It's a privilege to share my views, to be invited, to talk about developing a midwifery workforce in India, the success and the barriers that surround this. India, with its annual birth rate of 26 million a year and the government making it mandatory for all women to come into hospitals to birth. Poses of variety of challenges in terms of offering safety, respectful maternity care. And making sure every birth is a positive experience for that woman. While India has succeeded in lowering its maternal mortality ratio. According to the 2015, 17 sample, registration system was down to 122. It still remains unacceptably high. Countries that have lowered their maternal mortality ratios have done so because of a very strong midwifery workforce that forms its backbone of maternity services. India needs to develop this unique mid force or rather this unique workforce. Right now we are at that cusp of doing that, why am I saying this? Because in December 2018, the Health Minister of India released a book titled Guidelines on Midwifery Services in India. And this was at a very prestigious international meeting called the Partners' Forum. Which was WHO lead, global forum for maternal, newborn and child health. Now this indeed was a landmark event in the history of India. Because this was a public commitment made by the Government of India on a global platform. The government believed that midwifery care was a major step in offering respectful maternity care and also to help reduce unnecessary interventions, including cesarean sections. So 2019 found the Ministry of Health and Family Welfare, Government of India, working with various stakeholders, both National, International and Global Funding Agencies. This was the idea was to bring people together to plan a strategy of how to roll out professional midwifery training across India. A decision was made initially to create six midwifery National Training Institutes in across the country, and they were chosen North, South, East, West. Fernandez Foundation was chosen as one of the National Training Midwifery Institutes. The objective was to train a minimum of 86,000 midwives, over a period of three years. Certainly an audacious plan. So what are the challenges? Or what are the challenges we face today? To begin with, when the word midwife is used, most people associated with the untrained birth attendant. Yes, this workforce, I daresay, had its role to play when we had no other alternatives. But today, when we use the word midwife, we certainly are talking about a highly skilled, competent, accountable professional. And who is accountable for two lives, the mother and her baby. So this is our first challenge to describe who a midwife is and what is her role. To convince people, ordinary women, couples that a midwife plays a very definite, important role in their journey. Parenthood. In India, the second challenge, in India, women are used to seeing a doctor during their pregnancies, and to be assisted by a doctor during childbirth. If a woman sees anybody else other than a doctor, somewhere in her mind, she thinks she is getting sub optimal care. India has a very strong medical lead environment, in terms of pregnancy and childbirth. In this country we face a huge crisis surrounding childbirth, and I refer to three areas. One, women are coerced into accepting unnecessary interventions, or being coerced into accepting things that they're not very comfortable accepting. For example, induction of labor or the use of synthetic oxytocin, or labor being augmented. But the biggest challenge we face is a rise in C sections, so in this strong medically lead environment. We need to introduce a midwife as a professional that women need to trust, and not just the women, the obstetricians also. So this leads us to the third challenge, and the third challenge would be to convince the obstetrician that midwives are required. Having practiced only obstetrics, my entire professional life, for about two decades. I was under the mistaken impression that obstetricians are the most important people in a birthing room. For once I got involved with midwifery and introduced midwifery in our work environment. My attitude to birth understanding of midwifery, the role of a midwife changed, in fact, I took a 180 degree turn. I am absolutely convinced, every woman needs to see a midwife when she is pregnant, and only if required, needs to see an obstetrician. So this is where the third and the most difficult challenge lies, in introducing midwifery in India. To convince the obstetrician to accept the midwife as a professional and trusted colleague. We know there's enough research over the years, to show that the majority of women who are healthy and enjoy uncomplicated pregnancies, do not have to see an obstetrician. They can be looked after very well, and given the best care in the hands of a professional, well trained, highly skilled, competent midwife. We also know the outcomes are far better, and women are happier at the end of this. But, the challenge lies in getting the obstetrician to let go. And getting the obstetrician to accept that she or he is no longer required in the arena of low risk mothers, we need to step out and let the midwives in. Part of this fear of the obstetric community lies in the fact that, there is no medical legal delineation or protection for the midwife. Today, if there is an adverse event, then, who takes the responsibility? Is it the obstetrician, or the midwife? Because today, while the Indian Nursing Council has a one year post basic diploma course. That qualifies or certifies the nurse who has taken this training, as a nurse practitioner in midwifery. That qualified midwife does not have the legal rights to practice as an autonomous practitioner. Neither does she have the legal rights to admit a woman under her care. So why we want midwives to be there in the antenatal phoenix Also, care to all pregnant low risk mothers. She is not given the legal right to accept full responsibility. And this is where the confusion lies and the fear lies among the obstetricians. I've often been asked this question, so who takes the responsibility and I've sort of retorted, wherever midwives are employed, they ought to be protected by us obstetricians, and we must learn to work together as a team. The 5th challenge lies in getting the obstetricians to welcome midwives into the birthing rooms, into the antenatal clinics, and also postpartum clinics. I've often been asked, Dr. Fernandez, if the midwife according to you takes care of majority of our women who are low risk, and if she takes care of these women through her pregnancy, childbirth, postpartum, then what do we do? I suspect part of this fear is the threat to our personal financial resource or financial income, because obstetricians in quite a few hospitals are paid for every case they attend. So we do have some very real challenges in this country. And more so because women. Out of 26 million births, 14 to 16 million are in public hospitals. The rest are in private hospitals where income and finance matter. So these are the real challenges that we face in India. But the final challenge, which I think is equally important, remains in the quality of training of this task force. We do not or did not have this unique task force, so therefore we don't have educators or trainers. The success of a midwifery training program lies in the trainers. The clinical credibility of the trainer is so very important, because midwifery is almost an apprenticeship model. Particularly when you're with a woman helping her birth. It involves that close mentorship, and as a result, we in India as part of our strategy for rolling out the program, are looking for educators and trainers from outside this country. Example, we look at the UK, Netherlands, Sweden, as examples from where we can get trainers, educators of clinical credibility. Why is this important? Because the quality of training needs to be monitored. And this is because we must meet global standards of competency. If we want a unique, an effective or highly skilled midwife, or a midwifery task force in this country, the secret lies in selection and training. What gives me hope? The Indian Nursing Council, the president of the Indian Nursing Council, last year in November, when we launched the first cohort of trainers of the national midwifery educators program here in Hyderabad made two very important announcements at the inaugural session. The president of the Indian Nursing Council said, the Indian government will set up a nursing and midwifery council. Now this certainly brings in a lot of legislation. And the second announcement, he said the parliament has to pass the nurse and the midwifery act. With this, the midwife will certainly Maybe given the license to be an autonomous practitioner, to be accountable and also given the license to admit patients under her care. And this is what gives me hope because the Government of India, the Indian Nursing Council are working together. Finally, I look forward to an India where the maternity services the backbone of maternity services will be formed by this well trained, well regulated, well defined supported Carter of professional midwives. Who will offer midwifery care to every pregnant woman across this country, regardless of her social economic status or the medical complications that her pregnancy is surrounded with. Thank you.
