Midwifery

Volume 27, Issue 5, October 2011, Pages 700-706

Midwives of India: Missing in action

Author links open overlay panelDileep Mavalankar Dr
PH (Professor) , Parvathy Sankara Raman MSc (Project
a

Associate) , Kranti Vora MPh (Doctoral Candidate)

b c

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Abstract
India had well-trained European and indigenous midwives during
the time of British rule. The strong midwifery profession lost its
importance after independence for various reasons. As a result
maternal mortality remains high in India. This paper analyses
reasons for the dilution in the midwifery profession, which include
amended regulations, lack of social or political priorities, and
change in health programme directions. This paper also presents a
framework for midwifery-based maternal health services. This
analysis shows that there are local as well as internationally
supported efforts to improve midwifery in India.
Introduction
Worldwide, about half a million mothers lose their lives every year,
due to childbirth and from related complications (Koblinsky and
Campbell, 2003). About 90% of these maternal deaths are in the
developing world (WHO, 2007). Historically, Sweden reduced its
maternal mortality ratio (MMR) significantly by providing skilled
care at birth for home births by trained midwives before caesarean
section and blood transfusion became safe (Hogberg, 2004).
Evidences from Sri Lanka and Malaysia in the 20th Century showed
that attendance at delivery by well-trained public health midwives
with the back-up of emergency obstetric care (EmOC) services
helped in the reduction of maternal mortality, even in resource-
poor settings (Hecht, 2003, Pathmanathan and Liljestrand, 2003,
Vidyasagara, 2003).
India has a high MMR in spite of a long history of programmes to
improve maternal health, which is primarily due to lack of
consistent policies and absence of focus on evidence-based
interventions (Ved and Dua, 2005). Along with these policy-level
issues, certain background factors have also contributed to the
increase in maternal mortality, including anaemia, malaria,
malnutrition, poverty, low status of women, and low education
levels among women, etc. (International Institute of Population
Sciences,1999; Rush, 2000, UNICEF, 2000). The MMR reported by
the Registrar General of India is still high at 254, although this is
gradually declining (Sample Registration System, 2009). India’s
maternal deaths account for 25% of the total global maternal deaths
(WHO, 2007). Most of these deaths are due to preventable causes
such as hemorrhage, sepsis, pregnancy-induced hypertension and
abortion-related complications. Prevention and timely management
of life-threatening complications of birth is one of the key primary
health-care needs of any country.
The joint statement of the World Health Organization, the
International Confederation of Midwives and the International
Federation of Gynecology and Obstetrics defines a skilled birth
attendant as ‘an accredited health professional – such as a midwife,
doctor or nurse – who has been educated and trained to proficiency
in the skills needed to manage normal (uncomplicated)
pregnancies, childbirth and the immediate postnatal period, and in
the identification, management and referral of complications in
women and newborns’ (WHO, 2004). Evidence shows that
maternal deaths can be averted by the presence of a skilled birth
attendant at the time of childbirth. In spite of global evidence of
effectiveness of well-trained midwives and skilled birth attendants
in reducing maternal mortality, the Government of India has chosen
to provide a short (two to three weeks) refresher course to female
multipurpose-workers. Historically, these workers were trained for
18 months as auxiliary nurse midwives (ANMs) and conducted
deliveries. However, since the the 1970s, their role has changed; few
of them conduct births on a regular basis in the community, and
most focus on family planning and immunisation. As a result, most
have lost their skills for conducting births.
Under British rule, India started to develop a good midwifery-based
maternal health-care system. In those days, doctors were
infrequently available in rural areas and had similar expertise as
skilled midwives in birth care. However, for some reason,
independent India veered away from the midwifery-based maternal
health system. This paper attempts to analyse why midwifery did
not develop in the independent India. It suggests actions to revive
the role of midwives for providing skilled birth care for rural women
to prevent maternal deaths. The paper also puts forth a framework
for midwifery-based maternal services for India.

Section snippets

Development of midwifery in India: a historical

perspective
As early as 1797, a ‘lying-in-hospital’ for maternity was built in
Madras city (now called Chennai). It was in this institution in 1854
that, the British Government sanctioned the opening of the first
formal training school for midwives. These midwifery schools had
trained midwives from Britain and also indigenous midwives who
were trained by the European midwives. These midwives were
skilled in their profession and were able to practice independently
to provide childbirth care. During the 19th

Regulations in nursing and midwifery

The British Government established the Central Board of Nursing
and Midwifery in India during 1902. The Board was established to
ensure safe births by providing quality services by the well-trained
midwives, who were required to follow the regulations and code of
conduct decided by the board (Khanna, 2006). At the same time,
the chief matrons and nursing and midwifery superintendents in
the Madras Presidency decided to start an examination board for
the unification of training and practices of

