INDEX

SL. CONTENT PAGE

NO NO
1 Introduction
2 Terminologies
3 Historical milestones in the care of mothers and infants
4 Historical evolution of maternal and child health services:
 History of development of midwifery in united states
 History of development of midwifery in India
Before independent, In independent
Present and future in India
5 Contemporary perspectives:
 Integrative health care
 Childbirth practices
 Certified nurse- midwives
 Views of women
 Breastfeeding in the workplace
 Family leave
 Violence
 HIV and aids in pregnancy and the new born
 High- technology care
 Community based care
 Increased in high risk pregnancies
 High cost of health care
 Limited access to care
 Increased emphasis on preventive care
 Healthy people goals
Current trends in maternal- new born health care:
 Family centered care
 Regionalized care
 Advance in research
 Bioethical issues
 Demographic trends
 Poverty
 Cost containment
 Cost containment strategies
6 Conclusion
7 Bibliography
INTRODUCTION:
Obstetrics word came from a Latin word
“OBSTETRIX” means “MIDWIFE”.
MIDWIFERY, as known as obstetrics, is a health
science and health profession that deals with pregnancy,
childbirth, and the postpartum period (including care of
the new born), bedsides sexual and reproductive health
of women throughout their lives.
Maternal and child health is as old as the history of
human species. The term “maternal and child health”
(MCH) refers to the promotive, preventive, curative and
rehabilitative health care of mothers and children. It
includes the sub areas of maternal health, child health,
family planning, school health and health aspects of the
adolescents, handicapped children and care for children
in special settings. Maternity nursing teach about
pregnancy; the process of labor, birth and recovery; and
parenting skills; and provide continuity of care
throughout the childbearing cycle. Tremendous
advances in the care of mothers and their infants have
taken place ring the Past 150 years.
The role of midwife whether she participates in hospitals,
health centre’s or domiciliary conditions has been
recognize as one of the most rewarding jobs. Her
functions carry great responsibilities and demands
specific knowledge and skills.
Healthy women are the key to the health of any nation,
primarily because of their vital role in co-creating
healthy infants and co-caring for the family.
Providing health care to women is not only a health issue
but a matter of human rights issue.
In women’s life childbirth is a special event. A mother
will never forget a midwife who delivered her baby; and
who was ‘with the woman’ during childbirth, which is
the very essence and identify of a midwife.
Hence a midwife is an obvious catalyst in providing safe
motherhood in the fabric of our society.

TERMINOLOGIES:

1. MIDWIFERY- the knowledge necessary to

perform the duties of midwife.
2. OBSTETRICS- the branch of medicine, which
deals with the management of pregnancy, labour and
puerperium.
3. GYNECCOLOGY- branch of medical science,
which treats diseases of the female genital organs.
4. REPRODUCTION- process by which a fully
developed offspring of its kind is produced.
5. PREGNANCY- state of carrying fetus inside the
uterus by a woman conception to birth.
6. GESTATION- pregnancy
 7. GRAVIDAE- state of pregnancy irrespective of its
duration.
8. MULTIPARA- woman who has given birth more
than once
9. NULLIPARA- woman who has not given birth
before
10. PRIMIGRAVIDAE- woman carrying first
pregnancy
11. MULTIGRAVIDAE- woman carrying
pregnancy more than once
12. ALTERNATIVE BIRTH CENTER- a setting
for birth separate from a hospital
13. NURSE- MIDWIFE- nurse who assists
women with pregnancy and childbearing either
independently or in association with an obstetrician;
can assume full responsibility for the care and
management of women with uncomplicated
pregnancies.

HISTORIC MILESTONES IN THE CARE OF

MOTHERS AND INFANTS:

1847 - James Young Simpson in Edinburgh,

Scotland, used ether for an internal podalic version
and birth, the first reported use of obstetric
anesthesia.
1906 first program for prenatal nursing care
established
1907- Childbirth classes started by the American
Red Cross
1911 First milk bank in the United States established
in Boston.
1912 -U.S. Children's Bureau established.
1923 First U.S. hospital center for premature infant
care established at Sarah Morris Hospital in
Chicago.
1933-Natural Childbirth published by Grandly
Dick-Read.
1941-Penicillin used as a treatment for infection.
1953 - Virginia Apgar, an anaesthesiologist,
published Apgar scoring system of neonatal
assessment.
1955 Jonas Salk's injected polio vaccine was found
to be safe and effective.
1956 - Oxygen determined to cause retrolental
fibropia sia (RLF) (now known as retinopathy of
prematurity [ROP]).
1958- Edward Hon reported on the recording of the
fetal electrocardiogram (ECG) from the maternal
abdomen (first commercial electronic fetal monitor
produced in the late 1960's).
1960-Birth control pill introduced in the United
States.
1962 -Thalidomide found to cause birth defects.
1967 - Rh (D) immune globulin produced.
1968 Rubella vaccine became available.
1969-Nurses Association of the American College
of Obstetricians and Gynaecologists (NAACOG)
 foundered; renamed Association of Women's
Health, Obstetric and Neonatal Nurses (AWHONN)
and incorporated as a organization in 1993.
1973 Abortion legalized.
1974 -First standards for obstetric, gynecologic and
neonatal nursing published by NAACOG
1975-The Pregnant Patient's Bill of Rights published
by the International Childbirth Education
Association.
1978-Louise Brown, first test-tube baby, born.
1991- Society for Advancement of Women's Health
Research founded.
1998 - Newborn's and Mother's Health Act put into
effect.
2000- Working draft of sequence and analysis of
human genome completed.

HISTORICAL EVOLUTION OF MATERNAL

AND CHILD HEALTH SERVICES:
 History of development of midwifery in United
States
 History of development of midwifery in India
a) History of development of midwifery in United
States:
THE BIRTH OF MIDWIFERY - ANCIENT TIMES
As women gave birth, they sought and received care
from supportive others. At an unknown point in the
cultural evolution, some experienced women became
designated as the wise women to be in attendance at
birth. Thus, the profession of midwifery began. Indeed,
as historians have noted, midwifery has been
characterized as a social role throughout recorded
history, regardless of culture or time.
Biblical recognition of the functions of midwives
included several verses recounting the experiences of
two Hebrew midwives who refused to kill male infants
in defiance of the King of Egypt (Exodus 1:15-22). Other
verses in the Bible also make passing references to
midwifery attendance at birth, implying that it was
ubiquitous (Genesis 35:17, 38:28). Historians have
found the practice of midwifery referred to in other
papyri as well as in ancient Hindu records.
In Greek and Roman times, midwives functioned as
respected, autonomous care providers to women during
their reproductive cycles. Some qualifications for the
practice of midwifery began to evolve during this period.
For example, in Greece the midwife was a woman who
had born children herself. This requirement has remained
a commonality in the practice of midwifery throughout
several cultures and exists even today.

