Midwifery in India
History, Current Scenario and National Health Programs
Table of Contents
Introduction to Midwifery Practice in India
Midwifery practice in India has a rich and diverse history, evolving from traditional birth attendance to modern professional practice. At its core, midwifery is the art and science of providing care to women during pregnancy, childbirth, and postpartum period, while also caring for newborns. In the Indian context, midwifery has played a pivotal role in maternal and child healthcare, especially in rural and remote areas where access to medical facilities is limited.
The World Health Organization (WHO) recognizes midwifery as a crucial component in reducing maternal and infant mortality rates. In India, the maternal mortality ratio has significantly improved over the years but continues to present challenges, making the role of skilled midwifery practice in India all the more significant.
Key Concept
A midwife is defined by the International Confederation of Midwives (ICM) as “a person who has successfully completed a midwifery education program that is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education.”
This comprehensive guide explores the historical roots, current status, transformative education approaches, and national health programs related to midwifery practice in India. By understanding these aspects, nursing students can appreciate the evolution of midwifery and its crucial role in community health nursing perspectives.
History of Midwifery in India
The history of midwifery practice in India dates back thousands of years. Indian midwifery exists right from 4000 years B.C. (Vedic period). It flourished during the Sushruta-era (600 B.C.) and Charak-era (150 A.D.), showcasing remarkable progress at such an ancient period.
Ancient Midwifery Practices
In ancient India, care of women and practice of midwifery were primarily in the hands of indigenous village ‘dais’. These traditional birth attendants not only helped during childbirth but also served as consultants for various conditions related to childbirth. They were midwives in the literal sense, being “with women” during the most intimate and significant events of their lives.
Colonial Influence on Midwifery
When medical missionary women from England came to India, they observed that indigenous dais were unable to manage difficult deliveries and pregnancies, resulting in high maternal and neonatal mortality. This observation led to the development of formal midwifery training in India.
The first training school for dais was established in 1877 by Miss Hewlett, an English missionary of the Zenana Missionary Society. However, the training of dais wasn’t formally adopted by the Government of India until 1900, when Lady Curzon established a fund to improve childbirth conditions in the country.
Pre-Independence Developments
Several significant developments occurred in the pre-independence era:
- In 1872, a small group of Indian Christian nurses received two years of training in Delhi.
- By 1899, the Zenana Bible and Medical Mission began training nurses.
- In 1918, with help from the Dufferin Fund, the Lady Reading Health School was established to train Auxiliary Nurse Midwives (ANMs).
- The Madras Registration of Nurses and Midwives Act was passed in 1926, promoting the role of registered midwives for service during childbirth.
- In 1936, the Dufferin fund provided grants to numerous Dufferin hospitals to build hostels, supply teaching materials, and employ qualified sisters in nursing schools.
- Prior to independence, midwifery training began as a separate course in India, with young girls at the middle school level (8th grade) selected for training.
Post-Independence Evolution
After independence in 1947, significant changes were implemented in midwifery education:
- The Indian Nursing Council, after its inception, combined nursing and midwifery courses into a single three-and-a-half-year program, with the entry qualification being 10th grade.
- The Bhore Committee (1946) emphasized the need for qualified midwives, health visitors, and training of dais.
- In 1955, the Shetty Committee recommended the training of Auxiliary Nurse Midwives (ANMs) in health centers for maternal and child health services.
- Bishoff, a technical consultant, supported the training of two types of nursing personnel in 1959: ANM and General Nurse Midwife (GNM).
- The Kartar Singh Committee in 1975 recommended shortening the ANM course from two years to one and a half years, with entry after 10th grade. These ANMs were designated as female health workers, specially trained in midwifery and child health care services.
Mnemonic: “MIDWIFE” – Historical Milestones
- M – Missionary influence (1877): First training school by Miss Hewlett
- I – Indian Christian nurses trained (1872) in Delhi
- D – Dufferin Fund established (1900) by Lady Curzon
- W – Women’s health priority: Lady Reading Health School (1918)
- I – Independence-era change: Combined nursing-midwifery course (1947)
- F – Female health workers: ANMs designation (1975)
- E – Education standardization through Indian Nursing Council
Historical Timeline of Midwifery in India
4000 BC – 600 BC
Traditional birth attendants (dais) provide maternal care in ancient Indian society during the Vedic period.
600 BC
Midwifery flourishes during Sushruta-era with documented techniques for childbirth.
150 AD
Charak Samhita period witnesses further advancement in midwifery practices.
1872
First formal training of Indian Christian nurses in Delhi for two years.
1877
First training school for dais established by Miss Hewlett, an English missionary of the Zenana Missionary Society.
