Your Body’ explained.

Pelvic floor dysfunction can also lead to organ prolapse where a woman’s uterus or rectum may sag or drop down from its position and get exposed outside the vagina. This not only causes incontinence but can also lead to severe discomfort and chronic pain.

To avoid this, pregnant women are required to do certain exercises that strengthen the pelvic floor. But this information is accessible to a privileged few. The National Rural Health Mission-approved training guide for ASHA workers, who form the most integral link between our rural population and the public health system, does not have a single section on incontinence or organ prolapse. “We are not told about these issues or given any training on how to help women if they come to us with this problem,” said Pinky, an ASHA worker in Delhi’s Dhansa village.

Dr Cherian also pointed out that the care provided by ASHA workers usually ends with the delivery. There is no equivalent cadre-based effort to provide postnatal care and raise awareness on issues that can crop up during the crucial period after childbirth.

“If I oversee 40 deliveries in a week then the number of women who come back for postnatal checkups is about 10% of that,” she said. This, despite the CMC hospital being one of the few in India that house a postnatal clinic.

‘Normal’ deliveries 

According to data from the National Family Health Survey (NFHS), the prevalence of caesarean section deliveries in India has been increasing. The percentage of such deliveries rose from 9% in NFHS-3 to 17% in NFHS-4 and a further rise of 4.5% in data from NFHS-5.

Despite this, there is still a high demand for vaginal births or what are dubbed ‘normal’ deliveries in India, according to Prayagraj-based Dr Narendra. “It’s because there is a sense of failure attached to a caesarean-section as if womanhood can only be achieved if you go through a vaginal delivery. Women are still often pressured to not opt for c-sections even if that’s medically not the best choice for them,” she said.

A ‘routine’ procedure in vaginal deliveries in India – known as an episiotomy – involves making a 3-4 cm long cut below the vagina to allow the baby to emerge. “We try to fix it as much as we can but the pain of an episiotomy is lifelong for some,” Dr Narendra told me over a zoom call.

Explaining why episiotomies are so common in India, Dr Cherian said “The function of an episiotomy is to speed up the delivery. Our hospitals – and I’m not talking about private ones – are usually overcrowded and the doctor-to-patient ratio is very low. So we try to deliver the babies faster by reducing the duration of labour.”

“In other countries, women are allowed to assume the various positions of labour and a midwife stays with the patient till they feel the urge to push. This is not the practice in India. As soon as any signs of the head are seen, the patient is instructed to push,” she added.

There is a growing international consensus on why episiotomies shouldn’t be a routine procedure but only be administered on a case-to-case basis. “In situations like fluctuation in the foetal heart rate an episiotomy becomes important but it should definitely not be used like a catch-all procedure for everyone,” Dr Cherian said.

Why the science on this is missing

Most doctors consulted for this story said that they were unaware of any focused research happening on permanent changes in women’s bodies as a result of pregnancy and childbirth. However, the number of women affected by chronic diseases after pregnancy is large enough to form a pattern according to them.

“Pregnancy has a lasting impact on the human body and while we understand the antenatal period fairly well now, we’re still extremely far behind in our understanding of the long-term impacts of pregnancy and the related changes,” said Dr Narendra.

Dr Cherian pointed out that a lot of chronic diseases like hypertension, diabetes and thyroid issues begin during pregnancy. “International bodies have now started addressing this as the stage where we can prevent the progression of chronic diseases. Identifying and dealing with them at the right time will definitely have implications on the long-term health of a woman,” she explained.

However, the only time Dr Cherian sees women, especially those from rural backgrounds, back in the hospital after childbirth is for the immunisation schedules of their newborns, not for themselves. “Women from higher socio-economic backgrounds have more time to take care of themselves but this is not the case in our villages where women get no time to recover from what they have gone through,” she said.

According to Delhi-based feminist scholar Srinjoyee Dutta, this may be the case because mothers are expected to restructure their life around the child. That’s why her concerns as a woman and what her body has gone through are often ignored.

“There are well-documented cases of postpartum depression and women who’ve had irrevocable mental health and other problems after pregnancy. But this narrative goes against the traditional idea of motherhood which is pedestalized and has a sacrificial connotation,” she said.

Dutta and Dr Cherian both pointed out that the lack of research or concern for pregnancy-induced lifelong changes in women is part of a larger and well-documented history of disregard for women’s pain.

Elisha Vermani is a student at the Asian College of Journalism, Chennai.