The Government has decided to develop a cadre of midwives as one of the strategies to reduce maternal and infant mortality
Shanti Devi is a household name at Nichla Badho Village in Jagjit Nagar of Solan district, Himachal Pradesh. This is not surprising considering that as a traditional birth attendant or dai, she delivered more than half the population of the village, including six of her grandchildren.
Even after she turned 80, Shanti remained the dai a pregnant woman in distress turned to or if the fears of a first-time mother-to-be needed to be soothed. Midwives can provide 87 per cent of the essential care for expectant mothers and newborns if they are educated and trained, says the World Health Organisation (WHO). But most importantly, as an integral part of a woman’s life, they provide quality care, support and play an important role in reducing preventable maternal deaths.
WHO research has shown that women were less likely to give birth prematurely or lose their babies before 24 weeks of gestation if midwives were the main providers of care during pregnancy. Further, global data indicates that 83 per cent of all maternal deaths and newborn deaths could be averted with the care provided by midwives. Considering four women die giving birth every hour in India, midwives can be the game-changers in this grim scenario.
This is perhaps why the Government finally recognised that midwives could provide quality assistance through the 30 million pregnancies that take place every year and become a cost-effective and efficient model to improve reproductive, maternal and neonatal health services. The decision to develop a cadre of midwives as one of the strategies to reduce maternal and infant mortality was shared by the Indian Government at the recently-concluded International Conference on Population and Development (ICPD+25) in Nairobi. India was among the 179 countries that signed the first international agreement recognising the right to sexual and reproductive health and women’s empowerment at the ICPD in Cairo in 1994. This announcement was made as a part of its commitments to reduce preventable maternal deaths and provide an enabling environment to facilitate women’s autonomy in reproductive decisions.
Although, there has been a decline in the maternal mortality rate (MMR) from 167 to 122 per 100,000 live births (SRS 2016), India has a long way to go to ensure that no woman dies while giving birth. Nearly 32,000 pregnant women still lose their lives during pregnancy, childbirth and the postnatal period every year. Factors like inequalities in access to quality health services, poverty, distance to facilities, lack of information, inadequate and poor quality services and cultural beliefs remain significant barriers to achieving the Sustainable Development Goal (SDGs) to reduce MMR to less than 70 per 100,000 births by 2030.
Besides, disrespect and abuse of women during childbirth at health facilities contribute to maternal mortality and morbidity. While formulating its guidelines on midwifery care, the Ministry of Health and Family Welfare accepted that these were some of the reasons that deterred women from opting for institutional delivery. Although the Government’s LaQshya programme mandates promoting respectful maternity care, its implementation remains poor. However, midwifery-led care could address these issues by promoting quality and continuity of assistance through the provision of women-centric care and help expectant mothers have a positive birth experience, according to the Ministry.
While the Government may have come to this conclusion now, women in Himachal Pradesh realised it much earlier. They also understood that women attended by midwives needed fewer epidurals. This is probably why Shanti was a much sought after dai as she used traditional knowledge and promoted natural birth. She even induced labour pains by giving hot herbal drinks made by boiling fenugreek and carom seeds with soya. Women have often stated that they prefer to have home deliveries by someone they know, rather than an unknown doctor, especially when respectful maternity care is missing.
With health facilities in rural areas being far, the balance in favour of the midwife is heavily tilted. In Shanti’s case, not only was she right there and readily available but her personal touch boosted the confidence of pregnant women. They also knew that she would accompany them to the nearest hospital for delivery if she felt that the pregnancy was complicated and beyond her capabilities.
Shanti’s long experience enabled her to predict when a delivery would take place and she also had the skill to deliver a breach baby. Besides, she provided information on immunisation, birth registration and nutrition. Her abilities, skill and knowledge prompted families living in distant villages to seek her help with deliveries. This also included families belonging to the upper caste, which traditionally shied away from taking the help of a dai belonging to a lower caste.
There are over 10 lakh dais like Shanti serving rural and urban communities. They can be lifesavers in places where there is an acute shortage of trained medical personnel. At present, there are only 1,859 obstetricians at Community Health Centres in the country as against the requirement of 5,510 (2016 Rural Health Statistics). This lack of specialists can be critical for pregnant women, as one of the major causes of maternal deaths (almost 46 per cent according to a 2014 Lancet study) is the poor quality of intrapartum care. This is where trained midwives can make the difference by supporting the overburdened secondary and tertiary care facilities that do not have enough obstetricians.
Severe bleeding after birth can kill a healthy woman within hours if unattended and simply injecting oxytocics effectively reduces this risk. The second major cause of maternal deaths is infection after childbirth.
This can be eliminated if good hygiene is observed and if early signs of infection are recognised and treated promptly. Third, if pre-eclampsia is detected and appropriately managed before the onset of convulsions and other life-threatening complications, maternal deaths can be reduced. In this case, administering drugs such as magnesium sulfate for pre-eclampsia can lower a woman’s risk of developing seizures. These risks could be reduced by midwives who are usually from the same communities as the pregnant women and are familiar with their medical history.
Therefore, investing in harnessing the power of existing midwives across the country by upgrading their skills could mean the difference between life and death for women.What makes the case in favour of trained midwives even stronger is the fact that the financial costs of ending preventable maternal deaths are now known.
A collaborative study between UNFPA, John Hopkins University, Victoria University, University of Washington and Avenir Health shared at the Nairobi ICPD+25, gave a breakdown of the collective costs of ending preventable maternal deaths in 120 countries, including India.
According to Natalia Kanem, Executive Director UNFPA, these figures were a drop in the ocean compared to the dividend expected and the funds available. Speaking at the summit, she said that it would be wrong to even refer to this as a cost as these were smart, affordable investments that would transform the lives of women. What was needed next was the political will and financing to get the job done. The cost of inaction would be much higher, she said.
The decision to build a cadre of trained midwives is a good move to reduce the costs of inaction. But it must not overlook the knowledge and skills that traditional birth attendants have. They must be supported and trained for the sake of the millions of pregnant women they continue to save. After all, even a single preventable maternal death is one too many.
(The writer is a senior journalist)
