A Nurse-Midwife Champions Postpartum Family Planning in Rural Bihar

By Atul Mittal and Indrani Kashyap

Nurse-midwife Rati Rani (right) speaks to a client about the benefits of healthy birth spacing for mother, newborn and family.

Begusarai, India—The mother of four children, a very pregnant Anita Devi arrived at the primary health center near her village for one of her antenatal visits. Nurse-midwife Rati Rani made the 35-year-old mother comfortable and, as part of the visit, talked with Anita about her family and the risks of having children too close together. This child would be Anita’s fifth in nine years of marriage; three of her children were born within a year of each other.

“My mother-in-law was against any form of contraception,” Anita explained to the nurse when asked about her previous pregnancies. “Though my second child was a son, she said that I should try for more sons, so that, God forbid, if something happened to one son, we’ll have another one to fall back on. But my next children were girls. I was tired and felt I had nothing left in my body.”

Nurse-midwife Rani had heard such explanations before. In Bihar, as in many places in India, women usually live in their husband’s family home, where the mother-in-law runs the household and is extremely influential in decisions about family life. Here, families have on average 3.7 children,[1] which is the highest fertility rate in the country. The mean age of marriage[2] for girls is 17.6 years and only 32.4 percent of women use any family planning method.[3]

In counseling Anita, Nurse-midwife Rani explained the benefits of healthy birth spacing—delaying pregnancy for at least two years after the birth of a child gives the mother and baby time to heal, grow and thrive, enhances family life so other children stay healthy and contributes to fewer maternal and child deaths. 

Nurse-midwife Rani and more than 300,000 other nurse-midwives across India[4] are at the forefront of a targeted effort by the Government of India to save lives by reinvigorating postpartum family planning (PPFP) services. With the support and technical expertise of Jhpiego and partners, India’s nurse-midwives are educating and counseling women about their family planning options during antenatal visits and introducing them to the intrauterine contraceptive device (IUCD). This long-acting method lasts for 10 years and can be inserted within 48 hours after giving birth.

After talking with nurse-midwife Rani, Anita persuaded her husband that an IUCD would be best, and they chose to have it inserted after she gave birth to her fifth child, a girl. “Every time I feel doubtful, I come to Didi,” she said, invoking Nurse-midwife Rani’s colloquial name. “She explains it all beautifully to me and now I am confident that I have done the right thing.” 

Nurse-midwife Rani, 35, says the government initiative is having an impact in the 42 villages served by the Teghra Primary Health Center, which is located in the district of Begusarai. Since January of this year, 241 women have been provided postpartum IUCD services, 186 of them by nurse-midwife Rani.[5]

Nurse-midwife Rati Rani with her client Anita Devi (left) who chose to have an IUCD after giving birth to her fifth child.

“Prior to Jhpiego’s training, we did not provide any family planning option to women when they came in for their delivery,” says Nurse-midwife Rani, herself a mother of two children. “We would tell the woman to come back six weeks post-delivery... But many of these women would not return, some would come only after they were pregnant again, some would come for abortions.”

“We were losing out on providing a viable family planning option to so many women,” she continued. “With PPFP options, we can now encourage these women to adopt a family planning method of choice while they are still at the facility, which is convenient and ensures prevention from unwanted pregnancies.”

Nurse-midwife Rani, who was trained by Jhpiego under the Bill & Melinda Gates Foundation-supported PPFP initiative, says she has the opportunity to help women make a life-changing decision that will better their lives and that of their families and “this motivates me every day.”

Nurse-midwife Rani has seen firsthand the challenges women and their families face when burdened with too many children, often struggling to provide them with food and clothing. “The mother suffers in silence,” says Nurse-midwife Rani. “Only if we have smaller families will we be able to have healthier families where the children will get better nutrition and opportunities to educate themselves. Only then can we ultimately have a better and healthier society.”


[1] Total Fertility Rate of Bihar: SRS 2009.

[2] District Level Household Survey 3.

[3] Ibid.

[4] World Health Organization. 2011. The State of the World‘s Midwifery 2011.

[5]Data as of August 2012.

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