I have the huge honour and privilege today of being in conversation with Priyanka Edikula who runs Birth Village. India's, it's a freestanding birth centre in Cochin, in beautiful Kerala. Priyanka, I think it's fair to say, is a legend, pioneer, path breaker and just somebody who's inspired so many of us with her birth work in India, Asia and just globally. So it's my immense pleasure, honour and privilege. We have so many of your fans here Priyanka, so take it away. Thank you, Sangita. It's a very flattering intro that you gave me and I don't know how many of you did the same. Welcome all of you. Happy VidM to all of you. It gives me the pleasure to really talk about our journey, which we are here, our friends, close to 13 years now, slowly reaching our teenage right now. In the presentation of my focus today primarily is the entrepreneurship and midwifery. The audio is not clear? Yes, it's a little bit, yeah, it's breaking, you're breaking up in parts. Now, is it clear? Yes. It's clear? Better. Shall I just go ahead and continue or do you want me to re-log or come up or anything? Shall I just continue? Yeah, just continue I think. Okay, is it clear now? It's slightly choppy, but yeah, we can make sense I think. Priyanka, try to hit your leave audio and then sign back in. Let's see if that fixes your sound. Okay, I shall try that. Hello? Yes. Let's hear. Still a bit. Now, is there a separate microphone hanging from the headphones? No. Okay. Well, let's see how you sound from here. Okay. All right, so I'm just going to start. Currently, I don't have the icon to go forward with the slides. I don't have the class button from Sangita. Is my voice clear? Shall I go ahead? Yeah, I think I'll go ahead. Yes, you've got it now. Okay, got it. Okay, so I shall just continue speaking if you're not able to hear me. You can just type in the public chat for those of you who can't hear me. So I'm just going to proceed to the presentation. So I always begin my presentation with a little bit of intro about my country and I'm coming from. I think that's very important for people in the rest of the world. So basically, I'm obviously representing India. You have 1.3 billion. That's very important right now. It also comes with 0.7% population, so that's huge. In India, I'm basically coming from down south. You can see the red. We're in different ways. We're probably the only states in the country where we have a sex ratio of 1.84. Which means a number of women in our cities that have to be more than men. We have over 10,000 fests celebrated in the state every year. The National Geographic actually meets Kerala as one of the 10 paradigms of the world and 50 must-see destinations of lifetime. Kerala's literacy rate is also really, really high. And especially, I would say that we are one of the highest as far as the country is concerned. We are also currently, we have the Communist Party in power and it's also the state where citizens are really involved. Are you all able to hear me so far or is it still breaking? That's one part of these online conferences that I don't really can't be able to decipher whether people can hear me completely or not. Can you all hear me so far? Are you with me? I'm really sorry, but I'm doing the best that I can and I have no idea why it's broken. But any questions, please type in. So we can always collect at the end of it. Now going forward, when we go to our next slide, one of the interesting things that Kerala faced in 2018, there was on the right side, you can see we had this image of two healthcare workers and you can see a lot of image bags being piled up. We had an outbreak in our virus, which was released, but we have an extremely robust healthcare system that continued to be equally and we also had a huge flood, which was all over the news. And it was massive because we lost around 480 people, 140 missing and about a million people were evacuated in 2018, but in no time the state was able to rebuild itself. So there was huge things that our state faced in one year itself. Kerala prides itself a lot for its healthcare system, but we're going to look a little more deeper as to where midwifery stands amidst all of this. So this is something I think all of you are familiar with right now, it's the pandemic and again Kerala has done pretty well as far as containment is concerned. We are also one of the states that leads in terms of breaking the chain and I'm sure if you can read it down, if you look up on VTC and with Kerala healthcare model and how the pandemic is going to be for the entire world. Now as we go forward to this slide, now look, despite all the businesses we have made, we still have strong gaps in our maternity care system. Despite being the second most focused country in the world, I still have to say that independent midwifery still has to make its mark. We're still not there yet, but most often they're not over-medicalized and primarily by obstetricians in hospitals. Our C-section rates are super high. It's between 40 to 80%, I would say, and in dormant hospitals it's at 30%. Now amidst all this we have birth village with a very simple birth center that we have. As you can see, you can see our pictures on the screen in front of you. You can see how our water room looks like, you can see how our bathrooms look like and it's taken a lot of effort to reach us to this point where we are standing right now. Now how we did this, our journey from the start is what I'm going to be looking at. My focus is to come in. Now when I go, I would like to also go back and there is a section which I think is very important, which is our past, because there is no present picture without our honoring our past. I would like to honor also a traditional birth attendant in this slide. You can see there is collection of much. She's there in the small picture on the left side. She was a traditional birth attendant who was probably attending