2.1. National Nursing and Midwifery Commission Act, 2023

The National Nursing and Midwifery Commission Act, 2023 represents a significant milestone in the evolution of midwifery regulations in India. This Act repeals the Indian Nursing Council Act, 1947, and establishes a comprehensive framework for regulating nursing and midwifery practice across the country.

The Act defines “midwifery” as a skilled, knowledgeable, and compassionate care for childbearing women, new-born infants and families across the continuum from pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life. This care includes preventive measures, promotion of normal birth, detection of complications, accessing medical care, appropriate referrals, and emergency measures as specified by the Commission.

Under the Act, a “midwifery professional” is defined as a person who has obtained the recognized basic or advanced qualification and is granted a license to practice by the National Nursing and Midwifery Commission. Additionally, it defines “midwifery associate” as a member of the health team who assists doctors or nurse practitioners in midwifery in the delivery of babies and provides care during pregnancy, labor, and postpartum period.

2.2. Indian Nursing Council Regulations

The Indian Nursing Council (INC), now transitioning to the National Nursing and Midwifery Commission, has been instrumental in shaping midwifery regulations in India. The Council has developed various regulations and guidelines for midwifery education, training, and practice.

The INC regulations emphasize competency-based education aligned with international standards, particularly the Essential Competencies for Midwifery Practice defined by the International Confederation of Midwives (ICM). These regulations are designed to ensure that midwives in India have the necessary knowledge, skills, and attitudes to provide high-quality care.

2.3. Ministry of Health and Family Welfare Guidelines

The Ministry of Health and Family Welfare (MoH&FW) has issued comprehensive guidelines on midwifery services in India to support the implementation of midwifery regulations in India at the state level. These guidelines provide a strategic framework for integrating midwifery care into the public health system.

The MoH&FW guidelines outline the establishment of Midwifery-led Care Units at selected LaQshya certified high case load public health facilities. These units are staffed by Nurse Practitioners in Midwifery (NPMs) who have completed 18 months of post-basic training in midwifery in accordance with ICM standards.

The guidelines also address key aspects of midwifery practice, including:

• Selection criteria for NPM candidates
• Curriculum and training duration
• Integration of midwives into the public health system
• Range of services to be provided by NPMs
• Administrative structures for midwifery-led healthcare
• Career progression pathways for midwives
• Regulatory framework and certification

These guidelines align with the broader midwifery regulations in India and provide practical guidance for implementing midwifery services within the existing healthcare infrastructure.

3.1. Definition and Classification of Midwives

Within the framework of midwifery regulations in India, midwifery professionals are classified into specific categories, each with defined roles and responsibilities.

The National Nursing and Midwifery Commission Act, 2023 provides these statutory definitions to clarify the roles and responsibilities of different midwifery practitioners within the healthcare system. These definitions are essential for implementing midwifery regulations in India and ensuring appropriate scope of practice for each category.

3.2. Authorized Practices and Limitations

The scope of practice for midwives in India is clearly defined by midwifery regulations in India, particularly the Scope of Practice for Midwifery Educator & Nurse Practitioner in Midwifery issued by the Indian Nursing Council and now under the purview of the National Nursing and Midwifery Commission.

Authorized practices for Nurse Practitioners in Midwifery (NPMs) include:

The Nursing and Midwifery Ethics and Registration Board, established under the National Nursing and Midwifery Commission Act, regulates the standards and scope of practice of registered nursing and midwifery professionals. This includes defining the limited prescribing authority for nurse practitioners in all specialties, including midwifery.

3.3. Framework for Autonomous Practice

The midwifery regulations in India emphasize the importance of autonomous practice for midwives within defined parameters. The National Nursing and Midwifery Commission Act, 2023, along with the Guidelines on Midwifery Services in India, provides a framework for autonomous midwifery practice.

The ultimate aim of regulation, as stated in the Guidelines on Midwifery Services in India, is “to allow nurse midwives to practice autonomously and provide full range of midwifery care efficiently.” This autonomy is balanced with accountability and is subject to certain conditions:

The framework for autonomous practice includes the establishment of Midwifery-led Care Units where NPMs are the first point of contact for pregnant women. In these units, NPMs screen all pregnant women using well-defined criteria, provide care to women without complications, and refer those with complications to medical officers or specialists.

To ensure effective autonomous practice, the midwifery regulations in India specify:

• Minimum staffing requirements for different levels of healthcare facilities
• Administrative structures with a Chief Midwifery Officer as supervisor
• Clear referral pathways to higher levels of care
• Regular competency assessments linked to annual performance appraisals
• Continuous professional development requirements

This framework aims to balance the autonomy of midwives with the need for integrated healthcare delivery and ensure that women receive appropriate care at all stages of pregnancy, childbirth, and the postpartum period.

4.1. ICM Code of Ethics and Its Implementation

The International Confederation of Midwives (ICM) Code of Ethics provides a global ethical framework for midwifery practice that informs midwifery regulations in India. This code establishes fundamental principles that guide midwives in their professional relationships, practice, responsibilities, and advancement of knowledge.