1899
Zenana Bible and Medical Mission begins training of nurses.
1900
Government of India adopts training of dais with a fund established by Lady Curzon to improve childbirth conditions.
1918
Lady Reading Health School established with Dufferin Fund help to train Auxiliary Nurse Midwives (ANMs).
1926
Madras Registration of Nurses and Midwives Act passed, promoting the role of registered midwives.
1936
Dufferin fund provides grants to hospitals to build hostels, supply teaching materials, and employ qualified sisters in nursing schools.
1946
Bhore Committee emphasizes the need for qualified midwives, health visitors, and training of dais.
1947
After independence, Indian Nursing Council combines nursing and midwifery courses into a single three-and-a-half-year program.
1955
Shetty Committee recommends training of ANMs in health centers for maternal and child health services.
1959
Bishoff technical consultant supports training of two types of nursing personnel: ANM and General Nurse Midwife (GNM).
1975
Kartar Singh Committee recommends shortening the ANM course to one and a half years, with entry after 10th grade.
2013
Government of India commits to establishing a midwifery cadre as part of health system strengthening.
2018
Guidelines on Midwifery Services launched by the Government of India.
2019
Fernandez National Midwifery Training Institute, in collaboration with the Government of India, launches the Nurse Practitioner Midwifery Educator (NPME) training programme.
2023
National Nursing and Midwifery Commission Act passed to strengthen nursing and midwifery workforce.
Current Scenario: Midwifery in India
The midwifery profession, as defined by the International Confederation of Midwives (ICM), is relatively new in India. The country, like many others, is moving towards embedding professional midwifery practice in India into its health system as a way to improve sexual, reproductive, maternal, and newborn health outcomes.
Current Status
- The lack of a specific midwifery profession in India has been identified as a critical gap in maternal healthcare.
- In December 2018, the Government of India committed to establishing a midwifery cadre called Nurse Practitioners in Midwifery (NPMs).
- The Indian Government has committed to educate 90,000 midwives in accordance with international standards.
- Currently, 353 NPMs across 32 districts are providing quality midwifery care, significantly increasing normal birth rates.
- Three national midwifery training institutes have been established in Maharashtra, Uttar Pradesh, and Madhya Pradesh.
Midwifery Cadres in India
- Trained Nurse Midwife (RN, RM): Undergone a diploma (GNM) of 3.5 years or a B.Sc. Nursing of 4 years.
- Auxiliary Nurse Midwife (ANM): Designated as Multi-purpose health worker (female), registered as a midwife. Currently a 2-year course with entry after 12th grade.
- Skilled Birth Attendant (SBA): People with midwifery skills trained to manage normal deliveries and refer complications.
- Nurse Practitioner in Midwifery (NPM): The new cadre being developed with international standard training.
Challenges in Current Midwifery Practice
Despite having a large cadre of ANMs educated and trained in midwifery, they conduct only about 12% of deliveries in India. This underutilization occurs primarily because program priorities have emphasized family planning and immunization as their main work, neglecting delivery care. Current challenges include:
Training Gaps
Insufficient practice-based training and lack of standardized education based on international competencies.
Role Delineation
Unclear boundaries between nursing and midwifery roles, leading to midwifery being an appendage rather than independent profession.
Resource Limitations
Inadequate infrastructure, equipment, and skilled faculty for training quality midwives.
Current Government Initiatives
The Government of India has recognized the importance of strengthening midwifery services to improve maternal and child health outcomes. Key initiatives include:
| Initiative | Year | Key Features |
|---|---|---|
| Guidelines on Midwifery Services | 2018 | Framework for creating a cadre of Nurse Practitioners in Midwifery (NPM) skilled in accordance with ICM competencies |
| National Midwifery Training Institutes (NMTIs) | 2019 | Established in Maharashtra, Uttar Pradesh, and Madhya Pradesh to train midwifery educators who will return to their states to educate and mentor new midwives |
| Nurse Practitioner Midwifery Educator (NPME) program | 2019 | 18-month training program to prepare educators who will train future midwives |
| State Midwifery Training Institutes (SMTIs) | 2020-2023 | Being established across states to increase the reach of midwifery education |
| National Nursing and Midwifery Commission Act | 2023 | Significant milestone in bolstering nursing and midwifery education, skills, and professional development |
Significance of Midwifery
The World Health Organization states that the presence of a skilled midwife at birth is the single most important factor for achieving safe motherhood. Countries that have introduced professional midwifery have seen significant declines in maternal and neonatal mortality rates.
