(https://www.health-check.

in)
 

India Readies A New Cadre Of Certi ed Midwives To

Improve Maternal, Infant Care
Sunaina Kumar (https://www.health-check.in/author/sunaina-kumar/)      February 4, 2019

       0

Karimnagar (Telangana) and Delhi: “As a nurse, we used to refer to mothers as patients.
The rst thing we learned as a midwife was to treat them as mothers and not patients,” said
Jyothirmayee Akkaladevi, 35, as she rattled o a list of everything she had to unlearn to train
as a midwife.

Akkaladevi is from the rst batch of professionally trained midwives in India, part of a pilot
programme started by the state government of Telangana. When we met in November
2018, she had completed a year-long academic training for midwifery at the Mother and
Child Health Centre in Karimnagar.
This programme will now be studied closely as India gets ready to introduce midwifery-led
care in the country. The government of India announced Guidelines on Midwifery Services
(http://nhm.gov.in/images/pdf/programmes/maternal-
health/guidelines/Guidelines_on_Midwifery_Services_in_India.pdf), which include
recommendations for midwifery training and certi cation, at Partners' Forum
(https://www.who.int/pmnch/about/governance/partnersforum/2018/en/), a World Health
Organization (WHO)-led global forum for maternal, newborn and child health, in Delhi in
December 2018. The development has taken years of advocacy and international pressure,
and represents a big shift in India’s maternal health policy.

“This is going to be a game changer for the country,” said Dinesh Baswal, deputy
commissioner for maternal health at the central ministry of health and family welfare, “We
need to accelerate the decline in maternal and infant mortality, and we see this as an
e ective intervention.”

The cadre of midwives would support overburdened secondary and tertiary care facilities
that do not have enough obstetricians, helping meet India’s Sustainable Development Goals
related to infant and maternal health. “It would also improve the quality of care and help
women have positive birth experience,” Baswal said.

Globally, midwives are known to save lives and provide quality care during pregnancy and
childbirth--83% of all maternal deaths and newborn deaths could be averted with midwifery
care, WHO data (https://www.who.int/maternal_child_adolescent/topics/quality-of-
care/midwifery/case-for-midwifery/en/) show.

When midwives were the main providers of care during pregnancy, women were less likely
to give birth prematurely or lose their babies before 24 weeks of gestation, research by the
WHO has shown. Women attended on by midwives needed fewer epidurals, fewer assisted
births and fewer episiotomies, and were less likely to have caesarean births.

Too many caesarean sections

The Telangana government launched India’s rst midwifery course in October 2017 in the
district of Karimnagar. Two years on, by the middle of 2019, Akkaladevi and 29 other women
will graduate and be posted as midwives in public hospitals across the state.
Trainee midwives at Mother and Child Health Centre, Karimnagar in Telangana. The state launched India’s first midwifery course in October
2017 in Karimnagar. Two years on, by mid-2019, 30 women will graduate and be posted as midwives in public hospitals across the state.

To know why Karimnagar was chosen for implementing the project on midwifery, the
following data are instructive. Telangana had the highest rates of caesarean births in the
country, with 74.9% in the private sector and 40.3% in the public sector, according to the
National Family Health Survey (http://rchiips.org/nfhs/NFHS-4Reports/India.pdf) (2015-2016).
Globally, 10-15% is considered the “ideal rate”, as per the WHO.

Although caesarean sections are becoming more common around the world, Karimnagar
recorded (https://timeso ndia.indiatimes.com/life-style/health- tness/health-
news/Telangana-tops-in-C-section-deliveries-in-pvt-hosps/articleshow/51821782.cms) an
alarming gure of over 80% of caesarean births.

The case of B. Nandini and her family is illustrative.

Nandini is a 25-year-old accountant, and a mother of two from Laxmipur village in

Karimnagar. She has had two babies, both through caesarean section. Her mother Nirmala,
42, also had children through cesarean section. The only woman in their family to have given
birth naturally is Nandini’s grandmother Bhu Devi.

“In my time it was di erent. But now, everyone has an operation,” Bhu Devi, now in her 70s,
told IndiaSpend, “I’m not sure why it’s changed.”
Over the decade upto 2016, the percentage of caesarean deliveries doubled from 9% to
18.5% in India, as IndiaSpend reported (https://www.indiaspend.com/caesarean-deliveries-
have-doubled-in-india-mostly-in-urban-private-hospitals/) on December 20, 2018. The
caesarean section is recognised globally as a maternal health-care indicator: When
caesarean section rates rise towards 10% across a population, maternal and newborn
deaths decrease; if the rate goes above 10%--as in India--there is no evidence of
improvement in maternal or neonatal mortality, IndiaSpend reported
(http://archive.indiaspend.com/cover-story/led-by-wealthy-urban-women-caesarean-
sections-rise-in-india-45728) on February 10, 2017, based on a WHO study.

One of the solutions, experts agree, is to bring in midwives--it would lower the caesarean
birth rates, reduce unnecessary risks to women and their babies, and improve maternal and
infant health overall, as global evidence shows.

How midwives can help

Midwifery-led care is based on the principles of dignity, privacy and compassion for women
and respectful maternal care.

“When I signed up for the course, I thought to myself, what new thing can they teach us
about birthing? We did not know anything about respectful maternal care. Now when we
counsel a mother to opt for a normal delivery in the case of low-risk pregnancy, it’s only after
communicating with her, gaining her trust and making her aware of her choices,” Akkaladevi
said.
A midwife attends to a mother at the Mother and Child Health Centre, Karimnagar in Telangana. Midwifery-led care is based on the principles
of dignity, privacy and compassion for women and respectful maternal care.

