Kozhikode: As per the data of the health department, the instances of home births (non-institutional deliveries) is considerably higher in Malappuram compared to the rest of the districts in Kerala. There is always an increased risk of neonatal and infant mortality, associated with such practices. 

266 instances of home births were identified in the Malappuram district in the previous financial year (2022-23), now that’s a staggering number, when compared to statistics coming in from the rest of the districts in the state. 

“It is saddening that in 240 out of the total 266 home births in the previous financial year, those responsible including the mothers hailed from highly educated communities. The very fact that such practices still exist in mainstream societies is absolutely disheartening,” says Dr Pameeli NN, who is both the deputy DMO and District Reproductive and Child Health Officer, of Malappuram.

Looking back over the years, there were around 270 incidents of home births reported in Malappuram district in the year 2021-22. In 2017-18, the numbers stood at 215. So the numbers have obviously spiked post the pandemic.

Infant mortality rate and Neonatal mortality rate

According to UNICEF, the infant mortality rate is the probability of dying between birth and exactly one year of age; it is expressed per 1,000 live births. On the other hand, neonatal mortality rate is the probability of dying during the first 28 days of life, the index is also expressed per 1,000 live births.

“Interestingly, it is easier to convince people from vulnerable communities including the tribes to undergo institutional deliveries, rather than persuading the well-educated city dwellers to undergo the process. For example, in the year 2022-23, the total number of home births among tribal communities in Malappuram district stood at 10. Now that paints a better picture. It's strange, it's predominantly the privileged mainstream communities who are red flagging the institutional delivery practices here,” tells Dr Pameeli.

The Deputy DMO told Mathrubhumi online that a well-equipped government Maternity Centre is being built in Chungathara, specially for serving the tribes. The works of the facility are nearing completion. It is expected to attract tribal dwellers from the surrounding regions including those in the Ambumala colony, the facility will turn out to be their perfect option for performing institutional deliveries. 

It should be noted that the Cholanaikkan tribes majorly reside inside the forest areas in the Karulai and Chungathara regions in the Nilambur taluk. A particularly vulnerable tribal group, they are one among the last remaining hunter-gatherer tribes in the Nilambur forests. The newly coming up Maternity Centre in Chungathara is expected to improve the accessibility for tribals in the region to such facilities. 

Meanwhile, a comparatively higher number of home births were reported in towns like Tanalur (Valavanur), Edavanaa, and Vengara, over the last few years. “However things have drastically changed now. It's frightening to say that the trend is slowly catching up in other areas of Malappuram. So far this year, roughly 140 home births have been reported in the district. These are extremely disheartening numbers, definitely, not something a progressive state like Kerala should be proud of,” says Deputy DMO Dr Pameeli. 

For newborn babies, there are stipulated screening procedures, which are done at the hospitals. Such procedures usually help in detecting any sort of heart disorders, hearing problems, or even metabolic disorders in infants. In the case of home births, the babies fail to go through such procedures, which may prove to be fatal in some cases.

“For example, we sometimes hear the news of infants dying after choking on breast milk and all, we never know, sometimes such incidents might be triggered by some unidentified heart disorders in babies. Home births tend to invite such miseries. However, nothing can be confirmed until a post mortem is done,” added the Deputy DMO.   

Traditional midwives or Dais lack the expertise for handling medical emergencies like uterine ruptures that might happen in women while delivering babies. In the worst cases, the mothers end up losing their lives, which adds up to the Maternal Mortality Rates. MMR, is the number of maternal deaths per 100,000 live births. For the same reason, due to our increased population, instances of maternal deaths often go unnoticed. One should remember that with the death of a mother, so many lives surrounding her plunge into uncertainty.

“Unlike in certain North Indian states like Uttar Pradesh, we officially do not promote trained Dais (traditional birth attendants) down south in Kerala. But throwing all caution to the wind, the Dais, even acupuncture and naturopathy practitioners, people from rather unrelated fields, actively canvass people and eventually convince them to practise home births. This is a sad reality,” laments Dr Pameeli.  

On a daily basis, concrete efforts are being made to thwart the practice of home births by raising awareness among the people regarding the ill effects of giving births to infants in their homes. Array of health professionals ranging from top officials to JPHNs and ASHA workers are actively involved in the pro institutional delivery campaigns. 

The Dais in the district are often known to engage in home births, by putting an ambulance on standby, outside the residence. This is for rushing the mother to the hospital in case of any health emergency. In such mishaps, they won’t be willing to take up any responsibilities, they will blame the hospital staff instead.

