This article is written by Saswata Tewari from the University of Petroleum and Energy Studies Dehradun. This article talks about the functioning of the alternative maternity care providers in the country and its regulation done by the government of India.

Introduction

For a country to focus on the health of its citizens and promote their well-being, the government needs to put its center of attention on the core health indicators which include maternal and infant mortality.

India has developed and prompted the health of pregnant women and their newborn child by introducing government schemes like Janani Suraksha Yojana, Janani Shishu Suraksha Karyakram which have greatly reduced the maternal and infant mortality rate in India. Not only the health but the government has also reduced the cost expenditure required by a family during childbirth. The government has now made the guidelines for the alternative maternity care providers also known as midwives nurses, to further develop the quality of healthcare services and to make sure that pregnant women and their newborns are getting the right healthcare treatments.

The ‘Midwifery Services Initiative’ started by the government of India, seeks to make a group of Nurse Practitioners in Midwifery (NPM) who are skilled, knowledgeable and can provide compassionate women-center, maternal, reproductive and newborn child-related health care services and develop a helpful environment for the integration of the NPM group into the public health system, to accomplish the sustainable development goals for maternal and newborn wellbeing.

Funding for the midwifery initiative 

The financial support for all the services under the midwifery initiative and for establishing the midwifery enabled healthcare units are provided by the government scheme of National Health Mission.

Guidelines regulating midwifery practices in India

Acknowledging the present condition of India concerning maternity services, the need for properly trained professionals to provide quality care services to pregnant women grows rapidly.

The Ministry of Health and Family Welfare (MoH&FW) has developed certain principles keeping in mind that a proper framework for midwifery care in India can provide cost-effective and efficient models to give quality care and effective services. The present guidelines are developed from taking guidance from National and International experts to support the different Indian states to roll out midwifery services. These guidelines will cover areas about midwifery programs such as their education, regulation, human resources, and career progression, operational miniatures in aspirational districts and urban areas, and observing and research priorities, etc.

Broad principles of the midwifery services

Organizing midwifery services

• The midwifery services should be primarily put into operation within the public health system and these guidelines should be used for integrating the midwifery professionals into the public health system.
• The midwifery care shall be integrated through the introduction of the Midwifery-led care units which are to be established at chosen high caseload public health facilities that are certified by the government program Laqshya. 
• It is expected from the midwifery initiative that the midwives should only get indulged in providing maternity care based on the scope of work defined by the government. Midwives shall be the first person to be contacted for maternity services for pregnant women in areas where midwifery enabled units are functional.
• At the healthcare facility, all pregnant women will be examined by a Nurse Practitioner in Midwifery (NPM). Only those pregnant women will get access to the midwifery services who are not having any medical complications.
• All those pregnant women identified as having medical complications will be further referred to a medical officer or specialist for their further management. These midwifery-led units must have strong referral linkages to First Referral Unit (FRU) and Special Newborn Care Units (SNCUs) to come in help whenever necessary. These referral facilities should be accessible easily and in a short time. 
• The NPM will be held accountable for the promotion of the health of women with a special focus on the childbearing years of a woman and their newborns. She will be responsible for providing healthcare to healthy women before pregnancy, during the pregnancy, childbirth, and postnatal period and will be held accountable for his/her practice. NPMs will be able to encourage safe, natural birthing processes by giving proper respectful maternal, newborn, and post-abortion care services.
• To promote the inclusion of NPMS into the public health system, current medical and nursing staff, and communities will be made aware of the midwifery care services in advance.

Regulations regarding nurse practitioner in midwifery

• Nurse Practitioner in Midwifery is a registered nurse-midwife having a supplementary 18 months of post-basic training in midwifery services. 
• Usually, candidates who are GNMs/Bsc level staff nurses having 2 years of experience in maternity care are qualified for the 18 months of NPM training. The NPM training will allow the eligible nurses to mix high-quality clinical skills with evidence-based decision making.
• When the selected candidates are sent for training and are away for 18 months residential course, other contractual staff will replace these candidates to ensure that there is no compromise in the service delivery for women and newborns.
• If the contractual staff is chosen for the NPM training then their continuity within the system must be ensured with the aid of a service agreement with these contractual candidates.
• The education and training of the NPMS should be held at accredited NPM training institutes that are acknowledged by the Indian Nursing Council (INC). The training to be provided should be skill-based and should comply with the Essential Competencies for Midwifery Practice given by the International Confederation of Midwives for a total time of 18 months.
• It is expected that one National Midwifery Training Institute and five Regional Midwifery Training Institutes will be established and accredited for the provision of this course. All the NPM candidates will be certified by the INC.

Training of the educators of NPM training

The NPM training will be conducted by educators having prior experience in advanced midwifery education, and before conducting the NPM training, these educators will have to first undergo a 3 months midwifery course.