"Midwife" is a word which in English was translated to

mean "with woman", implying the supportive, not
interventive, functions of the practitioner. In French a
midwife is a Sage femme, or a "wise woman". A general
thread in all of the references regarding ancient
midwifery was support of the woman in labor. Labor was
perceived as a basically natural process.
The profession of midwifery continued without major
changes throughout the centuries, even through the Dark
and middle Ages. In their practices, midwives routinely
used herbs and potions, as forerunners of today's modern
pharmaceuticals. The midwives of these centuries
generally continued to learn by the apprentice model. As
an apprentice, skills and knowledge’s were shared from
generation to generation but without the development of
a formalized system of university education. Therefore,
midwives did not benefit from the scientific inquiry that
developed early in medical schools. Eventually
midwifery in most affluent countries developed
formalized programs, although apprenticing still may be
part of some.
Midwives are the most common birth attendant in the
world. The average child born in this world is born into
the hands of a midwife.
380-322 BC:
 Aristotle, the father of embryology, described the
uterus and the female pelvic organs.
 He also discussed the essential qualities of the
midwife
 Soronus, in the second century, was the first to
specialize in Obstetrics and Gynecology. His book
was used for 1,500 years. He used a vaginal
speculum, advised on cord care, and wet nursing.
  From the 5th to the 15th centuries, which was the
period of decline of the Roman Empire, untrained
midwives controlled the practice of midwifery.
Midwives did not usually seek medical aid until the labor
was hopelessly obstructed, as in the
15H-16H CENTURY:
 Leonardo da Vinci made anatomical drawings of
pregnant uterus. In 1513, the first book on
midwifery was printed in Germany, based on the
teachings of soronus.
 In 1543, opened the full term pregnant uterus in a
lower animal, extracted the fetus, and demonstrated
uterus as a single chamber organ.
 Ambroise Pare laid the foundations of modern
obstetrics.
 He also sutured perineal lacerations.
 Julius Caesar Aranzi wrote the first book for Italian
midwives. He advised cesarean section for
contracted pelvis.
 William Harvey, the father of British midwifery,
wrote the first English textbook on midwifery. He
described the fetal circulation and the placenta and
was the first to deliver the placenta by massaging the
uterus.
 Case of gross pelvic deformity.
THE AGE OF THE MIDWIFE: BEFORE 1750
1660-1750:
Parliament regulated Colonial imports and
exports for more than a century before the American
Revolution. During much of that time, the 13 Colonies
prospered, as their trade was valuable to Britain. But
after 1763, restrictions upon America became
increasingly onerous. Even more serious in creating
American discontent were efforts on the part of Britain
to tax the Colonies for revenue to support the British
army and officials in North America.
 New York City required licensing of midwives.
Such licenses placed the midwife in the role of
servant of the state, a keeper of social and civil order.
 Death during childbearing not accurately reported,
but one historian estimated that birth was still
successful 95 percent of the time.
 Men did not attend births during Colonial times, as
it was considered indecent. Also, there were few
doctors around.
 Women faced birth not with joy and ecstasy, but
with fear of death and eternal judgment.
 One major reason that doctors were becoming more
involved in birth was the decline of witchcraft.
Doctors did not feel comfortable around witchcraft,
and in the new colony, less was practiced.
  Women began to view problems in birth as a part of
nature, where doctor ruled. They gave over medical
control but not the spiritual aspect

MEDICINE IN A DEMOCRATIC CULTURE:

1750-1850
Doctors were usually not educated. Books that were
popular at the time were on self-help measures, common-
sense medicine.
The development of religious thought-not medical
progress first brought about the decline of magic in
healing and other spheres of life.
1751-1850: Formation of two kinds of hospitals:
o Voluntary hospitals, operated by charitable lay
boards, nondenominational but in fact Protestant,
and
o Public hospitals descended from almshouses and
operated by municipalities. Counties and the
federal government.
1752: The Pennsylvania Hospital in Philadelphia became
the first permanent general hospital in America built
specifically to care for the sick.
1760: First licensure law calling for prospective
examination of doctors was passed in New York City.
1765:
 First medical school in Philadelphia was chartered.
  Dr. William Shippen opened the first formal training
for midwives. Midwives' beliefs that childbirth is
normal and inherently within the domain of female
competence may have prevented women from
seeking formal training, especially from men. Few
women were literate, many could not afford schools,
and the Puritan philosophy did not encourage
education for women.
1766: First provincial medical society was organized in
New Jersey.
1796: Popular medicine included bloodletting, powerful
emetics and cathartics.
At the end of the 18th century, most people assumed that
midwives had no formal training, even though some did,
and common existing beliefs held that women were
emotionally and intellectually incapable of learning and
applying the new obstetric methods. Well-to-do families
soon came to believe that physicians could provide better
care than female midwives could and thus offered the
best hope for a successful birth.
THE NEW MIDWIFERY - BETWEEN 1790-1890
 1799:
A short course for midwives began in New York City,
led by Dr. Valentine Seaman. Dr. William Shippen
began a course in anatomy and midwifery in
Philadelphia. Few women came as students, but men
came.
 1812:
The War of 1812 was thought of by Americans as a
"second war of independence."
In Colonial America, women in the home routinely
provided most medical care. Women were also
prominent as lay practitioners.
After the War of 1812, medical schools began to
proliferate.
The shift from using midwives to in urban using
doctors started among women in middle classes.
A more general decline of women in the field of
medicine paralleled social influences; these stated
that women, once married, should assume a strictly
domestic role. The New Democracy did not include
women.
 1816:
René T. H. Laennec introduced the first crude
stethoscope, auscultation allowed the physician to
penetrate behind the externally visible to "see" into the
living. Doctors had previously observed patients; now
they examined them.
 1817:
Dr. Thomas Ewell of Washington, D.C., proposed to
establish a school for midwives connected with a
hospital (such as in Europe) and sought federal
funding. The funding was denied, and the school never
came to be.
  1825:
German immigrants brought homeopathy to America.
Homeopathic medical schools admitted women
willingly.
 1828:
The word "obstetrician" was formed from the Latin,
meaning "to stand before
 1830:

"Popular Health Movement" peaked and remained

influential throughout the century. (Health was
coming to be regarded as each person's
responsibility.)
Between the periods 1820 to 1840, many licensing
laws were being rescinded or abolished.
Sometime during the mid-1800s, some doctors went
into "contract practice," which is actually a primitive
form of health insurance.
 1847:
Elizabeth Blackwell was accepted into the Geneva
(New York) Medical College. She graduated at the top
of her class.
 1848:

The American Medical Association was founded to

enforce standards on medicine as well as its practice.
Dr. Walter Channing of Boston first used ether for
childbirth, for humanitarian reasons
1850 to 1900:-
1850: A variety of more "particularistic" hospitals
were formed. These were primarily religious or ethnic
institutions and specialized hospitals for certain diseases
or categories of patients. They were also owned by
medical sects, mainly homeopaths. There were a large
number of Catholic immigrants.
1856:
The New York Infirmary for Women and Children
was founded.
Puerperal (childbed) fever was at epidemic
proportions during the 1800s.
The limited training of doctors in the 1800s was not
so much an expression of ignorance as it was a
response to economic realities the limits of effective
demand.
1860: The factory, through the aid of improved means of
transportation, was able to supply the needs of the people
for manufactured commodities.
Late 1870s: Phones became available and dramatically
reduced the cost of doctors' visits by making it easier to
locate and contact the physician. 1860: The average
earnings of physicians put them at lower middle class.
1863: President Lincoln issued the Emancipation
Proclamation on January 1, declaring that slaves in
rebellious states, or parts of, were to be "forever free."
 1864: Elizabeth and Emily Blackwell opened a medical
college for women in conjunction with the infirmary.
1873: Three training schools for nurses were established
in New York. The professionalization of nursing
furthered tendencies toward order and cleanliness.
Between the 1870s and 1880s, a common support for the
restoration of medical licensing was sought among all the
competing groups.
1880: Louis Pasteur demonstrated that the microbial
chains of streptococci he had discovered in 1860 were
the major cause of puerperal fever. 1886: American
Federation of Labor was formed,
1888: The American College of Obstetricians and
Gynecologists (ACOG) was formed.
1891: Andrew Still began teaching the practice of
osteopathy in Missouri.
1890-1910: Phase 2 of public health. First applications
of bacteriology emphasized isolation and disinfecting.
1890:
The advent and spread of profit-making hospitals
took place. Operated by physicians singly or in
partnership as well as by
Corporations, the hospitals large growth was due in
part to the new potential for profit from surgery.
Christian Science and chiropractic medicine came
into being.
1894: The first cesarean section was performed in
Boston.
1895: The X-ray was developed.
AROUND THE TURN OF THE CENTURY
 Economic changes made families less self-
sufficient.
 Scientific discoveries and the development of more
effective treatments led to increased public
acceptance of medicine.
 Automobiles and smooth roads made hospital access
easier.
 Some large city hospitals opened prenatal clinics.
Anesthesia was introduced in the late 1800s and
"twilight sleep" in 1914.
 As medical education and care improved, physicians
organized to solidify their status and authority.
1900s-1920s:
 Public hygiene was successfully applied. Key
scientific breakthroughs in bacteriology came about,
and new water-sand filtration systems and
regulation of the milk supply cut typhoid fever as
well as infant mortality.
 Other useful bacteriology occurred in surgery. The
advent of antiseptic surgery sharply reduced the
mortality from injuries and operations and increased
the range of surgical work.
 Immigration was limited during and after World
War I and thus reduced the supply both of foreign-
 trained midwives and the number of foreign-born
women, the most loyal clientele of midwives.
Physicians were becoming wealthier and being
integrated into middle- and upper-class societies.
Prejudice against the intelligence and capability of
women, immigrants, black people and poor people
was used to defame midwifery.
 Midwives were not in a position of power; they
made relatively little money, were not organized and
did not see themselves as professionals.
 Vaccines against typhoid and tetanus were
developed.
 Doctors were among the first to purchase
automobiles.
 Industrialization and urban life also brought an
increase in the number of unattached individuals
living alone in cities. Urban growth led to higher
property values, forcing many families to abandon
private homes for apartments in multi-family
dwellings, which limited their ability to set aside
rooms for the sick or those in childbirth.
 At the turn of the century, the main field of surgical
intervention was the abdomen.