birth still, I guess till 19 in the 1990s in a small slum here. And she's attended, I mean, she has lost count herself with dozens and dozens and dozens of births right from the age of 14. She is a testament of India's history with a traditional birth attendant. On the right side, you can see a small picture with this British India, because in 1902 is when British India introduced midwifery in this country as a profession. It's interesting that the force was scrapped three years after its entry. And it's always a question not as to why it exactly happened. Currently in our country, we have nurse midwives. Our curriculum is still in the process of our government of upgrading curriculum. We have a six-month training program as part of the bachelor's in nursing course. So that's where we are standing with respect to education. Now as we look forward as to seeing where we start off. Now personally, I started off my career as a childbirth educator. I left another profession. I was really inspired to bring childbirth education to the women in my state. I began at a time when nobody really understood what childbirth education class was. This is way back in 2007. It was really hard beginning at this point of time because most of the time question I would get is why attend class? What's the point of going to a class? Why can't the elders in our family help us? So there was a lot of barriers to break as far as that was concerned. So initially when I started off my batches, my batches really didn't go that pretty well. My first four batches I would say were complete disasters because they just kept having C-sections after another. From that point, I saw couples attending births in hospitals. There was definitely an improvement. And in 2010 when I sat for a lot of classes, one of my mommas in class said, I want to have a baby in watching. I said, why not? We facilitated and worked on the first midwife-led birth in a hospital from birth. And it went remarkably well for her. But it was really heartbreaking for me. And I explained why that was. So I've still not forgotten their porphyry guests as she released her bubbles as she was taking a baby. I realize how little respect we had for natural physiology along at that point of time. There was another four-term baby born with anomalies and we all know babies don't have to be born perfect. And this bar probably had an hour or so. But what really hit me again at that point of time was how my mother never had that baby and she was wheeled off quickly while this baby was placed in a plastic container and everybody right from the coop herself, the janitor is cleaning the table with a little one at the beginning of two hours or one to hold it or take it by, just a reflection of how cold we are in the medical field as a community. And I was very clear in my mind that we needed to have a facility that would respect women's choices where she would lead the way with no one else really telling her what to do and how what should be supreme. And that's how I began my midwifery journey with the National College of Midwifery in the United States. It was really arduous, I would say, because I was a student and a director and running my center from 2010. It was kind of interesting all at the same time. As one of my preceptors in midwifery poetry she never had to report to her student. It was definitely trying times but I think we all pulled through it and it's been 10 years since then. As we move along, now I'm sure a lot of you, the lawyers who are attending this, you're all big fans of using water for women. It's what we call the midwife's epidural. And trust me, I don't know how many of you guys would have done this out there. Now, when in the water picture that I put up at the beginning of my presentation, now, when we started our water baths in 2010, we didn't have hot water in our water bath room. We didn't have a line that connected the water. So, how do we do it? So, what we did is we heated the water in the kitchen which is downstairs. We heated close to 100 liters of water on the stove. We didn't do it once. We didn't do it twice. We didn't do it twice. We actually did it for four years according to buckets of water from the kitchen all the way up. This is how we did it for four years. And in our fourth year, we actually put our plumbing down and we could afford solar panels in. And when we saw hot water coming out of that pipe, I cannot tell you the joy that you all worked as a team. But, you know, people ask us, were you crazy to run a water bath up and down all the time? But honestly, that's how much we cared for our women, right? So, that's how important that was to us. Now, when we look at all our services, what all do we offer? So, all elements of the hospital did be free as many women would. You know, you can look at our pictures. You can see women working and skin to skin. And again, when you see the picture right in the middle with a man and both, now, this was a very Indian concept when we started out. Of course, it's different now. But when we started out, it was really, really different. Yeah, it was because men were always kept out of the bathroom, right? So, that was a whole new venture that we bought to a community. Patience. Now, this is something that I think is very important because when we look at where we're going in the world, we're going to learn more in the technocratic model of care, more tests, machines.  