Transformative Education for Midwifery Practice in India
Transformative education is revolutionizing midwifery practice in India through innovative approaches that focus on relationship-based and woman-centered care. This approach moves beyond traditional teaching methods to create midwives who can transform healthcare delivery and maternal outcomes.
Core Philosophy of Transformative Midwifery Education
The Fernandez National Midwifery Training Institute, in collaboration with the Government of India, launched the Nurse Practitioner Midwifery Educator (NPME) training programme in 2019. The core philosophy centers around:
- Making the birthing mother the focal point of all decisions regarding her and her baby’s health
- Transforming current practices into women-centric best practices
- Emphasizing respectful and positive birthing experiences
- Promoting evidence-based care over traditional, non-evidence-based practices
- Ensuring holistic support throughout the maternal care continuum
- Developing a collaborative approach among healthcare professionals
Transformative Learning Elements
Transformative learning in midwifery education involves:
- Critical reflection on assumptions and practices
- Experiential learning through clinical placements
- Building relationships with women and families
- Developing autonomous decision-making skills
- Understanding physiological birth as normal
- Cultivating compassionate care approaches
Key Components of the NPME Program
The NPME programme covers maternal care at all stages of pregnancy and highlights the importance of collaboration among healthcare professionals:
Antenatal Period
- Comprehensive assessment
- Health education
- Risk identification
- Birth planning
- Nutritional guidance
Intrapartum Period
- Physiological birth support
- Non-pharmacological pain relief
- Delayed cord clamping
- Immediate skin-to-skin contact
- Respectful maternity care
Postpartum Period
- Breastfeeding support
- Newborn care
- Maternal recovery monitoring
- Family planning counseling
- Psychosocial support
Transformative Practices Being Implemented
The education program promotes several transformative practices that change the traditional approach to childbirth:
| Transformative Practice | Traditional Approach | New Evidence-Based Approach |
|---|---|---|
| Language Use | Use of terms like “patient” and sometimes verbal abuse | Respectful language, calling the woman a “mother” or by her name, strict prohibition of verbal abuse |
| Birth Interventions | Routine inductions and episiotomies often without consent | Selective use of interventions with informed consent, supporting physiological birth |
| Cord Management | Immediate cord clamping | Delayed cord clamping to benefit newborn’s iron stores and transition |
| Mother-Baby Contact | Separation after birth for routine procedures | Immediate skin-to-skin contact promoting bonding and breastfeeding |
| Privacy | Limited privacy in traditional settings | Ensuring 100% privacy during labor, delivery, and postpartum care |
| Decision-Making | Provider-led decisions with limited maternal input | Partnership model where mother and midwife work together for decisions |
Mnemonic: “RESPECT” – Transformative Midwifery Principles
- R – Relationship-based care connecting midwives and mothers
- E – Evidence-based practices over traditional methods
- S – Skin-to-skin contact immediately after birth
- P – Privacy and dignity during labor and birth
- E – Empowerment of women through informed choices
- C – Compassionate care without verbal abuse
- T – Team collaboration among healthcare providers
Structure of Transformative Education
The structure of midwifery education has been transformed to meet international standards:
Nurse Practitioner in Midwifery (NPM) Training
- Duration: 18 months
- Eligibility: GNM/B.Sc Nursing with minimum 2 years of clinical maternity experience
- Curriculum: Based on ICM essential competencies for basic midwifery practice
- Recognition: By Ministry of Health and Family Welfare, Government of India
- Clinical Component: Extensive hands-on practice with sufficient birth numbers
Nurse Practitioner Midwifery Educator (NPME) Training
- Advanced training for those who will educate future midwives
- Focus on both clinical skills and teaching methodologies
- Includes mentorship components
- Emphasis on evidence-based teaching
- International standards of midwifery practice
Practitioner Insight
“It’s been an amazing journey. We were fortunate to see and practice international standards of midwifery. This is my calling where I can practice independently.”
— Dr. N Prasuna, teaching faculty member and NPME learner
National Health Programs related to RMNCH
The Government of India has implemented various national health programs related to Reproductive, Maternal, Newborn, and Child Health (RMNCH) to improve maternal and child health outcomes. These programs directly impact midwifery practice in India and the provision of care to women and children.
RMNCH+A Strategy Framework
Following the Government of India’s “Call to Action Summit” in February 2013, the Ministry of Health & Family Welfare launched the Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (RMNCAH+N) strategy to influence key interventions for reducing maternal and child morbidity and mortality.
