Primary midwifery care in rural India
Twenty year old Mangi (name changed) was visiting her parents in the third trimester of her first pregnancy, when on 23 April 2024, she suddenly noticed vaginal bleeding and began to feel weak. Her alarmed parents brought her to ARTH’s health centre located near their village, in Kumbhalgarh block of Rajsamand district, Rajasthan. Vandana, the senior nurse-midwife on duty quickly assessed her vitals and anaemia status, deliberately avoided performing a pelvic examination (which could have aggravated the bleeding) and ran an intravenous drip to hydrate the anxious woman. She could not detect fetal heartbeat even with an electronic monitor. Vandana filled out a referral note outlining Mangi’s clinical condition and indication for emergency referral to the government District Hospital in Udaipur (antepartum haemorrhage — APH, with intrauterine fetal death), helped arrange transport and quick departure, then called up the ARTH helpline worker based in Udaipur.
Bharat, ARTH’s helpline worker, received the family on arrival at the hospital in Udaipur and expedited her admission. The resident doctor on duty scanned the referral note, examined Mangi and confirmed the key findings. An ultrasound revealed that Mangi’s placenta had partially detached (“abruptio placentae”) leading to hidden blood loss, and the fetus had succumbed to asphyxia. In consultation with a senior obstetrician, 2 units of blood were transfused and labour was gently induced, leading to the delivery of a stillborn infant. Mangi recovered and was discharged after 3 days – in grief at the outcome of her pregnancy, but relieved that she had pulled though a critical emergency. Prompt referral by ARTH’s nurse-midwife-led team enabled timely admission and life-saving treatment by obstetricians and hospital staff, and hence averted a maternal death. Vandana is a part of a team of 8 nurse-midwives that have undergone induction and regular refresher training – they rotate through 24×7 duties at two ARTH rural health centres. They are supported by young, locally trained health assistants and clinic attendants, backed up by helpline workers at Udaipur. Over 25 years (1999-2024), two nurse-midwife-led care teams have attended over 17,500 deliveries (without doctors being present), of which 1,355 (7.8%) women and/or newborns with complications have been referred to a higher health facility for emergency or specialised care. The local community values the friendly and respectful approach of the midwives, women’s freedom to move about early in labour, the ability to deliver in sitting or squatting positions, and referral only if indicated. The experience has helped ARTH visualize a Basic Midwifery Model that upgrades the skills of existing nurse-midwives (there are over 3.5 million1 ANM, GNM and BSc qualified nurse-midwives in India), equips and empowers them to provide access to maternal-perinatal health care in interior rural areas.
Since 1999 when midwifery services commenced, more than 50 nurse-midwives have worked in ARTH clinics and moved on, with a few continuing till today, thereby providing continuity of values and retaining institutional memory. On the occasion of International Day of the Midwife (5 May 2024), ARTH felicitated its midwives with a memento as a token of appreciation of their role in responding to women and families round the clock. In a panel discussion, seven nurse-midwives reflected on how their own understanding of midwifery, and how their own practices and interaction with community members, evolved over the years.
Onwards from 20182, Government of India has expanded investments in midwifery and initiated an 18-month training course for graduate nurse-midwives as Nurse-Practitioners in Midwifery, in midwifery training institutes attached to state and district hospitals in several parts of India. A key goal of this move is to reduce rampant medicalization of childbirth and excess caesarean deliveries in towns and cities. Meanwhile, the home-grown Basic Midwifery Model optimizes skill-based training and deployment of the existing cadre of nurse-midwives in primary care facilities, to reduce unnecessary labour augmentation and similar procedures, and to provide rural women with access to safe, scientific and compassionate care during pregnancy, delivery and after.
There is space, there is need, for complementary midwifery approaches to co-exist in India.