The National Nursing and Midwifery Commission Act, 2023 establishes the Nursing and Midwifery Ethics and Registration Board, which is responsible for regulating professional conduct and promoting nursing and midwifery ethics. This Board ensures compliance with ethical standards through:

• Development and enforcement of a code of professional and ethical conduct
• Collaboration with State Commissions to monitor and regulate the conduct of nursing and midwifery professionals
• Establishment of mechanisms for receiving complaints and providing grievance redressal
• Taking disciplinary actions in cases of ethical misconduct

The implementation of the ICM Code of Ethics in India is adapted to the local context while maintaining alignment with global ethical principles. The midwifery regulations in India incorporate these ethical standards into education, practice, and regulatory frameworks to ensure that midwives provide care that respects the dignity, rights, and cultural preferences of women and their families.

4.2. Key Ethical Challenges in Indian Context

Despite the comprehensive midwifery regulations in India, midwives face numerous ethical challenges specific to the Indian healthcare context. These challenges stem from social, cultural, economic, and structural factors that impact maternal and neonatal care.

Specific ethical challenges in the Indian context include:

The Guidelines on Midwifery Services in India acknowledge these challenges and emphasize the need for additional training in areas such as:

• Human rights and gender-based violence
• Respectful care: non-judgmental, non-discriminatory behavior
• Cultural sensitivity and cultural appropriateness
• Addressing emotional abuse and physical neglect

The midwifery regulations in India aim to address these ethical challenges through education, training, and regulatory frameworks that promote ethical practice while acknowledging the complex social and cultural context in which midwives operate.

4.3. Respectful Maternity Care

Respectful Maternity Care (RMC) is a cornerstone of ethical midwifery practice and is explicitly emphasized in midwifery regulations in India. It encompasses care that maintains dignity, privacy, and confidentiality; freedom from harm and ill treatment; informed choice and continuous support; and equitable care without discrimination.

The Guidelines on Midwifery Services in India note that “disrespect and abuse of women during childbirth acts as a deterrent for the women and her family to opt for institutional delivery.” The Government of India has stressed “Promoting Respectful Maternity Care and Cognitive Development of Baby” under the LaQshya program, and this is a key component of midwifery training and practice.

Key elements of Respectful Maternity Care in the Indian context include:

• Protection of women’s dignity, privacy, and confidentiality
• Prevention of disrespect and abuse during childbirth
• Promotion of informed decision-making and consent
• Support for physiological labor and birth processes
• Facilitation of continuous support from a birth companion
• Provision of equitable care regardless of socioeconomic status, caste, or religion
• Recognition and respect for cultural preferences that do not harm the mother or baby

The National Nursing and Midwifery Commission Act, 2023 and related midwifery regulations in India provide a framework for implementing RMC through:

• Inclusion of RMC principles in midwifery education and training
• Development of standards and protocols that incorporate RMC
• Monitoring and evaluation mechanisms to assess adherence to RMC principles
• Establishment of grievance redressal mechanisms for women who experience disrespect or abuse

5.1. Registration and Licensing

The midwifery regulations in India establish a comprehensive system for registration and licensing of midwifery professionals and associates. This system is managed by the Nursing and Midwifery Ethics and Registration Board under the National Nursing and Midwifery Commission.

The process for registration and licensing under the midwifery regulations in India includes:

1. Acquisition of recognized qualifications from approved institutions
2. Application for registration to the State Nursing and Midwifery Commission
3. Verification of qualifications and credentials
4. Entry into the State Register
5. Automatic inclusion in the National Register through data sharing
6. Issuance of registration certificate
7. Periodic renewal as specified by regulations

The National Nursing and Midwifery Commission Act also provides for:

• Temporary registration for foreign professionals under certain conditions
• Recognition of qualifications granted by institutions outside India on a reciprocal basis
• Withdrawal of recognition of qualifications that fail to maintain standards

This registration system ensures that only qualified professionals practice midwifery, thereby maintaining quality standards and protecting public safety. It also provides a mechanism for tracking and regulating the midwifery workforce across the country.

5.2. Quality Assurance and Monitoring

Quality assurance and monitoring are integral components of midwifery regulations in India, ensuring that midwifery services meet established standards and continuously improve. The National Nursing and Midwifery Commission, through its Autonomous Boards, implements various mechanisms for quality assurance.

The Guidelines on Midwifery Services in India outline additional monitoring parameters for midwifery services:

• Proportion of normal deliveries conducted by NPMs
• Proportion of women receiving respectful maternity care
• Rates of maternal and neonatal complications
• Timely referral of complicated cases
• Client satisfaction with midwifery services
• Documentation and record-keeping practices

The midwifery regulations in India emphasize continuous quality improvement through:

• Regular internal and external audits of midwifery services
• Data collection and analysis for performance monitoring
• Feedback mechanisms for service users
• Continuous professional development requirements
• Sharing of best practices and lessons learned

These quality assurance mechanisms ensure that midwifery services meet established standards, continuously improve, and remain responsive to the needs of women and newborns.