In the early 1900s, medical societies offered to handle

malpractice suits for members. Doctors formed alliances
to one another and testified on behalf of one another. If a
doctor did not belong to the medical society, he had
trouble getting insurance.
By 1900, physicians were attending about half the
nation's births, including nearly all births to middle- and
upper-class women. Midwives took care of women who
could not afford a doctor.
1900: Less than 5 percent of women gave birth in
hospitals.
Between 1880 and 1924, more than 26 million
immigrants came to America. The peak year was 1907,
when more than 1.2 million came.
1904:
 A crisis in hospital finance brought about new
management, new policies and increased
contributions from patients.
 As more and more doctors became educated, they
began to see midwifery as perpetuating uneducated,
indecent ways. They also experienced an increase in
financial rewards.
 The railroad industry led in developing extensive
employee medical programs around 1900.
 The early 1900s saw the rise of partnerships, group
practices and clinics in medicine. Before 1900,
fierce competition and patient-stealing attitudes
were prevalent.
 After 1900, most women were attracted to hospitals
because hospitals could offer painless birth not
available in homebirths.
1904: The appearance of the first maternity clothes by
Lane Bryant took place. 1904: The Socialist Party was
the first American political party to endorse health
insurance.
1910:
 New Public Health offered an emphasis on
education in personal hygiene and "the use of the
physician as a real force in prevention" by
organizing medical examination of the entire
population.
 The Carnegie Foundation for the Advancement of
Teaching published Abraham Flexner's critical
report on medical education in North America.
Flexner concluded that America was oversupplied
with poorly trained doctors and recommended that
most medical schools in operation be closed, that
only the best remain open, and that all that remained
open be strengthened based on the model provided
by Johns Hopkins, Flexner singled out obstetrics as
making "the very worst showing."
1912: The Federal Children's Bureau was founded to
investigate mortality in birth and to provide accurate
information on the health of children, among other
responsibilities.
1914: Dr. Eliza Taylor Ransom founded a maternity
hospital in Boston's Back Bay and also began the New
England Twilight Sleep Association to force hospitals to
offer the procedure.
1915: The Association for the Study and Prevention of
Infant Mortality published a paper in which Dr. Joseph
Delee described childbirth as a pathologic process. He
believed that childbirth was not a normal function and
that midwives had no place in childbirth.
By 1915 there were at least 538 baby clinics in America,
five times more than in 1910. When the National
Association for the Study and Prevention of Infant
Mortality was formed.
1915: The American Association of Labor Legislation
drafted the first bill for health insurance. It would pay for
medical costs, sick pay, maternity benefits and a death
benefit.
1917:
Two developments changed the entire complexion of the
health insurance debate:
1. Even though the AMA House of Delegates in June
1917 approved a final report from its social insurance
committee favoring health insurance, this action did not
reflect the sentiment in state medical societies.
2. The United States entered World War I in April, many
physicians went into the service, and the AMA closed
down its committee on social insurance.
1918: The United States stood 17th out of 20 nations in
mortality rates.
1918:
The Maternity Center Association of New York was
founded to provide prenatal care in poor neighborhoods
and education of mothers.
In Victorian times, women were thought to be socially
"frail" and tried anything to rid themselves of pain in
childbirth.
Until specific cures for puerperal fever were available in
the late 1930s, each woman felt she needed preventive
treatment.
Midwifery in 1920s-1950s:
 Health insurance vanished during the 1920s.
 Economic prosperity during the 1920s increased the
size of the middle class, which directed women not
to work. Upper- and middle-class women wanted
doctors, not lower-class midwives.
 By 1920, doctors believed that "normal" deliveries
were so rare that interventions should be made
during every labor to prevent trouble. Dr. Joseph
DeLee, author of the most frequently used obstetric
textbook of the time, argued that childbirth is a
pathologic process from which few escape
"damage." He proposed a program of active control
over labor and delivery. Attempting to prevent
problems through a routine of interventions. Delee
proposed a sequence of medical interventions
designed to save women from the "evils" that are
"natural to labor." Specialist obstetricians should
 sedate women at the onset of labor, allow the cervix
to dilate, give ether during the second stage of labor,
cut an episiotomy, deliver the baby with forceps,
extract the placenta, give medications for the uterus
to contract and repair the episiotomy. His article was
published in the first issue of the American Journal
of Obstetrics and Gynecology. All of the
interventions that DeLee prescribed did become
routine.
 Maternal mortality reached a plateau, with a high of
600 to 700 deaths per 100,000 births, between 1900
and 1930.
 By the 1920s, the medical profession had won
stronger licensing laws and turned into support of its
powers the threats to its position that were made by
hospitals, drug manufacturers and public health.
 The medical profession controlled corporations' and
mutual societies' entry into health services and also
succeeded in controlling the development of
technology and organizational forms as well as the
division of labor. The medical profession helped
shape the medical system so that its structure
supported professional sovereignty instead of
undermining it.
 Woman suffrage and the right of women to vote
were big issues.
1921:
The Sheppard-Tower and Infancy Protection Act became
a federal law. It encouraged states to make their own
plans to improve maternal and child health and provide
funds to train people who would be needed to implement
the plans. Thirty percent to 50 percent of women gave
birth in hospitals.
1925:
 Mary Breckenridge founded The Frontier Nursing
Service of Hyden, Kentucky.
 The first five nurse-midwifery schools were
developed to meet the needs of special populations,
which were isolated by geography, poverty,
language. Culture or race.
1930:
The American Board of Obstetricians and Gynecology
was established. During the 1930s, general practitioners
and specialists had a division of labor. Specialists such
as obstetricians sought to achieve ascendancy over the
non- physician specialists, such as midwives, in their
specialized areas. Specialists also sought to impress upon
the general practitioner the limit of his or her abilities.
1932: The MCA began to train qualified public health
nurses in midwifery.
1933: The White House Conference on Child Health and
Protection issued a report stating that maternal mortality
had not declined between 1915 and 1930, despite the
increase in hospital
Delivery, the introduction of prenatal care and more use
of aseptic techniques. The number of infant deaths from
birth injuries actually increased by 40 percent to 50
percent from 1915 to 1929 for one of two reasons: either
women received inadequate or no prenatal care or
excessive intervention took place and was often
improperly performed.
1935: Thirty-seven percent of births occurred in
hospitals.
1939: Fifty percent of all women and 75 percent of all
urban women delivered in hospitals.
The 1940: During World War II, more than 3 million
women were recruited for war- related jobs. 1944: Dr.
Grantly Dick-Read's book on natural childbirth was
published in the United States.
The 1950s 1960s:
1950s: Sister Mary Stella, CNM, introduced the concept
of "family-centered maternity care."
1950: Eighty-eight percent of births occurred in
hospitals.
1952: The Midwifery Section of the National
Organization for Public Health Nursing developed a
philosophy that emphasized pregnancy and childbearing
as a normal process, as well as a family-centered event
in growth and development. 1954: The polio vaccine was
developed.
1955: The American College of Nurse Midwives
(ACNM) was formed.
1955: Columbia-Presbyterian-Sloan Hospital in New
York City became the first mainstream medical
institution to open its doors to nurse-midwives.
1956:
 La Leche League was founded.
 In the postwar period, considerable money was
invested in medical research by private groups,
government, universities and insurance companies.
 The infusion of money into research and training
programs created new opportunities for medical
schools. Medical schools became sprawling,
complex organizations that now saw their missions
as threefold: research, education and patient care.
The 1960s-1990s:
The Kennedy administration took up the cause of
"community care" and turned it into a major federal
program in the 1960s.
1960:
 Ninety-seven percent of births occurred in hospitals.
 The birth control pill became available.
 Continuous electronic fetal monitoring was
introduced.
 The Children's Bureau began to fund selected nurse-
midwifery education programs.
 The Food and Drug Administration issued the birth
control pill for prescription in the United States.
1965:
 President Johnson on July 30 signed into effect
Medicaid and the Medicare Law.
 Adolescent (teen) pregnancy was on the rise and of
"epidemic" proportions until the mid-1970s.
 The use of medical services by the poor increased
sharply.
The 1970s
 In the early 1970s, the sense of crisis in health care
was accompanied by considerable optimism about
the possibilities for successful reform.
 By 1970, public officials began to regard the rising
costs of health care as too high and to doubt that the
investment was worth the return in health.
 Doctors made more money per hour in a hospital
visit than they did in an office visit.
 Only about 9 percent of medical students were
women. By the end of the 1970s, this had risen to 25
percent.
 Federal government began to support the
development of family planning services for the
poor. National Certification in nurse-midwifery
educational programs was in place.
 In the 1970s, the three branches of the U.S. military
service began to train and use nurse-midwives.
1971: The Farm was started in Tennessee by Stephen
and Ina May Gaskin, and Ina May began to attend births.
In 1975, she published her book, Spiritual Midwifery.
1972: The American Hospital Association adopted a
Patient's Bill of Rights.
1973:
 The ACNM stated, "The preferred site for childbirth
because of the distinct advantage to the physical
welfare of mother and infant is the hospital.”
 Roe vs. Wade guaranteed the right to terminate
pregnancy.
 The incentives that favored hospital care promoted
the neglect of ambulatory and preventive health
services. The incentives that favored specialization
also caused primary care to be neglected.
 The concept of "health care as a matter of right, not
privilege" captured the spirit of the time better than
any other single idea.
 Concerns of the new health rights movements
included such rights in health care as the
# right to informed consent,
# the right to refuse treatment,
# the right to see one's own medical
records,
# the right to participate in
therapeutic decisions,
# the right to due process in any
proceeding for involuntary commitment to a mental
institution.
  A movement developed to "deinstitutionalize" the
dependent and "demedicalize" critical life events,
such as childbirth and dying. The interest in hospices
and homebirths derived, at least in part, from a
desire to escape professional dominance as well as
from the desensitizing environment of the hospital.
 In the early 1970s, women's groups also began
learning gynecological self-care and encouraging a
revival of lay midwifery. Feminists argued that
medical care needed to be demystified and women's
lives demedicalized. They maintained that childbirth
is not a disease and that normal deliveries do not
require hospitalization and the supervision of an
obstetrician.
 The conflict over homebirth proved to be one of the
most bitter between the medical profession and the
women's movement. While no state forbade
homebirth, ACOG actively discouraged it. Doctors
who participated in homebirths by offering backups
in emergencies were threatened with loss of hospital
privileges and even their medical licenses.

