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India – Bring the missing midwives back #healthcare

Illustration: Deepak Harichandan

Illustration: Deepak Harichandan

The development of professional midwifery is key to ensuring better quality maternity care.

The natural birth process is generally safe for both mothers and babies. However, to try natural labour while certain risk factors and medical conditions are present may be dangerous. When medically indicated, caesarean sections save lives. On the other hand, unnecessary caesareans carry with them the risks of major surgery and premature births, without any commensurate health benefits to the mother.

But the overuse of C-sections is today a cause for concern. C-section rates are rising around the world, including in several States and urban areas in India. According to the National Family Health Survey 2015, the figure in States such as Telangana was as high as 63 per cent, followed by 48 per cent in Andhra Pradesh. This calls for a fundamental shift in the way maternity care is being organised.

The rate of C-sections is an indicator of the quality of maternal and child health care in general and of obstetric care in particular. Very low rates indicate non-availability of obstetric care, while very high rates indicate one or more of several maladies in the system. The first would be poor quality and reliability of basic emergency obstetric care for normal deliveries. C-sections can be performed only in medical institutions and hospitals equipped for surgery. Doctors skilled in comprehensive emergency obstetric care ought to be available. When women, their relatives as well as health workers are faced with doubtful competence, poor availability, inadequate resources for normal deliveries, the C-section, with the attendant aura and reassurance of a technological intervention, presents itself as an obvious option.

Professional midwife-led maternity services backed by obstetrician support achieve similar or better results compared to purely obstetrician-led maternity services. Hence, the way obstetric care is organised affects the quality and cost of maternal and child care services.

Midwives play a central role in the organisation of maternity services in countries such as Australia, Denmark, France, Sweden, the Netherlands, New Zealand and the U.K., all of which have low maternal mortality at less than 10 per 100,000 live births. Here, perinatal mortality and C-section rates among women primarily cared for by midwives with back-up physician services, are low.

The National Maternity Hospital in Dublin is one of the best examples. There, midwives are responsible for the management of women in labour, including private patients delivered by midwives with the personal physician in attendance. Midwives are involved in training physicians.

Training diluted

Unfortunately, various programmes and policies have diluted midwifery training, marginalised the midwifery role of nurses, and gradually obliterated midwifery models of care. Obstetricians as a professional group have no time to seriously ponder about the organisation of obstetric care. For example, the official journal of the Federation of Obstetric and Gynaecological Societies of India does not have a section on this.

Ambiguity in the role of midwives has muddled policy and confused action. Professional midwifery is often confused with traditional dais. Thus, any discussion on the development of midwifery services ends up with the skill upgradation of traditional dais and home births. At best, midwifery is viewed as a part of general nursing. The female multipurpose health worker is primarily trained as an auxiliary nurse midwife.

Countries with a long tradition of midwife-led care help us identify the key features of professional midwifery. A survey of midwifery systems in such countries found that they have bachelor degree level midwifery courses spread over three to four years of study consisting of 50 per cent theoretical and 50 per cent clinical work. Internships and guided experience of 40 to 60 births is the usual criteria for a midwifery licence. Licensed midwives usually practise in hospitals, with admitting privileges and authority to prescribe.

The development of professional midwifery will be a win-win for all. Good maternal and child care meets almost half of the healthcare needs within close proximity of any community. Professional midwives backed up by doctors, as needed, will be well-qualified to render good quality maternal and child care. We are still struggling with poor availability of MBBS doctors in rural areas. Rendering high-quality and reliable maternity care entirely manned by doctors is an unrealistic goal. Going by the differences in availability of doctors and allied health professionals in remote and rural areas, we can predict that professional midwives will be more accessible and enhance the quality of maternal and child care.

Time to train

The long duration required to develop a cadre of professional midwives is often an alibi to postpone action. Well, we were not deterred by such considerations to develop the cadre of physicians. And yet we have procrastinated for more than 60 years to even recognise the need for professional midwifery.

In any case, here are some practical steps to get cracking. First, develop mid-career midwifery courses for registered nurses wanting to branch off into full-time midwifery. Then revise maternity service staffing norms with a higher number of midwives. Eventually, confer admission privileges and prescription authority to midwives and nurse-midwives, for maternity and related services. Finally, introduce bachelor and master’s degree programmes in midwifery to sustain human resources for high quality and accessible maternal and child care.


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