Strict warnings are given to traditional Dais in the district from time to time. Health officials, at times, visit them personally at their homes, and advise them to stay away from such practices. Local politicians including ward members enter into the fray of things at times, warning the Dais to refrain from facilitating home births.

“Our democracy grants certain rights to every individual. The choice to perform home births or undergo institutional deliveries is extremely personal. As health workers, we are often caught in a conundrum, we often get blamed by the concerned officials who take note of the escalating number of home births in the district. Taking it further, in case we try to initiate legal action against the offender in such cases, the Human Rights Commission springs into action and reminds us of the constitutional rights and individual liberty of citizens in the country. On a personal level, I try my level best to convince people to undergo institutional deliveries, I even try to meet families personally, trying to educate them on healthy birth practices. But as you know, people are very stubborn these days! However I will never give up. I will keep trying my best to bring the home birth rates to near zero,” concludes Dr Pameeli.

People working in the health sector are unequivocally demanding the intervention of both the child rights commission and the women’s commission in the issue. Formulating rules putting an end to highly risky practices is the need of the hour.

“The eastern part of Malappuram is predominantly hilly areas, while the western part comprises the coastal regions. Lack of awareness, accessibility and infrastructural issues, are the major reasons for the home births among the tribal population in the Nilambur region, however the number of such instances have come down drastically. Thanks to the proactive measures adopted by the health workers and other volunteers in the state. On a personal note, I feel that setting up model health centres along the lines of the Noolpuzha FHC in Wayanad, will help in making the health institutions in Malappuram more conducive for its tribal population, reducing the apprehensions surrounding institutional deliveries among vulnerable communities,” says Arun Kumar, an active member of the Kerala Sasthra Sahithya Parishad, Malappuram wing.

“Shockingly, home births are prevalent among the educated lot living in the towns and villages of Malappuram. The final decision on whether to opt for institutional delivery or to give birth at homes, in most cases, do not rest with the couple. It is still decided by the group of elders in the family, the undue influence of certain religious leaders can’t be taken out of the equation. Similarly, vaccine hesitancy is also higher in the district, especially in the post Covid times,” added Arun Kumar. 

However, things can’t be generalised in any manner. A chunk of the population has embraced modern medical practices in the district. This includes both the senior population and the younger lot. For example, veteran scholars and priests including Panakkad Shihab Thangal and Kanthapuram A.P. Aboobacker Musliyar had vouched for measles, rubella (MR) vaccination among children a few years ago, busting the myths regarding immunisation among certain sections of the society. While progressive measures are being taken on one side, on the other side, detractors often try to malign such campaigns by spreading blatant lies.

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Representational Image
Vaccinations (Representational Image)

“Several religious teachers in the district are still against vaccinations. And when it comes to home births, I personally know of an incident in my neighbourhood, in which three back-to-back incidents of home births were reported from a single household. The lives of the mothers and infants were put in extreme danger here,” says an Anganwadi teacher in Malappuram, she refused to reveal her identity.

“Tdap vaccine is administered to pregnant women between 27 and 36 weeks of gestation, for the protection of the baby. Operation Indradhanush, an initiative of the MoHFW, launched in 2014, strives for ensuring full immunisation (with all available vaccines) among children up to two years of age and also among pregnant women. Amidst the adversities, commendable work is being done by the doctors, nurses, Asha workers and Anganwadi  teachers in the district, for ensuring the well being of the mother and the newborn. Monthly vaccination drives are being held in the Anganwadis for achieving the targeted immunisation,” said the teacher who has been serving in her locality for over 15 years now.

“The chances of mother and infant contracting infections are reasonably high in the cases of home births. Recently, a family demanded discharge from a hospital in our locality, when the hospital staff stressed on the need for administering vaccines to the infant, post an institutional delivery. This is one among the several instances in the district. We are trying our best along with the rest of the health workers to promote institutional deliveries and vaccinations among the general population, regular surveys are being conducted, and profiles of children between 0-15 years in the respective localities are always readily available with us. However, quite often, the regressive anti-vaccination and pro-home birth campaigns run by the religious groups in the district, end up spoiling our efforts,” said an Asha worker, who opted to remain anonymous.

In a stark contrast to the trend in Malappuram, the other districts in the state of Kerala, report comparatively lower number of home births (less than 20 in most of the cases) in an entire financial year. Data suggests that, on a regular basis, several children in the district of Malappuram, who are under the age of five, succumb to various health problems, often triggered by lack of proper vaccinations.

Health workers and few like minded people in the district continue to endorse institutional deliveries, they are putting in efforts to raise awareness on immunisation as well. However, certain conservative groups with vested interests mess up the entire plot, pushing a generation into eternal darkness. 

Please note: The State Health Minister’s Office was not available for comments.