1976:
The Division of Nursing began to fund nurse-midwifery
education programs.
Consumer criticism of aggressive medical management
of childbirth occurred within the social context of the
1960s and 1970s, including
  the civil rights movement,
 the women's movement,
 the consumer movement.
 the anti-war movement, and
 the back-to-nature and health food movement.
1979: The FDA convened a special meeting to discuss
results of a large national study that found lingering
behavior and motor deficits in children whose mothers
had received anesthesia in large doses of analgesics,
including Demerol. This press increased the interest in
natural childbirth and boosted the homebirth and
midwife movements.
1980: The ACNM developed guidelines for establishing
"alternative" birthing services and dropped a negative
homebirth statement (originally approved in 1971) in
favor of a statement that endorsed practice in all settings.
1982: The Midwives Alliance of North America
(MANA) began. One-third of its members were CNMs,
and the rest were other types of midwives.
1983: The Federal Trade Commission intervened in a
CNM-doctor case and negotiated an agreement that
prohibited the insurance company from any form of
discrimination against doctors who collaborate with
CNMs. The National Association of Childbearing
Centers was established.
1985:
 The AMA set out to create legislation and regulation
for all non-physician health care workers that would
 not allow these workers to practice independently.
The American Academy of Family Physicians
(AAFP) opposed nurse- midwifery and issued
formal statements to that effect in 1980, 1990 and
1993.
 AAFP stated the belief that all nurse-midwives
should work non-independently and that all
payments should go through the physician.
 During the 1980s, there was a widening and
deepening sense of crisis regarding the country's
ability to provide adequate and effective maternity
and other reproductive health care for all of its
women, Racial and ethnic minority women, rural
women, and women living in poverty and social
distress were particularly likely to have limited
access to effective care.
 Securing adequate and affordable professional
liability insurance was the most demanding
challenge faced by nurse-midwives during the
1980s.
 During the late 1980s, Congress enacted legislation
to make Medicaid available to more women and also
required states to make Medicaid-eligible women's
access to obstetric care equal to that of other women.
Also, most states began to pay more for maternity
care.
The 1990s
In the first half of the 1990s:
1. Physicians who were once disinterested in taking care
of poor, pregnant women became more willing to do so
as Medicaid increased fees paid for services and made it
easier to obtain these fees.
2. In areas where a large proportion of people were
enrolled in Managed Care Organizations (MCOs),
midwives who were not part of the MCOs became less
accessible to women who wanted midwifery care.
3. For a woman to have access to midwifery care, her
entire family might have to enroll in an organization that
provided it.
4. Directors of large MCOs tended to focus on the bottom
line-how to cut costs- and many did not understand the
nature and role of midwifery.
5. Although all MCOs were required to offer maternity
care, some smaller ones discouraged CNMs because they
attracted pregnant clients and because families during
childbearing use health care more.
6. Small MCOs needed generalists and were encouraging
family practitioners to re- enter obstetrics.
7. Some birth centers were bought out by MCOs, which
threatened to compromise their autonomy as well as the
type and quality of care they provided.
Midwifery from 1990s till now:
1992: The governor of New York signed a new
Professional Midwifery Practice Act into law in July.
The act defined midwifery as a profession with a specific
scope of practice and called for a board of midwifery to
regulate the profession.
1993: The first randomized, controlled trial to observe
the effects of epidural anesthesia was published. The
investigators stopped the study after they analyzed the
data from the first group and saw the high rate of
cesarean section. They determined it would not be ethical
to continue the study and reported their findings.