Akkaladevi had worked as a general nurse in Mother and Child Health Centre in Sangareddy
district in Telangana for 14 years when she saw a noti cation in a local Telugu paper inviting
applications for a course in midwifery. In the last two weeks of December 2018, a year into
the course and now working as a midwife intern, Akkaladevi had already assisted in the
delivery of more than a dozen babies at the Mother and Child Care Hospital in Sangareddy
district in Telangana.

“I have assisted in a delivery a day since the internship began,” Akkaladevi told IndiaSpend,
“At rst, the doctors and nurses were not happy to see us in the labour room and felt we
were trespassing, but when they saw our work and how we take care of the mothers, they
told us we are needed.”

There has been a singular emphasis in India over the last decade on increasing institutional
deliveries, but there has been little talk about the quality of care for mothers. The increase in
the number of institutional deliveries in India has been accompanied by calls to humanise
childbirth (https://www.epw.in/engage/article/urgent-need-to-humanise-childbirth-in-india)
so women can go through it with dignity and as autonomous individuals
(https://thewire.in/health/institutional-delivery-india-nightmare-women).

It was partly for this reason that the central ministry of health and family welfare had
launched a programme, 'LaQshya', in 2018 to improve the quality of care in labour rooms.

For a country that has been striving to improve its maternal health indicators, India has
greatly underestimated midwifery, lagging behind countries such as Sri Lanka, Bangladesh
and Afghanistan that have invested in creating a professional cadre of midwives.

There is little awareness on midwives as quali ed health professionals in India and the term
is still used interchangeably for traditional birth attendants (dais), auxiliary nurse-midwife
(ANMs) or registered nurse and registered midwife (RNRM). India has so far not recognised
midwifery and provides midwifery training only with nursing training to its ANMs and
RNRMs.

A certi ed midwife, in the globally accepted context, like in Europe where 75% of births are
attended by midwives, is someone who has completed a midwifery education programme
based on the International Confederation of Midwives standards, and has acquired the
requisite quali cations to be registered legally and licensed to practise midwifery.
“India is one of the few countries to have not made any progress in midwifery. We have been
deliberating it for a long time, but it has gained momentum only now,” Baswal said. Earlier
attempts to establish midwifery in India, in West Bengal and in Gujarat, for instance, failed to
take o .

The new guidelines on midwifery (http://nhm.gov.in/images/pdf/programmes/maternal-

health/guidelines/Guidelines_on_Midwifery_Services_in_India.pdf) in India, released in
December 2018, state that a cadre of Nurse Practitioner in Midwifery (NPM) will be created
that will be skilled in accordance with International Confederation of Midwives standards.
The NPM will be a registered nurse-midwife with an additional 18 months of post-basic
training in midwifery.

Five regional midwifery training institutes (for training of NPMs) are proposed to be set up in
the rst phase in Assam, Maharashtra, Gujarat, Tamil Nadu and Uttar Pradesh. “All pregnant
women would rst be screened at midwifery-led care units, which would be established at
public health facilities,” Salima Bhatia, lead consultant on maternal health in the ministry of
health and family welfare, said.

To create a cadre of well-trained midwives, it would be critical to have pro cient midwifery
educators to train the NPMs. One of the limitations of the Bangladesh model of midwifery
has been the shortage of competent midwifery educators. India has planned a national
midwifery training institute for education and training of educators, which will be supported
by international institutions and experts from countries in Europe where midwifery is well
established.

“India will need hundreds of thousands of midwives, but it is not impossible. We’ve seen how
the push for institutional deliveries has been successful,” said Mallavarapu Prakasamma,
founder of the Society of Midwives in India who now runs Answers Foundation, which has
for long advocated for midwifery in the country.

The way ahead

As India gears up to implement midwifery, the Telangana model will provide a crucial case
study. The state has created 126 new posts for midwives and o ers an additional Rs 15,000
as salary to nurses who complete the 18-month training (one year of combined
classroom/hands-on training and a six months’ clinical internship). The project has been
developed as a public-private partnership. The state government sought support from
UNICEF and Fernandez Hospital in Hyderabad, the only one in India to provide professional
midwifery services and training for midwives since 2011.
“It will be a few decades before professional midwifery gets embedded in the country to be
able to meet the needs of every woman,” said Evita Fernandez, managing director of
Fernandez Hospital. “The present guidelines do not allow for direct-entry midwives, as only
nurses can qualify for midwifery training. We do not have enough nurses in India and direct
entry would allow midwifery to ourish, but at least a start has been made.”

Apart from the institutional support it o ers, midwifery also creates jobs for women,
allowing them to enter a new profession, upgrade their skills and earn better. After years of
working as a general nurse, Akkaladevi said, “This course has allowed me to specialise, to be
better at my work. Nursing was my profession, midwifery is my calling.”  

(Kumar is an independent journalist based out of Delhi.)

Reporting for this story was supported by a grant from the European Journalism Centre, with
funding from the Bill & Melinda Gates Foundation.

We welcome feedback. Please write to respond@www.health-check.in

(mailto:respond@www.health-check.in). We reserve the right to edit responses for language and
grammar.

Sunaina Kumar (https://www.health-check.in/author/sunaina-kumar/)

Support HealthCheck

₹10 ₹50 ₹100

₹500 ₹1000 ₹ ...?

An Orcsnet partner website T & C Privacy

EN ह

 HEALTH (HTTPS://WWW.HEALTH-CHECK.IN/CATEGORY/HEALTH/)

HEALTH CHECK (HTTPS://WWW.HEALTH-CHECK.IN/CATEGORY/HEALTHCHECK/)

MOTHER & CHILD (HTTPS://WWW.HEALTH-CHECK.IN/CATEGORY/MOTHER-CHILD/)

       0