Core Components of RMNCAH+N
- Lifecycle approach focusing on continuity of care
- Inclusion of adolescence as a distinct life stage
- Linking maternal and child health to reproductive health and other components
- Connecting home and community-based services to facility-based services
- Creating continuous care pathways through linkages and referrals
Current Status of Key Indicators (2020-21)
- Maternal Mortality Ratio: 97 per 100,000 live births
- Neonatal Mortality Rate: 20 per 1,000 live births
- Infant Mortality Rate: 28 per 1,000 live births
- Under 5 Mortality Rate: 32 per 1,000 live births
- Total Fertility Rate: 2.0
Key National Programs Supporting Midwifery
Several national programs directly support midwifery practice in India and the provision of maternal and child healthcare:
| Program | Year Launched | Key Features | Relevance to Midwifery |
|---|---|---|---|
| Janani Suraksha Yojana (JSY) | 2005 | Conditional cash transfer scheme promoting institutional delivery among poor pregnant women | Increases demand for skilled birth attendance and institutional delivery |
| Janani Shishu Suraksha Karyakram (JSSK) | 2011 | Provides free delivery services including C-section, drugs, diagnostics, blood, diet, and transport | Reduces financial barriers to accessing skilled midwifery services |
| Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) | 2016 | Provides comprehensive antenatal care on the 9th of every month at designated facilities | Improves antenatal care, allowing midwives to identify high-risk pregnancies early |
| Labour Room Quality Improvement Initiative (LaQshya) | 2017 | Improves quality of care in labor rooms and maternity OTs for respectful care during delivery | Creates better working environments for midwives and improves birth outcomes |
| Midwifery Initiative | 2018 | Creates a cadre of Nurse Practitioners in Midwifery (NPM) skilled in accordance with ICM competencies | Directly establishes professional midwifery in India’s healthcare system |
| Surakshit Matritva Aashwasan (SUMAN) | 2019 | Provides assured, dignified, and quality healthcare with zero tolerance for denial of services | Promotes respectful maternity care, a core principle of midwifery practice |
| Extended PMSMA (e-PMSMA) | 2022 | Focuses on tracking high-risk pregnancies through additional visits and financial incentives | Enhances the role of midwives in monitoring and managing high-risk pregnancies |
| Optimizing Postnatal Care | 2023 | Strengthens post-natal care quality with emphasis on danger sign detection and ASHA incentivization | Complements midwifery care by extending support into the community postpartum period |
Comprehensive Abortion Care
Comprehensive abortion care is an important element in the reproductive health component of the RMNCH+A strategy, as 8% of maternal deaths in India are attributed to unsafe abortions. The Medical Termination of Pregnancy (Amendment) Act & Rules, 2021 has expanded access to safe abortion services:
Key Provisions of MTP (Amendment) Act, 2021
- Requirement of opinion of one registered medical practitioner for termination up to 20 weeks of gestation
- Requirement of opinion of two registered medical practitioners for termination of 20-24 weeks of gestation
- Enhanced upper gestation limit from 20 to 24 weeks for vulnerable groups of women
- Non-applicability of gestation limits for substantial fetal abnormalities diagnosed by a Medical Board
- Strengthened protection of privacy
- Failure of contraceptive clause extended to the woman and her partner
Midwifery Role in Abortion Care
- Providing pre and post-abortion counseling
- Ensuring women’s privacy and confidentiality
- Offering post-abortion contraception guidance
- Identifying complications and making appropriate referrals
- Community health education about safe abortion services
- Supporting women’s reproductive autonomy and choices
Infrastructure Development for Maternal Health
The government has also focused on strengthening infrastructure for maternal health services:
Delivery Points
Facilities identified with certain minimum benchmarks of performance to prioritize and direct resources. All delivery points are strengthened with trained personnel, infrastructure, equipment, drugs, and referral transport.
Obstetric HDU/ICU
Operationalization of Obstetric ICU/HDU in high case load tertiary care facilities to handle complicated pregnancies, supporting the referral system for midwives.
MCH Wings
State-of-the-art Maternal and Child Health Wings at District Hospitals and high case load facilities for providing quality obstetric and neonatal care.
Mnemonic: “MOTHERS” – National Programs for Maternal Health
- M – Midwifery Initiative (2018)
- O – Optimizing Postnatal Care (2023)
- T – Tracking high-risk pregnancies through e-PMSMA
- H – Health assurance through SUMAN initiative
- E – Empowerment through JSY financial support
- R – RMNCAH+N comprehensive strategy framework
- S – Safe delivery through LaQshya quality improvements
Challenges and Future Directions
Despite significant progress, the development of midwifery practice in India faces several challenges that need to be addressed for its successful integration into the healthcare system.
Current Challenges
- Shortage of Qualified Faculty: Limited availability of qualified midwifery educators with international standard training.