1994:
 The North American Registry of Midwives
(NARM) offered its first written examination to test
the knowledge needed for safe, beginning-level,
direct-entry midwifery practice to implement a
process to certify direct-entry midwives. It expanded
the process to include entry-level midwives in 1996.
 The managed care plans created turmoil for low-
income and Medicaid women. By moving women
from Medicaid programs into private hospitals and
managed care plans, the plans removed these
women from the very programs that were designed
to meet their specific needs.
 The move to managed care resulted in termination
of many special programs that used nurse-midwives
 to provide care to pregnant women with special
needs.
 CNMs in almost every state practiced under
different laws than those that affected other kinds of
midwives.
 The number of jurisdictions that grant prescriptive
authority to CNMs increased to 31 in 1995 from 14
in 1984.
 Federal law required all state Medicaid programs to
pay for care provided by CNMs.
1995: The AMA House of Delegates added a statement
that "The physician is responsible for the supervision of
Nurse Practitioners and other advanced practice nurses
in all settings."
1996: A coalition of American maternity care
organizations created Ten Steps for a Mother-Friendly
Childbirth Initiative.
Barriers Today
1. Despite many new, favorable laws, direct-entry
midwifery is still illegal in many states.
2. Licensing standards, where they exist, vary from state
to state, and there are no mandatory national standards
for entry into practice. As a result, there is no clear
definition of a "midwife" as a person who has met widely
accepted educational and competency standards.
3. The new MEAC and NARM processes are
competency based, neither requires completion of a
specified number of years of formal professional
education or requires an academic degree,
4. Americans generally associate an "apprenticeship"
with preparation for a craft or trade, rather than a
profession.
5. The MEAC/NARM accreditation and certification
processes are new, and the examination is an improved,
strengthened version of an earlier examination. Which
was known by the same name and did not require a
positive response.
6. There is very little reliable data about direct-entry
midwives and their practice. It is impossible even to state
with accuracy and confidence either the number of
direct-entry midwives who are practicing or the number
of births they attend.
7. Direct-entry midwives' sharp criticism of the medical
profession combined with their physical isolation from
the mainstream health care system has made it difficult
or impossible for many of them to acquire adequate
medical backup.
The United States provides the world's most expensive
maternity care but has worse pregnancy outcomes than
almost every other industrialized country.
Midwives are attending more births-5.5 percent in 1994,
compared with 1.1 percent in 1980.
The cesarean section rate is falling, from 25 percent in
1988 to 21 percent in 1995,
The use of forceps is declining, from 5.5 percent in 1989
to 3.8 percent in 1994.
Labor was induced in 14.7 percent of women in 1994, up
from 9 percent in 1989.
Eighty-five percent of women had electronic fetal
monitoring in 1994, up from 68 percent in 1989.
Adrian Feldhusen is a New Hampshire Certified
Midwife and CPM serving southern New Hampshire and
northern Massachusetts. She owns The Birth Cottage, a
free standing birth center. Adrian has a Bachelor of
Science degree in community and human services, with
a concentration in maternal and perinatal health, through
the State University of New York. In 1992 she began her
lifelong quest into midwifery. Her services include full-
scope midwifery and homebirth, birth center birth,
counseling for miscarriage and loss, breastfeeding
consultation, and well-woman services

B) HISTORY OF DEVELOPMENT OF MCH

SERVICES IN INDIA:
Pregnancy is the vital event in the life of a woman. It
needs special attention from the time go conception to
the postnatal stage. In ancient time, it was in practice in
India, the untrained dais, (maids) belonging to the lower
community were mostly responsible for conducting
deliveries. They were unclean in their habits. Even today
a large percentage of deliveries are conducted by these
women. This system leads to various complications and
increased maternal and infant deaths. Those were the
days when more than 2 lakh women used to die due to
childbirth or related facts and diseases.

Indian midwifery has three sections. They are

1. Midwifery in India before independence
2. Midwifery in independent India
3. Present and future midwifery in India

MIDWIFERY IN INDIA BEFORE

INDEPENDENCE

In ancient India, care of women and practice of

midwifery were totally in the hands of indigenous
village “dais”.
These indigenous dais, not only helped during
childbirth but also acted as consultants for any
condition of the mother related to birth.
When medical missionary women from England
came to India, the first striking observation they
made was that, since dais were unable to deal with
difficult deliveries and pregnancies, the maternal
and neonatal mortality were high.
The first training school for dais was started in 1877
by Miss Hewlett, an English missionary of the
zenana missionary society.
However, the training dais was not taken up by the
government of India (GoI) till1900 when a fund was
 established by Lady Curzon to improve the
condition of childbirth in the country.
But before that, in 1872, a handful of Indian
Christian nurses were trained for two years at Delhi.
In 1899 the zenana bible and medical mission
started the training of nurses, but untill1893 there
was no generally accepted scheme of training in the
hospitals.
In 1918 with the help of dufferin fund, lady reading
health school was established to train auxiliary
nurse midwives (ANMs).
In 1926 the madras registration of nurses and
midwives act was passed to promote the role of a
registered midwife for service during childbirth.
In 1936 dufferin fund sanctioned grant to a number
of dufferin hospitals to build hostels, supply
teaching materials and employ qualified sisters in
nursing schools.
Thus dufferin fund helped in raising the standards
of nursing and midwifery in India. In fact prior to
independence, midwifery training started as a
separate course, in India. Young girls at the middle
school level (8th) were selected to undergo this
training.
MIDWIFERY IN INDEPENDENT INDIA
In 1946, the bhore committee laid stress on the
need for qualified midwives, health visitors,
and the training of dais.
In 1955, the Shetty committee recommended
the training of auxiliary nurse midwife in health
centers for maternal and child health services,
provided there were adequate health visitors to
supervise them.
In 1959 bishoff, a technical consultant
supported the training of two types of nursing
personnel ANM and general nurse midwife
(GNM-3 years and midwifery- 1 years).
In 1947, the first step the Indian nursing council
tooks after its inception was to combine the
nursing and the midwifery courses into a single
course.
The course was designed to be of three and a
half years duration, with the entry qualification
being 10th class.
In 1975 the kartar Singh committee
recommended shortening of the two years
course of ANM to one and a half year and entry
after class 10th.
These ANM were designated as female health
workers. They were specially trained in
midwifery and child health care services. GoI
also invested heavily in the training of dais.
PRESENT AND FUTURE OF MIDWIFERY
IN INDIA
The presence of a skilled midwife at birth is
the single most important factor for
achieving safe motherhood (WHO).
The number of midwives available as per
population is important indicator of the
maternal health status in a country.
The maternal health status of women and
maternal mortality are closely related to the
presence of trained attendants at birth.
As the percentage of births attended by
trained personnel goes up, the maternal
mortality ratio goes down.
In India there are the following cadres of
midwives:
1. The trained nurse midwife (RN, RM): who
has undergone a diploma (Diploma in
general nursing and midwifery), which of
three and a half years duration. Or a degree
nurse who has done B.SC. (HONORS)
nursing, which is of four years duration.
2. The ANM, who designated at the multi-
purpose health worker (female), is registered
as a midwife.
Presently, this is a two years course with
entry classification being 12 th class.
India has a huge cadre of ANMs who are
educated and trained in midwifery.
 3. Skilled birth attendant (SBA) refers
exclusively to people with midwifery skills
(e.g. doctors, nurses, midwives), who have
been trained to get proficiency in the skills
necessary to manage normal deliveries, and
to diagnose, manage, or refer complications
to all levels of health care settings.
Midwifery skills are defined as a set of
cognitive and practical skills that enable the
individual to provide basic health care
services throughout the natal continuum
period and also to provide prompt actions in
emergencies including life saving measures,
when required.
DUFFERIN FUND:
It came into existence due to the interest and initiative of
a missionary doctor, Ms.Bielby. Who came to India in
1875 and opened a dispensary, and then a small hospital
at Luck now. In 1881, when Ms. Bielby was going to
England for higher study, the Maharaja of Punna
requested her to visit her old patient the Maharani of
Punna. During the visit, the Maharani gave her a gold
chain with a locket. Inside that she put a writing stating
the suffering of Indian women when they were in
childbirth and faced complications. She was asked to
deliver the chain personally to the Queen of England. On
receiving that message the Queen asked many questions
and enquiring about conditions and suffered of Indian
women.
When Lay dufferin came to India in 1883, the Queen
commanded her to arrange medical aid for women of
India. This leads to creation of dufferin fund to start
maternity hospitals and training of nurses and midwives
all over the country. With the help of this fund the Lady
Reading Health School was established in 1918 at Delhi
to train Health Visitors for providing public health
services, maternal and child health services and to
supervise auxiliary nurse midwives.
It was difficult in the early days to obtain girls for
training, but gradually Indian girls gained confidence and
came forwarded for training in the dufferin Hospitals
which were created for maternal and child care.
Benefits of dufferin fund:
 Sanctioned grants to number of hospitals to build
hostels
 Supplies teaching materials
 Employs qualified sisters in nursing schools Helps
in raising the standards of nursing and midwifery in
the country
 Increased the availability go training facilities in
maternity hospitals
 Encouraged hundreds of Indian women to join
nursing and midwifery training.
In 1885, Queen Victoria founded the "Lady Dufferin
fund" and established "Zenana Hospitals" in various
parts of the country. In 1940 there were about 400
dufferin Hospitals all over the British India.
In 1921, Maternal and child health services were first
organized by a committee of "The lady Chelmsford
League" which collected funds for child welfare and
established demonstration services on all India bases.
In 1931, Indian red Cross Society started maternity
centers in different parts go the country through its
"Maternal and Child Welfare Bureau".
In 1946, the Health survey and development committee
emphasized the need for maternal and child welfare
services and recommended that priority should be given
for MCH services in the National Health Services.
The constitution of India envisages the establishment of
new social order based on equality, justice and dignity of
the individual. In post-independence period, the Union
Government has created a post of an adviser for MCH at
the directorate General of Health services to look after
such services in the Union. International Organizations
like WHO and UNICEF, also began to help the nations
in improving MCH services to reduce the MMR and
IMR.
After Independence during the last years much efforts
have been made under planned development
programmes and the health and related sectors.
First five year plans
More than 200 MCH centers were started in different
states with the help of Union Government and
International Organizations,
Second five year plans
MCH services were integrated with the services of
PHCs. More staff such as public health nurses, lady
health visitors, and midwives, "dais", etc., were trained
and appointed to cater to the needs of MCH services all
over India. The number of the training schools for ANMs
was also increased to 470 along with the required number
of seats gradually all over the country.
During late sixties, the Government of India realized that
the children and the women of childbearing age
contribute 63 percent of the total population and they are
vulnerable groups of population. The Union Ministry of
Health and family Planning (1969), introduced the
following schemes for the proper care of the mother and
child health.
1. Immunization of Infants and preschool age children
against diphtheria, pertussis and tetanus.
2. Immunization of expectant mother against tetanus.
3. Prophylaxis against nutritional anemia of mother and
child
4. Prophylaxis against blindness in children caused by
vitamin 'A' deficiency.
The various reasons for considering mothers and
children, as the most vulnerable group of the society, as
one unit for providing health services are as follows.
1. since the conception, the development of fetus (280
days takes place in the mother's womb and receives all
nutrition and oxygen from the mother.
2. Healthy mother brings forth a healthy child. Healthy
mother can avoid premature birth, still birth or abortion.
3. Certain habits and disease conditions of expectant
mother will affect the child health i.e., taking drugs,
syphilis, German measles, etc.
4. After birth, the child is completely dependent upon the
mother for various reasons at least for a year; separation
of child from mother hinders the growth and
development
5. Child learns may self-care tasks from the mother.