This is something I have noticed. One of the men tell us when into services, I have never been palpated, no one touched my belly. It's really interesting for us to hear that because we are currently in a form of care where e-patients are the focus and where the touch of a midwife, which gives the healing effect to the mother, what we call as the hastavasi or the healing touch is so important. I think it's something to think about is we are increasing the number of medical colleges and medical seats and where is the future when we are dominated by computers and artificial intelligence? This aspect is really debatable and policy makers and health care providers must give a serious thought to this. This is precisely where it makes a free education course which combines touch and critical thinking, right? Now, with my next slide, we will be looking at, again, the other services that we do a part of our free work. We also have healing classes and active mama workout classes, another big change maker in the country on programs by midwives and parent classes. We also have course services led by the traditional massage therapists in the community. Hannah, all of these are interesting services that we still go forward with because we think about this really about pushing out a baby. It has to be so much more than that, right? So now when I look at our services bit, this is about a team. Like I said, we basically as a two-member team with our founder, we have grown from there to we are standing right now with 17 people on our team who includes now people who work on social media. But I think something I really like is how much we grow. We really don't want to lose our roots. It's important for us to stay in touch with women in the community who still offer hands-on services for mothers and babies. That is something that's really, really important for us at Bad Village. Now, this is about our statistics. You can see our statistics from which we've gone from 2010 to 2009. We have really worked hard to hold this vision and to generate a cultural space for this. It takes a great deal of effort to establish this model over the past years or so, especially when we don't have the basic midwifery in place. You can see all our statistics out there. The natural growth rate, which is 91.9% will be back success rate, 84.8%. The water growth, which has been using water for 42.26%. OP position, 1.6%. Breach, 0.23%. You can see our first course. It's right there, 96.68%. You can also see now people ask us, we get a lot of questions about it, because that is pretty much the norm in hospitals in India, which is close to 99%. For us, it's 1.42%. A lot of these, particularly these three factors, we often get questions on, and that's the reason why I inserted this. We've obviously, in India, one of the main reasons today for a C-sectionist, Maconi, which is, as I said, a lot here, but we've had 69%. We're facing 11.37%, right? I think it's important to be transparent for all of that as well. You can also see our transportation labor is 8.06%. Now, interestingly, we OP transfer rate, that is, we also have transferred, we've detected complications in them. We have also given equal importance to women who we feel that midwifery care may not be appropriate, and that's around 44.61%. So this slide shows that midwifery is really not about natural births or just leading women providing care. It's also where she's able to detect when something is wrong. We are able to do that because our appointments are pretty long and we know all of women really well to detect something, right? So I think there's a lot of, a lot of spaces where a woman can interact with a woman at many different levels. So it's not really just about the births. Now, when we go to the next slide, you can see our birth positions and you can see the different positions that we use. It's all out there on our slides here. I can definitely come back to it if you want to have a look at it a little more, right? So that's the SL stands for slide line, right? So just to clarify, I just put that over there. And the next slide also shows this class is OK. So I'm going to be clear here that Maldives are also included. Sorry, I'm going to put it out. I'm going to put it out. Yeah, Maldives also includes the V-backs. Because that also has a huge percentage, right? We have time ups which is 0.6 and Maldives are just 15.3, right? So that's fun. And then look at this. Lastly, this is another quick question that I get and see our first degree, second degree, third degree, fourth degree, all the statistics are pretty much there. Maldives are again including V-backs, first degree and second degree. This is another important thing because I remember in 2010 one of the biggest questions we got was who would do my episiotary? And it took us a lot of effort to explain that it's actually not part of an evidence-based practice. That is where our situation was in 2010, right? Data is very important for us. When I go forward to the next slide, you can see the weight of our babies. Now, this is another interesting slide because in India, people consider anything about 3 kgs as a big baby. So we've tried to tell people that actually it's not so and this is normal. And we also find that the persistent midwifery care babies are definitely more healthier and this is important for us today as well. So I hope, yeah, this is also another, this is something that I think has always been one of our plus points is our transfer for an epidural pain relief is zero. Now, it's something unique I feel as far as birthwear is concerned and this completely attributed to our women. The education, our birth classes, the commitment of the women who decide to birth with us and that's where we get the zero percent from. I think it's also what the hands-on comfort measures that we provide. There are so many reasons as to why we have a zero percent and we have had a lot of midwives who visit us and ask us how do you keep it at zero percent and I'm happy to explain that properly at the end of my presentation if somebody wants to hear more about it, right? Yes, going on to my next slide. Now, apart from healthy, low-risk mums, we have also been there a little bit of box. As you can see in 2018 was also a game changer for us as we had our first breach and our first set of twins. I have to be very honest to say that would we continue doing them or not? I wouldn't