- Infrastructure Limitations: Inadequate training facilities and clinical practice sites offering normal physiological birth experiences.
- Professional Identity: Lack of distinct identity for midwives, as midwifery is still perceived as a branch of nursing rather than an independent profession.
- Medicalization of Birth: High rates of unnecessary interventions and medicalization that run counter to midwifery philosophy.
- Implementation Gaps: Delays in implementing policies and programs at the state level.
- Community Awareness: Limited public awareness about the role and importance of professional midwives.
Future Directions
- Scaling Up Education: Establishing more midwifery training institutes across all states to reach the target of 90,000 trained midwives.
- Regulatory Framework: Strengthening the regulatory framework for midwifery practice through the National Nursing and Midwifery Commission.
- Career Pathways: Developing clear career pathways for midwives with opportunities for advancement and specialization.
- Research and Evidence: Promoting midwifery research to build India-specific evidence for best practices.
- Public Awareness: Increasing public awareness about the benefits of midwifery-led care through education campaigns.
- Integration with Existing Systems: Seamlessly integrating midwifery services within the existing healthcare structure.
Recommendations for Strengthening Midwifery in India
Based on current challenges and the roadmap for midwifery in India, several recommendations can be made:
Education
- Make six-weeks training compulsory as an induction course for newly recruited faculty
- Ensure faculty has 3-5 years clinical experience prior to teaching
- Organize regular knowledge and skills upgradation through refresher courses
- Develop skills labs for practical training
Clinical Practice
- Identify high case load facilities as clinical training sites
- Standardize clinical skills through collaborative discussions
- Appoint clinical preceptors to supervise students
- Provide sufficient hands-on practice opportunities
Administration
- Create and fill posts of district and block PHN
- Utilize monthly meetings for knowledge enhancement
- Implement career development pathways
- Strengthen nursing representation in executive committees
Global Best Practice
New Zealand’s midwifery model offers valuable lessons for India. There, midwives provide continuity of care throughout pregnancy, birth, and postpartum as autonomous practitioners. The model emphasizes partnership with women, respect for normal birth, and integrated services. Implementing similar principles could transform maternal care in India while respecting cultural context.
Conclusion
The journey of midwifery practice in India reflects a rich historical legacy that has evolved significantly from traditional birth attendance to modern professional practice. From the indigenous dais of ancient India to the internationally standardized Nurse Practitioners in Midwifery, the profession has continuously adapted to changing healthcare needs while maintaining its core philosophy of woman-centered care.
The current transformative education approach marks a pivotal shift in midwifery development in India. By focusing on relationship-based care, evidence-based practices, and respectful maternity care, it is creating a new generation of midwives capable of improving maternal and newborn outcomes while enhancing women’s childbirth experiences. The government’s commitment to training 90,000 midwives according to international standards demonstrates recognition of midwifery’s crucial role in achieving public health goals.
National health programs related to RMNCH provide a supportive framework for midwifery practice, integrating midwives into the broader healthcare system while creating enabling environments for their work. The synergy between these programs and professional midwifery has the potential to significantly reduce maternal and neonatal mortality while promoting positive birth experiences.
Despite challenges in implementation, faculty development, and establishing professional identity, the future of midwifery in India looks promising. With continued investment in education, infrastructure, regulation, and public awareness, midwives can become the cornerstone of maternal and newborn care, particularly in underserved areas. By valuing midwifery as an autonomous profession that complements medical care, India can build a healthcare system that truly responds to women’s needs and advances maternal health outcomes.
References
- Chhugani, M. (2014). Midwifery in India and its Roadmap. Journal of Asian Midwives, 1(1), 34-40. https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1004&context=jam
- National Health Mission. (2023). RMNCAH+N – Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition. https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=794&lid=168
- National Health Mission. (2023). Maternal Health. https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=822&lid=218
- International Confederation of Midwives. (2024). Professional Midwife-Led Care in India. https://internationalmidwives.org/professional-midwife-led-care-in-india/
- Fernandez Foundation. (2024). Empowering Birth: Transforming Maternal Care Through Midwifery Education in India. https://www.fernandezmidwifery.org/empowering-birth-transforming-maternal-care-through-midwifery-education-in-india/
- International Confederation of Midwives. (2024). Highlighting Success: The Fernandez Midwifery Initiative in India. https://internationalmidwives.org/highlighting-success-the-fernandez-midwifery-initiative-in-india/
- Indian Nursing Council. (2019). Guidelines on Midwifery Services in India. New Delhi: Indian Nursing Council.
- WHO. (2024). Midwifery Education and Care. https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/maternal-health/midwifery