CONTEMPORARY PERSPECTIVES
INTEGRATIVE HEALTH CARE:
Integrative health care encompasses complementary and
alternative therapies in combination with conventional
western modalities of treatment. Many alternative
healing modalities offer human-centered care based on
philosophies that recognize the value of the patient's
input and honor the individual's beliefs, values and
desires. Patient's often find that alternative modalities are
more consistent with their own belief systems and also
allow for more patient autonomy in health care decisions.
Use of complementary and alternative therapies is
increasing rapidly in Canada. Throughout the world, the
use of traditional medicine presents unique challenges in
terms of policy, efficacy, accessibility and utilization.
Five Types or Classification of complementary or
alternative therapies:
1. Alternative Medical systems (Homeopathic and
naturopathic medicine, traditional Chinese medicine)
2. Min-Body interventions (Patient support groups,
cognitive-behavioral therapy. meditation, prayer, art,
music, dance)
3. Biologically based therapies (Herbs, foods, vitamins)
4. Manipulative and Body based methods (e.g.,
Chiropractic or osteopathic manipulation, massage)
5. Energy therapies (eg, therapeutic touch, use of
electromagnetic fields)
CHILDBIRTH PRACTICES:
Prenatal care may promote better pregnancy outcomes
by providing early risk assessment and promoting
healthy behaviors such as improved nutrition and
smoking cessation. In 2003, 84,1% of all women
received care in the first trimester and 3.5% had late or
no prenatal care. There is disparity in use of prenatal care
in the first trimester by race and ethnicity:
 Non-Hispanic whites (89%)
 Non-Hispanic blacks (76%)
 Hispanic (77.4%)
Women can choose physicians or nurse-midwives as
primary care providers. In 2002,
 physicians attend 91% nurse-midwives attend 8% of
all births
 Hospital births accounted for 99% of births
 Home births 65%
 Free standing birth center 27%
 In clinics or doctors' choices 2% out of hospital
deliveries
In 2003, Caesarean births increased to 27.6% in United
States, whereas the Vaginal births after Caesarean births
(VBACs) declined to 10.6%
Changes are occurring in the conduct of the
second stage of labor (from 10 cm dilatation of birth of
the baby); Positions are varied, with more emphasis on
upright posture. The rates of episiotomy are declining,
resulting in fewer severe perineal lacerations. Midwives
perform ewer episiotomies than of physicians.
The method of analgesia varies, depending on the
condition and choice of the mother and the preferences
of the providers. Mothers typically are awake and aware
during labor and birth.
Percentage of Women Undergoing Various Obstetric
Procedures:

Procedure Percent
Electronic fetal monitoring 85.2
Ultrasound 68.0
Induction of labour 20.6
Stimulation of labour 17.3
Tocolysis 2.1
Amniocentesis 2.0

With family-centered care, fathers, partners,

grandparents, siblings, and friends may be present for
labor and birth. Fathers or partners may be present for
cesarean births. Father participation may include cutting
the umbilical cord. Doulas- trained and experienced
female labor attendants- provide a continuous, one-on-
one, caring presence throughout the labor and birth.
Newborn infants remain with the mother and are
encouraged to breastfeed immediately after birth. Parents
participate in the care of their infants in nurseries and
neonatal intensive care units, Kangaroo care, parent
holing an infant skin-to- skin, is supported for preterm
infants.
Childbirth education and parenting classes encourage the
participation of a support person, teach breathing and
relaxation techniques, and give general information
about birth, infant development, and parenting
In some cases a women labors, gives birth, and recovers
in the same room (labor- delivery-recovery); she may
stay in the same room for the entire birth experience
(labor- delivery-recovery-postpartum). Instead of having
one nurse care for the baby and another nurse care for the
mother, some hospitals have one nurse care for both the
mother and baby (couplet or mother-baby care). In some
hospitals, central nurseries have been eliminated, and
babies 'room-in" with their mothers. Many hospitals use
lactation consultants to assist mothers with
breastfeeding.
Discharge of a mother and baby within 24hours of birth
has created a growing need for follow-up or home care.
In some settings, discharge may occur as early as 6 hours
after birth. Legislation has been enacted to ensure that
mothers and babies are permitted to stay in the hospital
at least 48 hours after vaginal birth and 96 hours after
cesarean birth. Focused and efficient teaching is
necessary to enable the parents and infant to make a safe
transition from hospital to home.
Neonatal security in the hospital setting is of concern.
Cases of "baby-napping" an woe sending parents’ home
with the wrong baby have been reported. Security
systems are common in nurseries and mother-baby units,
and nurses are require to wear photo identification of
some other security badge.

