The Missing Midwives — A Critical Gap in India's Maternal and Newborn Health

Context

The Indian Express editorial makes the case that India’s progress on maternal and newborn health — despite significant reductions in maternal mortality — is being held back by the systematic marginalisation of midwives in the public health system. The editorial calls for a formal, regulated midwifery cadre with meaningful clinical autonomy, drawing on WHO recommendations and international evidence, as a cost-effective and scalable intervention for improving birth outcomes, particularly in underserved rural and tribal areas.

The Editorial Argument

1. The Midwifery Gap — Why It Matters

India’s Maternal Mortality Ratio (MMR) has improved from 254 per lakh live births (2004-06) to 97 per lakh (2018-20) — a remarkable reduction. Yet India still accounts for approximately 8-9% of global maternal deaths given its population scale, and wide inter-state disparities persist:

• Assam: ~195 per lakh (among highest)
• Kerala: ~19 per lakh (among lowest)

The editorial argues this gap is not primarily about hospital infrastructure but about the quality and continuity of care during childbirth — which is where midwifery interventions are most evidence-backed.

2. What Midwives Do — and Why India Has Marginalised Them

Midwives are trained professionals who manage:

• Normal vaginal deliveries — the vast majority of births
• Antenatal care — identifying risk factors early
• Postnatal care — immediate newborn care and breastfeeding support
• Emergency referrals — recognising complications that require physician or surgical intervention

In India, the medicalisation of childbirth — driven by liability fears, hospital-centric training, and OBGYN professional dominance — has effectively de-skilled midwives. The Auxiliary Nurse Midwife (ANM) role was historically the primary community-level midwifery resource, but ANMs have been increasingly reduced to immunisation workers and health record keepers rather than birth attendants.

India’s caesarean section rate has risen from 8.5% (2005-06) to 21.5% (2019-21) — with private hospital rates exceeding 40-50% in some states. This reflects over-medicalisation of what are largely normal pregnancies.

3. The 2018 Policy Reform — Insufficient Implementation

The Ministry of Health and Family Welfare introduced a Midwifery Cadre Policy (2018), creating a new category of Nurse Practitioners in Midwifery (NPM) with enhanced training (18-month advanced course) and defined clinical scope. The policy recognised midwives as autonomous birth attendants for normal deliveries.

The editorial notes this was a correct policy step but has had minimal implementation:

• Only a handful of states have started NPM training programmes
• Clinical autonomy remains contested in hospital settings
• Health facility protocols still require OBGYN countersignature for most delivery decisions

4. What Is Needed

The editorial calls for:

• Formal recognition of midwifery as an autonomous regulated health profession (alongside nursing)
• Scale-up of Midwifery-Led Care Units (MLCUs) — low-risk delivery units managed by midwives, with physician backup for complications
• Rural posting incentives — NPMs posted to high-MMR districts with financial and career advancement incentives
• WHO Global Midwifery Report (2021) implementation roadmap — India is a signatory to WHO targets

Key Data Points

UPSC Relevance

GS Paper 2 — Health, Governance

• Maternal mortality — India’s MMR trends, SDG targets
• Primary healthcare workforce — ANMs, ASHAs, NPMs
• Medicalisation of healthcare — C-section rates, systemic incentives

GS Paper 3 — Economy

• Healthcare as a public good — cost-effective primary care vs. tertiary specialisation
• Rural health infrastructure — gaps in last-mile delivery

Mains Angle

“India’s maternal health indicators show progress, but the over-medicalisation of childbirth and the marginalisation of midwives mask deep systemic inefficiencies. Critically analyse.” (GS2 + GS3)

Facts Corner