In a developing country like India, the government has established various incentive schemes and policies to achieve universal institutional births as a critical strategy to reduce maternal and newborn mortality. Furthermore, the causes of neonatal and maternal mortality and morbidity are inextricably linked, and maternal policy interventions can thus impact the mother’s and child’s health and well-being.

As per National Family Health Survey (NFHS 2019–2020), India is primarily dominated by institutional births, with much higher rates in urban areas across most states. Demand-side interventions like conditional cash transfers (CCTs) for institutional deliveries under Janani Suraksha Yojana (JSY) and extra payment for Caesarean sections have led to an overall increase in the uptake of institutional facilities. Still, little is documented about the quality of care provided and the medical guidelines used for high risk and low-risk pregnancies.

Despite the progress made in the recent decades, which is causing a decline in maternal mortality rates, causes for preventable or amenable mortality are still not being addressed adequately. Systemic challenges can deter optimal outcomes in terms of delays and even avoidable deaths. For instance, a lack of accountability in governance, such as provider negligence during delivery and a lack of grievance or redressal mechanisms and bureaucracy, can result in poor health outcomes.

Evidence suggests a potential to avert about 83% of maternal deaths, stillbirths and neonatal deaths when professionally trained midwives manage medical care. In light of this, it is essential to address issues related to India’s midwifery education, regulation and practice capacities. Midwives and nurses form the foundation of healthcare delivery, uniquely positioned to be frontline advocates for breastfeeding support for women and newborns in the community and health care settings.

The maternal health policy is restrictive in India, as substantial progress is still required to address the obstetric causes of maternal mortality to achieve the SDG goal. India did not independently train and explicitly recognise midwifery until 2020; nursing graduates are being prepared as registered auxiliary nurse-midwife (ANM), but this is changing rapidly. (WHO,2020). The recent bill National Nursing and Midwifery Commission (NNMC) Bill 2020, which aims to regulate and establish service standards for the nursing and midwifery professionals, is also not without flaws. There is a lack of vision for the roles to be undertaken by nurses and midwives and no guidelines for how integration will occur.

The impact of the socio-cultural environment in developing countries often limits women’s to access medical services. Even though institutional deliveries have taken the front stage, some women in rural and tribal areas still prefer natural or home birth to hospitals due to income inequalities and stark differences in infrastructure in state-funded public and private health sectors. A lack of coordination between various levels of care in the delivery system, fragmented care and delays in decision making also contribute to mortality.

Strategies and policy recommendations

One strategy to reduce maternal and infant mortality is to attend to cost-effective interventions such as skilled birth attendance at delivery, emergency obstetric care and antenatal and postnatal care. Moreover, prevention, detection and recognition of the midwifery model of care can play a huge role in reducing the maternal mortality ratio. Preventative interventions such as breastfeeding supported by midwives and nurses are an essential component of respectful quality care.

Health system strengthening with a focus on evidence-based maternal care and quality can help create performance indicators in service delivery. Training and capacity building can go a long way in treating regular deliveries and emergency obstetric care. This can improve community consultations and admissions in case of emergencies. The infrastructure and architecture of hospitals should be based on evidence-based design and consider various geographical barriers women face to access services.

The increased demand for delivery services needs to be complemented with regulation, planning and setting quality compliance standards across institutions. India is trending towards over-medicalisation, and mechanisms should be in place to incorporate high-risk pregnancies for caesarean sections and low risks for normal or vaginal births. Birth education can have an enormous impact here, encouraging mothers for antenatal and postnatal check-ups and training healthcare staff to inform patients to make autonomous decisions. For small and sick newborns, a collaborative multidisciplinary approach among midwives, nurses, neonatal nurses, physicians, and neonatal providers is fundamental.

The medicalisation of birth should be critically examined to understand women’s choices of homebirths and the trends toward over-medicalisation. Birth centres can offer a solution to normalise delivery, and integration of care should ease the transfer of care in case of complications. Furthermore, social and cultural conditions, beliefs, and practices should be considered for evidence-based policymaking to reduce maternal mortality and morbidity and reduce inequalities. Streamlined policies to target the disadvantaged populations, focussing on grassroots development can help reduce maternal health inequities to a great extent.

Further research should be done into places of birth and health architecture, exploring women’s perceptions of the maternal health system and cost-effective interventions in the continuity of care to reduce maternal mortality and refocus on the well-being of mothers while providing safe and sound quality care. It is necessary to conduct research on sexual and reproductive health (SRHR) to understand reproductive behaviours, spread awareness to empower women and girls, and further develop communication strategies encouraging their autonomy and agency.

Originally published here 

Picture credit: UNICEF India, 2022