CERTIFIED NURSE-MIDWIVES:
Certified nurse-midwives (CNMs) are registered nurses
with education in the two disciplines of nursing and
midwifery. Certified midwives (direct-entry midwives)
are educated only in the discipline of midwifery. In the
United Stated, certification of midwives is through the
American College of Nurse-Midwives, the professional
association for Midwives is the professional association
for midwives in the United Kingdom.
Many national associations belong to the International
Confederation of Midwives. Which is compose woe 83
member associations from 70 countries in the Americans
and Europe, Africa and Asia-Pacific region.
VIEWS OF WOMEN:
Women must be viewed holistically and in the context in
which they live. Their physical, mental, and social
factors must be considered because these interdependent
components influence health and illness, even the
language health care professionals use to describe
women and their problems news to be examined. For
example, practitioners describe women who have an
"incompetent cervix", who "ail to progress", or who have
an "arrest" of labor. They may describe a fetus as having
intrauterine growth "retardation". They also "allow"
women a "trial" of labor. Rea suggests that practitioners
use phrases such as "women who have recurrent
premature dilation of the cervix or "fetuses whose
intrauterine growth has been restricted". There is a
movement to refer to spontaneous pregnancy loss as a
"miscarriage" instead of the more politically charged
"abortion", especially when talking to patients.
BREASTFEEDING IN THE WORKPLACE:
Women are a significant proportion of the workforce.
Companies are recognizing that it is good business to
retain good employees and are making provisions for
women returning to work after childbirth. Lactation
rooms that provide space and privacy for pumping are
available at many work sites and on college campuses. In
some instances, breastfeeding women bring their babies
to work. Since 1999, by law, women may breastfeed in
federal buildings and on federal property. Some states
have enacted legislation to ensure that mothers can
breastfeed their babies in public places. These efforts
may help mother’s breastfeed longer and meet the
recommendation of the American academy of Pediatrics
that breastfeeding continue for at least 1 year.
FAMILY LEAVE:
The family and Medical Leave Act of 1993 provides for
up to 12 weeks of unpaid leave to eligible employees for
birth, adoption, or foster placement: for care of a child.
Spouse, or patent who is seriously ill; or for the
employee's own illness. This is of great benefit to women
because they are usually the primary caretakers of family
members.
VIOLENCE:
Violence is a major factor affecting pregnant women.
This includes battering (which may increase during
pregnancy), rape or other sexual assaults, and attacks
with various weapons. Approximately 8% of pregnant
women are battered. Violence is associated with
complications of pregnancy such as bleeding,
miscarriage, and preterm labor and birth
HIV AND AIDS IN PREGNANCY AND THE
NEWBORN:
Cases of perinatally acquired human immunodeficiency
virus (HIV) infection and AIDS peaked in 1992; since
then the rate of AIDS among infants has continued to
decline. Treatment with zidovudine of mothers who
tested positive for HIV before giving birth has resulted
in a dramatic decrease in the number of infants infected
with the virus; highly active antiretroviral therapy
(HAART) and elective cesarean birth reduce the rate of
mother-to-child transmission of HIV (European
Collaborative Study, 2005). Universal HIV testing and
access to quality prenatal care will contribute to reducing
the transmission of HIV and prolonging survival. For
women in labor who have how no prenatal care, rapid
HIV testing is available.
HIGH-TECHNOLOGY CARE:
Advances in scientific knowledge and the large number
of high risk pregnancies have contributed to a health care
system that emphasizes high-technology care. Maternity
care has been extended to preconception counseling,
more and better scientific techniques to monitor the
mother and fetus, more definitive tests for hypoxia and
acidosis, and neonatal intensive care units. The
electronic medical record is being used. Virtually all
women are monitored electronically during labor despite
the lack of evidence of efficacy of such monitoring
Telemedicine is an umbrella term for the use of
communication technologies and electronic information
to provide or support health care when the participants
are separated by distance. Telemedicine permits
specialists, including nurses, to provide health care and
consultation when distance separates them from those
needing care. It includes distance learning, virtual home
visits and remote monitoring of the infant after
discharge. These technologic advances have also
contributed to higher health care costs. Nurses must use
caution and prospective planning and assess the effect of
the emerging technology.
COMMUNITY BASED CARE:
A shift in settings, from acute care institutions to the
home, has been occurring. Even childbearing women at
high risk are cared for in the home. This has accepted the
organizational structure of care, the skills required to
provide such care and the cost to consumers.
Home Health Care:
Home health care also has a community focus. Nurses
are involved in caring for women and infants in homeless
shelters, in caring for adolescents in school-based clinics
and in promoting health at community sites, churches
and shopping malls. Nursing Education curricula are
increasingly community based.
INCREASE IN HIGH RISK PREGNANCIES:
The number of high risk pregnancies has increased,
which means that a greater number of women are at risk
for poor pregnancy outcomes. Escalating use has
contributed to higher incidences of prematurity, LBW,
congenital defects, learning disabilities, and withdrawal
symptoms in infants
Alcohol use in pregnancy has been associated with
miscarriages, mental retardation, LBW and fetal alcohol
syndrome.
The two most frequently reported maternal medical risk
factors are hypertension associated with pregnancy and
diabetes. Multiple births now account for 3.2% of all
births. The caesarean birthrate increased to 27.6% of all
births in 2003, with primary caesareans rising to 19.1%
and VBACs dropping to 10.6%. Births of babies born
vaginally assisted with forceps or with vacuum
extraction decreased to 5.9%.
HIGH COST OF HEALTH CARE:
Health care is one of the fastest growing sectors. The
United States spends proportionately more on health care
than any of the other 190 countries that make up the
world Health Organization,
Contributing Factors:
 A shift in demographics
 An increased emphasis on high-cost technology and
 Liability costs of a litigious society
Most researchers agree that the cost of caring for the
increased number of LBW infants in neonatal intensive
care units contributes significantly to the overall health
care costs. Midwifery care has helped contain some
health care costs. Nurses must become involved in the
politics of cost containment because they, as
knowledgeable experts, can provide solutions to many of
the health care problems at a relatively low cost.
LIMITED ACCESS TO CARE:
Early postpartum discharge programs also are used to
reduce costs. Barriers to access must be removed so
pregnancy outcomes can be improved. The most
significant barrier to access is the inability to pay. Lack
of transportation and dependent child care are other
barriers. In addition to a lack of insurance and high costs,
a lack of provides for low-income women exists. Many
physicians either reuse to take Medicaid patients or take
only a few such patients. This presents a serious problem
because a significant proportion of births are to mothers
who receive Medicaid.
INCREASED EMPHASIS ON PREVENTIVE
CARE:
A generally accepted theory is that it is better to keep
individuals well than to restore health after they have
become ill. Counseling parents on ways to keep their
homes safe for children is an important form of illness
prevention in maternal and child health nursing.
Research supporting the acts that accidents are still do
not receive preconceptual or prenatal care are testaments
to the need for much more anticipatory guidance in this
area.
HEALTHY PEOPLE GOALS:
Healthy People 2010 is the nation's agenda for improving
health. It has two overarching goals:
1) To increase the quality and years of healthy life and
2) To eliminate health disparities
Within Healthy people 2010 are 467 objectives to
improve health, which are organized into 28 specific
focus areas including one related to maternal, infant and
child health.
Healthy People 2010, focus Area 16, Maternal Infant,
and Child Health:
Goal: Improve the health and well-being of women,
infants, children and families
# Fetal, infant and child deaths
# Maternal death and illness
# Prenatal care
# Obstetric care
# Risk factors
#Developmental disabilities and neural tube defects
#Breastfeeding, newborn screening, and service systems
CURRENT TRENDS IN MIDWIFERY AND
OBSTETRICAL CARE: (slideshare, n.d.)
1. MIDWIFERY AS A SEPARATE
PROFESSION: Many countries have taken up
midwifery as a separate like nursing profession.
2. ENTRY IN MIDWIFERY PRACTICE – A
DEGREE IN MIDWIFERY FROM
UNIVERSITY: To make them more competent and
help them to perform high quality of maternal and
child health care. Independent nurse midwifery
practice.
3. MIDWIFERY MODEL OF CARE AND
REJECTION OF MEDICAL MODEL OF
CARE: Midwifery model is more women centered,
personalized care provided by midwives. Midwives
believes that pregnancy& childbirth normal
physiological phenomena& not pathological as in
medical model.
4. EPDURAL ANALGESIA IN LABOUR: It
provides better relief in labour during caesarean
section.
5. POSITION DURING SECOND STAGE OF
LABOUR: Upright or sitting position is good for
childbirth & lithotomy position has been banned.
CURRENT TRENDS IN MATERNAL-NEWBORN
HEALTH CARE
Family Centered Care: (trends, n.d.)
 Childbirth came to be viewed as a safe and natural
process as maternal and infant mortality rates began
to fall.
 Many women began to insist on natural childbirth
methods that allowed nature to take its course with
minimal medical involvement.
 Some women voiced the desire for increased control
over decisions about the timing and extent of
interventions during labor and birth.
 These efforts throughout the 1970s, 1980s, and
1990s led to family- centered maternity care, which
eventually became the norm for American hospitals.
 Physicians and other health care professionals began
to respect the rights of women to participate in
planning the type of care to be given during labor
and birth.
 Husbands were allowed first and then encourage to
participate in the birth process
 Siblings were allowed greater access to their mother
and the new baby.
 Birthing rooms and later labor, delivery and
recovery replaced the old assembly-line room, to a
recovery room.
 Couplet care in which the mother and newborn
remain together and receive care from one nurse,
became the norm for postpartum care
Regionalized Care:
 Providing high quality medical care for the at-risk
patient necessitated transporting the pregnant
woman or the newborn to medical teaching centers
with the best resources for diagnosis and treatment.
 The most intricate and expensive services and the
most highly specialize personnel were made
available in the centralized location: Perinatologists,
neonatologists, pediatric neurologists, neonatal
nurse practitioners, and clinical nurse specialists.
 In these large regional centers are found geneticists,
at-risk antenatal units, neonatal intensive care units,
computed tomography scanners, and other highly
specialized equipment and units.
 Regionalized care often takes the maternity and
neonatal patient far from home.
 Measures are taken to keep the hospitalization as
brie as possible and the family close and directly
involved in the patient's care.
 Many of these regionalized centers (tertiary care
hospitals) have accommodations where family may
stay during the hospitalization of the pregnant
women and the neonate.
ADVANCES IN RESEARCH: (wikipedia, n.d.)
Huge technological and scientific advances were made at
the same time the movement for family- centered care
was gaining momentum.
It became possible to save premature and low-birth
weight infants who previously would not have survived.
Diagnostic techniques were perfected.
Surgical techniques to intervene on the fetus while in
utero were developed.
New research and techniques have made it possible to
detect and treat children born with congenital problems
and disorders almost immediately after birth.
Two areas of intense scientific inquiry are the prediction
and prevention of preterm labor and the causes,
prevention, and treatment of pregnancy-induced
hypertension, a condition exclusively found in
pregnancy marked by high blood pressure, edema, and
loss of protein in the urine.
Gene therapy is used to treat certain immune disorders.
Scientific are studying ways to prevent and treat genetic
disorders with gene therapy, which likely will be
possible in the near future. Many animal, human, and
stem cell studies are being done to better understand and
treat a variety of obstetric disorders.
Much progress has been made in understanding and
treating infertility.
Other examples of current studies include the
identification of genes that are responsible for the unique
characteristics of Down's syndrome and therapies to treat
intrauterine growth retardation (IUGR), a condition in
which the fetus ails to gain sufficient weight
Bioethical Issues:
An ethical issue is one in which there is no one "right"
solution that applies to all instances of the issue
Recent scientific and medical advances have raised,
bioethical issues that did not exist in times past.
Examples of bioethical issues that are present in our
world today include the Human Genome Project,
prenatal genetic testing, surrogate motherhood, and
rationing of health care.
The Human Genome Project (HGP) was started in 1990
with the purpose of studying all of the human genes and
how the y unction. New concepts and ideas regarding
many aspects of health and disease emerge as the project
continues. Identification of gene mutations in people
who may be carriers of genetic disorders or who may be
are risk for developing inherited disorders later in life has
been a big part of the research innings in the project.
Today it is possible to know many things about a child
before the child is born. Ultrasound can reveal the gene
roe the fetus and certain abnormalities early in
pregnancy. Amniocentesis and chorionic villous
sampling show the entire genetic code of the fetus. In this
way, many chromosomal abnormalities can be diagnosed
during the first trimester. Decisions can be made about
continuing with the pregnancy or preparing to cope with
a child who has a genetic disorder. Some parents want to
know everything possible before the child is born,
whereas others do not wish to interfere with the natural
order of things and decline any type of prenatal testing.
Many ethical questions can be raised regarding prenatal
testing.
- Is it right to end a pregnancy because a child
has a mild genetic abnormality.
- Will we become a society in which a child
can be chosen or rejected for life based on his or her
genetic code?
- Is it right to bring a child into the world with
a severe effect, which may cause him and his caregivers
untold pain and suffering?
- Is it OK to make life and death decisions
based on quality of life?
- Or is any form of life sacred regardless of
the quality?
These and other questions have been raised in light of
technology that makes prenatal diagnosis possible.

