With 72.2 % of India’s total population being rural and more than 60% domiciliary deliveries in these areas, the situation calls for the adoption of skilled midwifery system, writes Shillpi A Sinha
The significance of midwives is existential from the pages of history. However, women playing an integral role in maternal healthcare have seen a downfall with the medical fraternity overlooking the role of midwives. According to The Nursing Association of India Journal, 2012, with the current population of 1.2 billion, India needs a total of 2.4 million professionals with midwifery competencies. Dr Leila Caleb Varkey, a renowned Public Health Researcher, midwife and a member of the White Ribbon Alliance India, explores the importance of midwives in improving maternal healthcare in India.
Why does India lag behind recognising midwifery-led maternal care?
To begin with, traditional midwifery is practiced by many illiterate women, called Dais, who assisted women for their delivery at home. Dais are considered ‘unskilled’ and are not remunerated as part of any formal government programme. The World Health Organisation and India (as a signatory) accepted the definition of “Skilled Birth Attendant” over Dais, as the latter is not professionally recognised. In case of trained midwives, the issues of recognition and services are linked with licensing. While all nurses study midwifery as part of General Nursing and Midwifery, B.Sc. in Nursing (governed under the Indian Nursing Council Act); there is no direct-entry ‘Midwifery course’. Until this status is changed, it is unlikely that Indian midwifery will change into a stand-alone profession with its own regulatory body.
Political will is also needed to change this scenario. The New Midwifery Education and Practice Act in Parliament is still languishing, as there has been no encouraging clarity in policy for financial and career progression after the course.
What are the challenges faced by midwives in India?
Indian mid-wives face a lot of challenges like lack of opportunity to assist in normal births. They also do not have clarity in career progression in case of specialisation in practical midwifery. Not only that, but they also face professional boundaries as doctors lack confidence in them.
What are the issues in training midwives?
As a part of the practicum, clinical instructors do not conduct deliveries themselves. Adding to this, Obstetrician/Gynaecologist (OB/GYN) department’s coordination is not up to the mark. In many places, the OB/GYN do not allow students to practise their skills for normal deliveries with the required clinical proficiency. On the clinical front, training for midwifery is a part of nursing training and not a separate one. Moreover, the duration of clinical practicum is also less.
Why is midwifery is dying practice in India?
It is because of the non-availability of official job positions and institutional midwives. The HR for private and public health care system in India is not designed at present for the inclusion of midwives. It only focuses on nurses and attendants. The current career advancement in midwifery is through the route of nursing only – beginning either in the hospital nursing area or public health nursing area. In neither of these cases, there is any recognition or promotion given to the midwife based on her expertise in clinical practice. In fact, it is usually based purely on the number of years of service. As a result, when a midwife is included, it is an imposition, which neither doctors nor nurses appreciate. Salary too being an issue, most nurses request transfers out of maternity units and do not want to be midwives.
What are the benefits of the midwifery model of healthcare?
It has a positive impact on maternal health. The countries which provide an encouraging environment for midwives have witnessed better maternal health results. Our neighbouring nations such as Nepal and Bangladesh which have achieved remarkable progress in reducing Maternal Mortality Rate (MMR) due to initiatives around midwives. The density of midwives and nurses in India is reportedly only 13 per 10,000 populations. Therefore, India needs to reconsider the role of midwives sincerely. At present, there are about 12.37 lakh nurses, and midwives and 6.02 lakh nurses so far have been registered with various state nursing councils in India.
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How others fare
Nepal recently started a professional midwives’ cadre that is working in rural areas. The MMR of Nepal is 258
Sri Lanka had the support of midwives as part of its public health system which has resulted in a high institutional birth rate. MMR of Sri Lanka is 30
Thailand has increased its practices of midwifery and has a direct entry midwifery programme. The MMR of Thailand is 20