say every breach we would try or every set of twins we would try. I would say it really depends on the mums. The mums, that's really important for us that they're super healthy. They have exercised. We are really present spiritually and emotionally for this. Only then would this come into the picture for us, right? I think that's really important for midwives is that we have that really good conversation with the women that we take care of to really assert whether they are the mums that we learn for the bond centre or not. I think that's a very individualised decision-making as far as heat centre is concerned. Moving on to my next slide. These are very strong guidelines for us, right? This is something I think we... I think this is important for us that we would like to stress about how relevant midwifery has to be with respect to specific program applications. As an Indian women's school midwifery from the United States, this is really important to me and I realise what's necessarily huge in the United States may not be here and vice versa. We are burdened today with so many consent forms and all this does not make any sense to a mother who has barely exercised any choice at all in her life, right from the education to the man she marries, which more or less is chosen by her family. So we are in a very unique position. We talk a lot about choice. We repeat that word so many times, choice, choice, choice.  So that's where we actually begin from, right? And in such situations, writing protocols that have no bearing or meaning, it's obsolete, right? I think that's important to keep in mind that we need to have a community very strong as the heart of a birth centrist concerned. Now, this is one of the biggest challenges as far as a birth centrist concerned. Isolation, being alone, people not really understanding what we are talking about. And it's taken us so many years to reach this point. It's almost like, you know, you feel like you're going round and round in circles all the time. But it's... I hope this picture really is able to relay what we are going through and where we have reached, right? I hope it makes some sense. Also, to my next slide, I hope you're on time. Some things that we changed over the period of time is initially in a birth centrist mandatory that, yes, the support person has to be present. Your support person is mandatory for births. But we changed that around two, three years back when we realized a lot of women may not have their men at birth, may not have support of families. But this is truly something she wants to do. And we supported those women and we got the men to join in through Zoom and WhatsApp to attend the births. You know, it's... We changed our mindset a little bit about that. We also have siblings attending births. And it's amazing how families... You know, there's a lot of shame with respect to births and with respect to sex and births and can children... Is it appropriate for children to be given births? It's taken us some time to say, and people that children have no shame, children are being positive, the births are being differently. It's taken us some time to really show our community that it's really okay. And then we actually did have older sisters and brothers at birth. It's just that the past 50 years or so, things have been a little bit upside down, right? So I think we reached that point where we have made those changes currently in our community. This is one thing that every birth centre might obviously be able to back on and that's where birthplace stands on. We grew not because of anything else but this financial world which is trust, right? This is a big, big thing. Without this, we couldn't have grown this far, right? So I think that's a big thing. Now, when we look... I'm sorry, the slide just went really fast. Sorry, I'm just going back again. When you look at the infantry model, this is how I have kind of divided it into four quadrants. So you have the business aspect. You have the practical side about it. You have your theoretical knowledge that you need and the impact is obviously on families. You need to really picturise your work in this manner, like the four quadrants. And you really need to write down where and what you're doing in each quadrant. This is really... It's almost like you're... It's not a business plan but it's like the first step that you need to establish as to where you're working and do this exercise or something. The next thing that I have seen is this. Right now. So if you look, you can see there are just this building blocks, sexual and reproductive health clinic, women's health centres, midwifery schools and digital platforms. Let's look at this. This is something I think that's interesting because when you look at this, you will see that the integration and creation models require resources. Apart from your personal funds, you may be donors, you may be from the sectors. You may need a lot more investment, which has been promoting, innovating, adopting scalability and sustainability. Right?  