5.3. Disciplinary Actions and Legal Remedies

The midwifery regulations in India establish a comprehensive framework for disciplinary actions against professional or ethical misconduct by midwifery professionals. This framework is implemented through the Nursing and Midwifery Ethics and Registration Board at the national level and the State Nursing and Midwifery Commissions at the state level.

Disciplinary actions that may be taken under the midwifery regulations in India include:

• Issuance of warnings or reprimands
• Imposition of monetary penalties
• Suspension of registration for a specified period
• Removal of name from the Register (deregistration)
• Mandatory additional education or training
• Restriction of scope of practice
• Supervision requirements

The process for disciplinary actions includes:

1. Receipt of complaint or allegation of misconduct
2. Preliminary inquiry by the State Commission or Ethics Board
3. Formal investigation if preliminary inquiry indicates potential misconduct
4. Opportunity for the professional to respond to allegations
5. Hearing before the appropriate authority
6. Decision and imposition of disciplinary measures if warranted
7. Appeal process for professionals who wish to contest the decision

The National Nursing and Midwifery Commission Act provides for an appellate process whereby a person aggrieved by a decision of an Autonomous Board may appeal to the National Commission within thirty days. Similarly, actions taken by a State Commission may be appealed to the Nursing and Midwifery Ethics and Registration Board.

These disciplinary mechanisms and legal remedies are essential components of the midwifery regulations in India, ensuring accountability, maintaining professional standards, and protecting the public from unsafe or unethical practice.

6.1. Referral Systems and Protocols

Effective referral systems are a critical component of safe midwifery practice under the midwifery regulations in India. The Guidelines on Midwifery Services in India emphasize the importance of establishing strong referral linkages between Midwifery-led Care Units and higher levels of care, particularly First Referral Units (FRUs) and Special Newborn Care Units (SNCUs).

Referral protocols under the midwifery regulations in India typically include:

1. Assessment of the woman using standardized screening tools
2. Identification of conditions requiring referral
3. Stabilization of the woman before transfer when necessary
4. Communication with the receiving facility
5. Arrangement of appropriate transport
6. Transfer of relevant documentation
7. Follow-up after referral

Common conditions requiring referral include:

• Antepartum: Pre-eclampsia/eclampsia, antepartum hemorrhage, severe anemia, intrauterine growth restriction, malpresentation
• Intrapartum: Obstructed labor, fetal distress, prolapsed cord, prolonged labor, meconium-stained liquor
• Postpartum: Postpartum hemorrhage, puerperal sepsis, retained placenta, severe pre-eclampsia/eclampsia
• Neonatal: Birth asphyxia, prematurity, low birth weight, congenital anomalies, respiratory distress

The midwifery regulations in India emphasize that midwives must be trained to recognize these conditions early, provide initial management, and refer in a timely manner. They must also be trained in communication skills to ensure effective handover of care.

6.2. Documentation and Record Keeping

Accurate and comprehensive documentation is a legal and professional requirement under the midwifery regulations in India. The National Nursing and Midwifery Commission and the Indian Nursing Council have emphasized the importance of proper record keeping for quality care, continuity of care, legal protection, and research purposes.

The National Nursing and Midwifery Commission promotes standardized documentation formats to ensure consistency and completeness. Key principles of documentation include:

• Accuracy: Information should be factual and objective
• Comprehensiveness: All relevant information should be included
• Timeliness: Documentation should be done contemporaneously
• Legibility: Records should be clear and easy to read
• Confidentiality: Records should be stored securely to protect patient privacy
• Non-judgmental language: Documentation should use neutral, professional terminology

With the increasing digitization of healthcare records, the midwifery regulations in India also address electronic documentation, emphasizing data security, regular backups, and appropriate access controls.

6.3. Continuous Professional Development

Continuous Professional Development (CPD) is a mandatory requirement under the midwifery regulations in India to ensure that midwives maintain and enhance their knowledge, skills, and competence throughout their professional careers. The National Nursing and Midwifery Commission and the Indian Nursing Council have established frameworks for CPD to promote evidence-based practice and quality care.

The midwifery regulations in India specify CPD requirements for midwives, including:

• Minimum number of CPD hours/points required for license renewal
• Types of activities that qualify for CPD credit
• Documentation requirements for CPD activities
• Verification processes for CPD compliance

The Guidelines on Midwifery Services in India emphasize the importance of CPD for NPMs, particularly in areas such as:

• Updates on evidence-based practices in maternal and newborn care
• Emergency obstetric and newborn care skills
• Respectful maternity care and communication skills
• Ethical issues in midwifery practice
• Leadership and management skills
• Quality improvement methodologies

The midwifery regulations in India also address the role of employers and institutions in supporting CPD for midwives, including:

• Providing study leave and financial support for educational activities
• Organizing in-house training programs
• Facilitating mentorship and clinical supervision
• Creating learning environments that promote professional growth
• Incorporating CPD activities into regular work schedules

Continuous Professional Development is linked to career progression and annual performance appraisals, ensuring that midwives remain competent, knowledgeable, and skilled throughout their professional lives.