No separate professional association for midwives

In India, the term nurse-midwife is used to represent the nursing
and midwifery staff of all cadres, including the staff nurses, ANMs
or village health nurse in some states (WHO SEARO, 2003).
Historically there was no separate association of midwives in India.
The 100-year old TNAI had a section for midwives, but as their
training got merged with nurses, this section lost its importance and
identity. This de-valuation of the profession of midwifery and its
merger with nursing and midwifery was

Socio-cultural factors
Nursing and midwifery have been regarded as low-value professions
to provide support to doctors and not as autonomous clinical
professions. In India, the majority of midwives and nurses are
female, whereas the majority of doctors are male. Most medical
students are from urban areas and higher castes, whereas the
nursing and midwifery students are from rural areas and lower
castes. In the past and to some extent in present times, upper
middle class Indian women do not enter these professions

Effects of medical technology on midwifery

Since times immemorial, giving birth remained largely natural with
littile technology or intervention. Traditional birth attendants or a
female relative looked after women during birth. In Western
Europe, the role of the midwife emerged as a trained professional
over the last 300 years. In India, GNM and ANM were trained to be
institutional-based midwives and community-based midwives,
respectively. However, untill recently, they were not allowed to use
life-saving drugs or any other technology

Political and programme priorities – transition from

ANM to multipurpose worker (female)
Post independence, the Government gave more emphasis to
national health programmes. For the same reason, more attention
was given to the establishment of medical colleges and
nursing/midwifery colleges and schools. Many medical colleges,
nursing and midwifery schools and colleges were built during the
early 1960s. During the 2nd Five Year plan, the government of India
allocated around two billion rupees (US$ 4.3 million) for the
formation of medical colleges and only 60 million rupees (US$ 0.13

Recent neglect of midwifery

WHO and other international agencies have re-discovered the
importance of midwifery, skilled birth attendance and EmOC over
the last decade. Instead of strengthening midwifery training, cadre
and services, the Government of India, under the internationally
funded Reproductive and Child Health Programme and the
nationally funded National Rural Health Mission (NRHM)
initiative, has developed a policy of promoting ‘institutional
childbirth’ by providing cash incentives to mothers. This
programme

Why India should not focus on TBA training for

provision of birth care
The experiences from Sweden, Sri Lanka and Malaysia reflect that
providing skilled care assistance at the time of birth can reduce
maternal mortality, along with other strategies such as a robust
health system and reliable referral system (Hogberg, 2004,
Pathmanathan and Liljestrand, 2003, WHO SERO, 2003,
International Institute of Population Sciences, 2007). According to
the World Health Organization, the term, TBA’ refers to a
traditional, independent and non-formally trained community
based

Benefits of a midwifery- based model

Globally, the care of pregnant women and assistance during birth
can be divided into three models. The first is home- based care by a
TBA and relatives; second is institution- based care provided by
midwives, nurses and obstetricians; and the third is home- and
institutional- based care, primarily by a trained midwife backed up
by obstetricians. The latter could be considered as a midwifery-
based model of care which not only includes professional care but
also humanised care (Stephens, 2007).
Revival of midwifery in India – new initiatives
After the long neglect of midwifery, there has been a recent revival
of interest in developing an independent midwifery profession in
India. A series of small but positive initiatives have taken place to
strengthen midwifery as a profession. In November 2000, the
Society of Midwives in India (SOMI) was formed to develop a
separate identity and provide a collective strength to the profession
in India by 2009. Currently, SOMI has around 50 chapters and
4000 members all over in India. There has

Framework for midwifery- based maternal health

services
In spite of the national policy of institutional births a substantial
proportion of home births continues in some areas of India. Women
still come to institutions for birth and are discharged within one to
two days. Thus, from conception to completion of the postpartum
period, women are largely at home, requiring domiciliary midwifery
services as many will not be able to visit health centres. The
majority of maternal deaths in India occur during birth and the
post-partum period due to lack of

Innovations in midwifery: direct - entry midwife

India should consider developing direct entry midwifery training
through a three-year diploma programme in midwifery for high-
school graduates, as is available in some countries of South
America, Denmark, the UK and some other European countries.
This would be a better option as re-training nurses could lead to
diversion of human resources and further shortage of nurses. As,
India has more than 2.5 million births/year it would require a large
number (about 250,000, i.e. one per 100 births per

Conclusion
India had well-established midwifery professionals before
independence, but due to the merger of nursing and midwifery and
the diversion of attention to other target-oriented preventive health
programmes the profession declined. As a consequence of this,
maternal mortality has remained high and births are continue to be
attended by untrained TBAs and relatives in rural areas.
Seventy percent of India’s population is rural and it is not possible
or advantageous to have doctors for all normal

Conflict of interest
None.