- Surrogacy is an arrangement whereby a woman or

a couple who is infertile contract with a fertile
woman to carry a child.
- A phenomenon that some have referred to as
"rationing of health care" is on the rise. On the one
hand, there have been enormous advances in
 knowledge, technology, and the ability to intervene
to change outcomes.
- On the other hand, individuals who live in poverty
are less likely than persons of higher socioeconomic
status to have access to these treatments and cures.
Demographic trends:
 Several demographic trends are influencing the
delivery of maternal-newborn health care in the
United States.
 The aging of society and the tendency of American
families to have fewer children have caused a shit in
focus from the needs of women and newborns to
those of the elderly.
 This trend has shifted fund allocation away from
health care programs and research that enhance the
health care of women and children.
 Nurses and other health care providers are expected
to provide culturally appropriate care
 The use of nontraditional methods of healing and
over-the counter herbal remedies must be assessed
and integrated into the plan of care
 More and more nurses are expected to accommodate
the unique needs of these populations.
Poverty:
 One social issue that greatly influences maternity
and newborn care
 These women are less likely to have access to
adequate prenatal care
  They are at risk for substance abuse and exposure to
diseases such as Tuberculosis, human
immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS), and
other sexually transmitted infections.
 Each of these factors are been linked to averse
outcomes for childbearing women and their children
Cost Containment:
 It refers to strategies developed to reduce
inefficiencies in the health care system
 Inefficiencies can occur in the way health care is
used by consumers.
 Inefficiencies also can relate to the setting in which
health care is given
 Inefficiencies also can exist in the way health
services are produced.
Cost Containment Strategies: (12)
There is no dispute that health care costs continue to
increase at a rate out of proportion to the cost of living.
This has challenged local, state and federal governments;
insurance payers, and providers and consumers of health
care to cope with skyrocketing costs while maintaining
quality of care
Some major strategies that have been implemented to
help control costs include
1. Prospective Payment Systems - Predetermines rates
to be paid to the health care provider to care for patients
with certain classifications of diseases. This system tens
to encourage efficient production and use of resources
2. Managed care - System that integrates management
and coordination of care with financing in an attempt to
improve cost effectiveness, use quality, and outcomes
3. Capitation - One method of manage care plans have
used to reduce costs
4. Cost sharing - Refers to the costs that the patient
incurs when using his health insurance plan
5. Cost shifting - Strategy in which the cost of providing
uncompensated care for uninsured individuals is passed
onto people who are insured.
6. Alternative delivery systems - another way to control
costs is to provide alternative delivery system.

CONCLUSION:
The history of midwifery in ancient days and now in
various countries reveals the importance of the maternal
and child health services in various aspects and its help
for the foundation for the practice of nursing depends
upon the utilization of the nursing process in all aspects
of patient care. Nowadays the goal for women’s health
has changed from treatment of problem to maintenance
of wellness, which promotes self-care through education
and support.
BIBLIOGRAPHY:
Book Reference:
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medicine", Bhanot publishers, Jabalpur, 19h
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No.: 601-608
3) Myles, Textbook of Midwives". Churchill
Livingstone, London, 14th Edition, 2003, Pg. No.:
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4) Adele Pillitteri, "Maternal and Child Health
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5) Wong and Perry, "Maternal Child Nursing Care",
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2-15
6) Robert K. Greasy," Management of Labor and
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Publications, New Delhi, 2004, Pg. No: 213-217
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Students", Jaypee Publications, New Delhi, 2002,
Pg. No.: 1-8
Journal Reference:
1. Dynamics of the twenty- first- century midwifery
practice, June 2023
2. Traditional midwives in social reproduction:
changing landscape in 20th century Bengal,
june2020
3. Nursing Outlook
4. Kerala Nursing forum, Maternal mortality",
September 2019,
5. Midwifery and midwives: A Historical analysis,
December 2013
6. Contemporary midwifery practice: art, science or
both? September 2015
7. History of midwifery profession in the republic of
Croatia, June
a. 2022
8. Global maternal health. 1. Traditions and birth in the
Philippines, June 2017
9. Historical narrative of the development of
midwifery education in Indonesia, February 2023
Net Reference:
www.midwiferytoday.com
www.Google.com
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www.wikipedia.com
www.bjog.com
www.scribd.com
www.slideshare.com