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

Indicator Figure
MMR (2018-20) 97 per lakh live births
SDG MMR target by 2030 <70 per lakh live births
India’s share of global maternal deaths ~8-9%
C-section rate (2019-21) 21.5% nationally; 40-50% in private hospitals
WHO recommended C-section range 10-15% (rates above this suggest over-medicalisation)
Midwifery Cadre Policy 2018 (NPM, Nurse Practitioner in Midwifery)
ANM (Auxiliary Nurse Midwife) Primary community birth attendant cadre
High MMR states Assam (~195), MP (~163), UP (~137)
Low MMR states Kerala (~19), Maharashtra (~33), TN (~58)

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

Item Fact
MMR (India, 2018-20) 97 per lakh live births
MMR decline From 254 (2004-06) to 97 (2018-20)
SDG 3.1 target <70 per lakh live births by 2030
India’s global maternal death share ~8-9%
C-section rate (2019-21) 21.5% (national average)
WHO optimal C-section rate 10-15%
Midwifery Cadre Policy 2018 (MoHFW)
NPM training duration 18 months (advanced midwifery)
High MMR state Assam (~195 per lakh)
Low MMR state Kerala (~19 per lakh)

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