What does that mean? It could be, let's say, new visual quality care, want really competent services that slow women. You could have clinical consultations. You could add on other services if you want. You could even have obstetric support provided by specialist doctors, emergency care, private rooms, breastfeeding counseling, pediatric consultation, everything. So sexual and reproductive health clinics essentially mean the whole gamut of services. You have this second option, which is women's health centres. Now, this is slightly different. Now, this is basically helping women stretching the bulk of their choice. Now, in this, it could be dedicated slightly differently, kind of providing additional services like prenatal yoga, childbirth preparation classes. It may not be focused on births per se, but it could provide, you could have support by a midwife in the bulk of the hospital with the support of midwife regular yoga sessions. That's how women's health centres function, right? You could have midwifery schools. Now, this model requires the creation of spaces to educate men versus models really essential for the creation and ongoing vibrancy of the entire midwifery system in using human capital. Midwifery schools, again, can be integrated with business models already proposed, can be handled through partnering with other models, right? So that's a different system. Another one that's obviously coming forward is digital platforms. Now, you could use this. Somebody could be using this to promote midwifery, disseminating information, frequency, midwifery abuses, sites' content to gain media exposure, network with potential clients. From an economic standpoint, this model has a potential to add value to all the other models described, right? So this is how I would say different building blocks going forward. I'm going to be... Now, the existing models that we have in India, obviously are hospitals and ventures. And the participants, I kind of put them down, right?  That's the one that's likely to rate even faster. The slowest might be the digital platforms. The investment, for example, you could, let's say, an average something $50 to access a digital platform. It is quite less, but that particular business model works on volume, digital platform works on models, right? So there's different ways to look at these business angles and let's say these are obviously women, midwives, midwives in training, trainers, parents, healthcare providers, and evaluators. Now, in my next slide, I think this is an important one for all of you out there. We have constant multi-taskers. A single birth worker who doesn't identify with this picture, right? But this is international midwife day and I think there's some important points and I'm not just talking about our own kids. I think the first concept of support at the end of all is family. There is a need, you know, the need is there to be for persons who are basically when you're younger and they definitely need you as they go older. I'm talking about our own parents, right? I think it's important to intersect, to communicate, you know, have a dialogue with yourself and inward journey actually takes you further. It takes you much more further than you expect. It gives you much more better aspiration to find your absolute power. I think that's very, very important, right? And one more thing in this slide and you can see that laptop. This is the media. You know, this is... I have different viewpoints on this. It's a re-engineering, right? By technological companies with a profit motive rather than social good. It thrives on an underlying human addiction which is a desire to get noticed, right? I think as midwives it's so important we're able to leverage our time and our sanity for the greater without really chasing likes because honestly it doesn't matter, right? It doesn't matter that old rat race doesn't matter. Right? And that's one thing that I think I've been talking about a lot. Now people have asked me where are we going forward and this is how we're going to look in probably the end of this year is our new center which we're hopefully a few months away from opening. We make this decision we're growing from a free-standing birth center to a family birthing center. Now as a midwife I should honestly say that I'm not a person who's really interested in OT, et cetera but there have been many incidents in my life our transfer rate is very, very low as you can see but even if I do 99 bucks naturally the one that I always think about is the birth electricity section and that is the hardest.  Priyanka? Because it's another institution. Yes? Priyanka we're going to need to close the room down in three minutes. Maybe you have time for one more question? Yeah, sure. So yes, if anybody would like to ask a question maybe I should stop the presentation with that. Can you ask any questions and send them back in presentation? Yeah, so we've probably got time for one question. Yes. Okay, so Kaveri is saying could you share any regulatory challenges that you may have faced to practice midwifery in India? So yeah, so currently my license is equalized in India so I really don't face that at this point of time. I've taken a couple of years to get that organized at least I would say six years to get that done. But right now it is not pretty easy because people never really understood what direct entry midwifery is because that's where I am but there are others on my team who obviously are on us at once. Okay, thank you. I think we have time for one more question. We've got a couple of minutes. What if a gynecologist wants to do midwifery? Of course. Absolutely. Why not? There is a definitely scope for that and that's definitely an option. Okay, one more. A few more. Do they need a separate degree? Yes, so midwifery and gynecology is two different things and definitely you will need to have a separate set of training for midwifery. It's a lot of people say but I'm a gynecologist, I can do midwifery. It's as much as a midwife is not a gynecologist and a gynecologist is not a midwife. That's just it. It's two separate compartments. Okay. They will need extra training for the lower risk. Yeah, that's correct. I agree with you on that. Yeah. Okay, I think we've got one more minute. So I'm going to sort of make a couple closing comments and thank you so much. I think this was great for all of us to see and I mean those statistics, wow. So thank you so much for joining us. I think this session was very useful. I think if I can summarize one thing, you focus really well on this cultural appropriate, I mean how do you tweak midwifery to be hyperlocal and relevant? I think, and then you shared very honest journeys of how you've made that change. So thank you very much. Priyanka, excellent presentation. Thank you.