Deployment and career progression

• When the candidates for the NPM training are to be selected, the State government must priorly ascertain the place of posting of the healthcare facility for the selected candidates. The State government must issue the posting order before the training for the NPMs commences.
• Candidates should provide their written consent mandating them to join at the predetermined place of posting and also getting the approval for the continuance of their services after getting trained as an NPM for a minimum period of six years. NPMs can be also posted at remote units but only after they have developed their capability for three years at high caseload units.
• Throughout the clinical service, NPMs will only be able to provide midwifery care and will not be moved to any other areas of nursing care. This will make sure that the NPMs 
  • retain their specific skills, 
  • Stop the attrition of the NPMs, 
  • Improve their quality of care for women and their newborns.
• The introduction of NPMs should be linked with a determined career advancement path.

Institutional arrangements 

• The enforcement of the midwifery initiative will be led by the task forces at the national and state level and will be assisted by the midwifery action group at the district levels.
• The National and State Midwifery Task Forces will be set up under the leadership of The Ministry of Health and Family Welfare and State governments to control the Midwifery Initiative. 
• The National and State Midwifery Task Force would be established to steer the midwifery initiative. The team of experts in this task force will be responsible for the total enforcement of midwifery services in the country. 
• State Midwifery Task Force will be established for checking over the implementation of the midwifery training and care facilities in their respective states with the guidance of the National Task Force.
• The District Midwifery Action Group will also be established and this group will be more action-oriented. This group will be accountable for the implementation of midwifery services in the respective districts.
• International and national collaborations would be set up and strengthened for the successful roll-out of the midwifery services. 

Regulation, Monitoring, and Evaluation

The Indian Nursing Council and State Nursing Councils (SNCs) will be accountable for the certification, regulation, and legal safeguarding of the NPMs. The National Midwifery Task Force (NMTF) will improve the observation and mentoring system to assist the midwives and will also make a mechanism for the separate assessment of the midwifery initiative.

A descriptive monitoring system involving checklist and monitoring indicators will have to be developed by the NMTF. Some of the important parameters are given below.

Parameters to be checked by the NMTF are:

• Observing the training of the midwifery educators. 
• Observing the midwifery training program. 
• Official Recognition of the midwifery training institute.
• Evaluation of the capacity and handholding of the regional training centers for the professional midwifery course being provided by the National Midwife Training Institute.
• Checking that the National Institute is not leaving any effort in the research and evaluation activities.

Parameters to be checked by the State Midwifery Task Force are:

• Observing the state-level policies for establishing the State Midwifery Task Force for monitoring and following up on the state service rules and clarified salary scales for the midwives only.
• Observing and following up on career and promotion methods for the midwives in the state.
• Observing and following up on the described range for practice for the NPMs.
• Observing and following up on the selection and giving out rules for the midwives in the state.
• Observing and following up on the issued posting orders for the qualified NPMs at recognized health facilities.
• Observing and following up on the provisions made by State for the Midwifery enabled units.

Parameters to be checked at the district level:

• Developing a midwifery educator pool as per the standards given by the International Confederation of Midwives (ICM).
• Adapting and designing the midwifery course curriculum as per the local language
• Ensuring the quality of the professional midwifery course as per the standards given by ICM.
• The areas of examination, certification, and registration of trainees have to be made by the respective State nursing councils.
• Making Hospital Superintendents and Medical Officers aware of the roles played by the midwives and ICM capabilities.
• Providing refresher training at predetermined intervals.

For observation of the Midwifery-Led Care Units and checking patient satisfaction, the following steps are taken:

• Making and strengthening the Midwifery enabled care units. 
• Making the staff and community at the healthcare facilities aware of the roles and functions of the NPMS.
• Seeing the general integrations of the midwives into the healthcare units.
• Providing supervision and refresher training of the NPMs.
• Checking the proper service delivery by the NPMs.
• Establishing referral linkages for the Midwifery enabled care units.
• Checking patient satisfaction and all other outcomes of the midwifery enabled care units.

Process of evaluation 

Usually, the internal and external evaluation of the Midwifery initiative is assessed by the national or international organizations and this assessment also includes the evaluation of the national training institute, regional training institutes, and the midwifery enabled care units.

At the starting point of the evaluation, where the midwifery enabled care units would be established to make sure that the influence of the midwifery initiative at these units and neighboring communities can be ascertained. 

The evaluation team can be made of the experts from National Health Systems Resource Centre (NHSRC), National Institute of Health and Family Welfare (NIHFW), Indian Nursing Council, Indian Council of Medical Research (ICMR), Regional Nursing Colleges, National and International cooperating organizations, etc.

The task forces would be accountable for ascertaining the composition and terms of reference for the evaluator team depending on their levels. Common review mission will also be used for the assessment of important parts of the midwifery program.

Conclusion

The Midwifery initiative supported by the government has addressed most of the health-related issues of pregnant women and their newborns and can be further developed to face the issues that are emerging in recent times. Midwifery services can help to develop proper maternal and newborn care facilities. Introduction of NPMs having specialized knowledge, in the midwifery enabled care units can help to strengthen the health workforce even in the regional areas, and developing the midwifery initiative, will promote an enabling environment for integration of the NPM cadre into the public health system and thereby positively influencing the maternal and newborns health measures in the long run.

References

• https://nhm.gov.in/New_Updates_2018/NHM_Components/RMNCHA/MH/Guidelines/Guidelines_on_Midwifery_Services_in_India.pdf

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