Celebrating International Nurses Day by revisiting one of India's oldest professions: Midwifery
It’s 'International Nurses Day', the 200th anniversary of Florence Nightingale’s birth, and we believe that it's time we recognized the myriad roles nurses and midwives play in our community.
Re-orienting healthcare delivery and bringing it closer to people's homes has been advocated for as far back as 1946 when the Bhore committee released its famed report. A key strategy in this process suggested to achieve this re-oreintation was the institution of frontline health-workers such as midwives.
Yet, India has long harbored an irrational fear of midwives. To some, it is a reminder of the village dais of yore—who were untrained, unlike proper midwives or trained dais—with their unhygienic practices and unscientific opinions. Understandably, therefore, many women are unsure of the quality of care they might receive from a midwife, compared to a doctor.
But, the fear is unwarranted. In a country like India where over 16% of all rural births are still initiated at homes, midwives hold great promise. In fact, there is growing evidence that trained midwives are as good as doctors in taking care of pregnant women and in overseeing uncomplicated births.
Midwives “who are educated and regulated to international standards,” according to the World Health Organization, can provide 87% of the essential care for women and newborns.
When it comes to health policy, India often strangely lunges at the mistakes of the US, ignoring better inspirations from Europe. For care of pregnant women too, we went with the American model of dominance of obstetrics and “medicalisation” of childbirth. The Indian health system, like the American, gradually phased out the intimate role of midwives in maternity care, in an improperly planned attempt to decrease deaths of mothers and babies during childbirth (maternal and neonatal mortality).
As for apprehensions about quality of care, midwifery is a profession, and like any other profession (including obstetrics), there will always be some members whose expertise is weak. Besides, if the government and administrators take care not to dilute the quality of midwifery education (for which there exist strict global standards) and the regulation of the practice, well-educated and proficient midwives can solve an important problem in women’s health.
Yet, it appears that Indian policymakers, perhaps advised mainly by doctors instead of representative teams with patient advocates and other health professionals (nurses/midwives, epidemiologists, pharmacists, etc.), believe that only doctors can provide good quality care to women.
The numbers entirely don’t support such an approach.
India has a maternal mortality ratio of 174, compared to 14 for the US and nine for the UK. India’s infant mortality rate is 38, compared to six for the US and four for the UK. Finland carries the figures of three and two, respectively. Both Finland and the UK have strong midwifery systems.
Currently, India does not explicitly recognise independent midwifery. The Indian Nursing Council, the regulator, registers its graduates as either a registered auxiliary nurse-midwife (ANM) or a registered nurse and registered midwife (RNRM). These students receive a few months of midwifery training along with other nursing training, compared to a full-fledged midwifery training spanning a couple of years, as is common in European countries and the US.
When it comes to health policy, India often strangely lunges at the mistakes of the US, ignoring better inspirations from Europe.
A better statistic, perhaps, is nurses and midwives (pdf) per 10,000 population. That’s 17 for India, 108 for Finland, and 88 for the UK.
On paper, India has a capacity to produce 46,000 ANMs and 101,000 general nurses and midwives (GNMs) per year. But when they graduate, the ANMs and GNMs generally are expected to perform routine nursing tasks and some basic midwifery, mostly under doctors’ supervision, which is a far cry from the high-level independent midwifery practised in Europe.
Although there have been suggestions to introduce a separate, more comprehensive midwifery training programme in India for some time now, the government and the Indian Nursing Council have never taken the matter further. Besides, there are questions about the quality of training already being imparted in the hundreds of nursing schools all over India, some of which were set up through corrupt means.
“I am extremely keen on recruiting well-trained and capable midwives, both to provide a better birthing experience, and to reduce the burden on obstetricians,” Abhishek Bhartia, director of Sitaram Bhartia Hospital in New Delhi, said. “But unfortunately, the midwifery component of nurses’ training is very weak in India.”
What makes countries such as the UK and Finland such ideal places “to be a mother” is, in large part, the whole-hearted acceptance of professional midwifery by their civil societies, medical communities, and political systems. Even the most recent mother in Britain’s royal family, the Duchess of Cambridge, had a normal delivery and was attended by midwives throughout. In nations where it is a respected profession, midwives and obstetricians work together and do not as competitors. Their health systems believe that both are essential and independent components of care: while pregnancy and normal childbirth are expertly looked after by midwives, the expertise of obstetricians is indispensable to manage complicated pregnancies.
Our singular focus on just the outcome (of reducing deaths) has sadly led to a gross neglect of the right methods to achieve it.
By and large, the most persuasive argument for making midwives more mainstream in India is a feminist one. It can hardly be contested that the current system in which women receive care here is heavily biased towards the convenience of doctors and hospital management, frequently overlooking scientific evidence, health of the mother and baby, and human rights. Disrespect and abuse of women in public facilities, and unnecessary interventional practices in private facilities, are not uncommon; it is women who end up suffering the most.
Our singular focus on just the outcome (of reducing deaths) has sadly led to a gross neglect of the right methods to achieve it, with the health system forgetting that a pregnant woman is a human being (and “not a birthing machine”) who deserves to be treated respectfully and provided all information honestly. Midwives are an important part of the answer here as maternity systems with midwives tend to be more humanistic and personal, more respectful of women, and less interventional.
Midwifery might not be a comprehensive answer to India’s maternity mess, but it is an important and necessary part of the answer.