Op-ed by Andrea Wojnar, Representative, UNFPA India and the Country Director for Bhutan, on the International Day of the Midwife

Through the ‘Midwifery Service Initiative’, the Government in India has committed to train about 90,000 midwives.

India has never been closer to realising the Sustainable Development Goal of 70 maternal deaths per 100,000 live births by 2030. Positive strides in maternal health that have saved the lives of millions of girls, children and women are reflected in a progressively declining Maternal Mortality Ratio (MMR) from 130 (2014-16) to 103 (2017-19) per 100,000 – a notable 21% reduction.

In spite of concerted efforts, each day in India 74 women die during pregnancy and childbirth. Against one maternal death, many more women suffer from serious injuries, infections or disabilities from pregnancy and childbirth related complications. Nearly 46 percent of all maternal deaths and 40 percent of neonatal deaths (deaths of new-borns within 28 days of birth) happen during labour or the first 24 hours after birth.

Yet, these deaths are largely preventable by enabling access to skilled birth attendants and emergency obstetric care. This is where a new pillar of healthcare providers in the public health landscape can change the game. They are Midwives Version 2.0.

Midwives save lives: The missing piece in the maternal healthcare puzzle

As we celebrate this week 100 years of the International Confederation of Midwifery (ICM) – a global organization with a presence in 120 countries and over 1 million members, we recognize the extraordinary contribution of midwives around the world, and highlight the mounting data and evidence for midwifery as a pivotal cornerstone of healthcare.

Contrary to popular belief, midwives do not just deliver babies. They do so much more…from preventing HIV transmission, streamlining family planning after delivery, and preventing and managing complications of pregnancies and childbirth. Moreover, they ensure a positive childbirth experience for women through respect and dignity for their patients.

In fact, the role of midwives is so critical that global evidence suggests that an increase in the number of midwives and the quality of care they provide, can save an estimated 4.3 million lives a year by 2035. Universal coverage of midwife-delivered interventions by 2035 would avert 67% of maternal deaths, 64% of neonatal deaths, and 65% of stillbirths. Midwives can provide about 90% of all sexual, reproductive, maternal, new-born and adolescent health (SRMNAH) care needed across the life course of a woman.

This is strongly affirmed by The State of the World’s Midwifery Report 2021, a flagship publication by the United Nations Population Fund (UNFPA), the World Health Organisation (WHO) and the International Confederation of Midwives (ICM).

Midwifery Services Initiative - A high-impact approach

In India, extreme inter-state variations in MMR exist, ranging from an MMR of 205 in Assam to 30 in Kerala (2019). This is where midwives can play a catalytic role by serving women across high-load MMR states, especially those in remote areas and from marginalised communities.

With task-shifting of normal pregnancy and childbirth care to midwives, the workload on doctors/obstetricians declines significantly. Moreover, it makes the provision of maternal care more cost-efficient by avoiding unnecessary medical interventions, particularly caesarean sections.

Although caesarean surgery can be life-saving, the procedure should be performed only when medically indicated, and not due to the increased work-load and time-crunch of doctors and specialists, and demands from clients among other factors. In India, the percentage of caesarean deliveries has actually increased from 17.2% to 21.5% between 2015-2016 and 2019-2021 whereas the WHO recommends that caesarean section rates should not exceed more than 10-15% in any country.

In India, there is an existing cadre of nurse-midwives performing a share of all deliveries in the public health system. In a landmark move in 2018, the Government of India initiated the formation and institutionalisation of a new staffing cadre of ‘Nurse Practitioner in Midwifery’.

Through the ‘Midwifery Service Initiative’, the Government has committed to train about 90,000 midwives informed by ICM standards. The focus is on setting up a robust midwifery education system and a scalable model of midwifery-led care units.

While the foundation towards ending preventable maternal deaths has been firmly laid, the following building blocks can accelerate the improvement of maternal healthcare:

• Training and beyond. The new cadre of midwives need initial on-job handholding to implement learned best practices and in the process gain confidence in providing international standard quality care in labour rooms. Moreover, midwives should be supported by a strong referral linkage system for emergency obstetric care. This will ensure that over time they become an inextricable part of maternal healthcare.
• Policies for long-term retention. Development of policies which take into account job-satisfaction, defining career trajectories, competitive salaries and motivators for midwives. This will help not just in the retention of these high impact staff but also the programme’s sustainability and eventual growth.
• Shifting to state-of-the-art training models. Introducing a technology-driven approach as part of the training curriculum will enable midwifery students to replicate a plethora of real-world situations to gain clinical experience without putting patients at risk.
• Bolstering acceptance of midwives. Up until now, pregnant women would approach physicians or labour room nurses as their first contact with the health system for deliveries.
• Promoting the synergistic nature among midwives and doctors/obstetricians is a definitive first step. Nurse Practitioners in Midwifery (NPMs) are the missing piece in the Maternal Health puzzle.

Investing in empowered midwives is one of the surest ways to safeguard life and protect the health and well-being of all. As a lynchpin for women’s health, the role of midwives in upholding women’s rights and ending preventable maternal deaths cannot be underestimated. Let’s give midwives the recognition they deserve by investing in their future and the future of the nation.

Andrea Wojnar is the Representative, UNFPA India and the Country Director for Bhutan

Originally published in The Quint.