EVEN today half a million mothers die in pregnancy and childbirth globally every year. Of these, 99% are in developing countries and sadly a majority of deaths are due to preventable causes¹ – a result of lack of skilled persons like a midwife or doctors to attend childbirth and provide emergency obstetric care (EmOC) when needed to tackle complications that kill.² This is when countries like Sweden were successful in reducing the maternal mortality rate significantly way back in the 18th century.³ Notably developing countries like Sri Lanka and Malaysia have reduced maternal deaths by providing midwives in rural areas with good back-up.⁴ The duration taken for reducing maternal mortality depends on strategies adopted, accountability of professionals and political will.⁵

Sweden was among the first countries to achieve a low maternal mortality ratio (MMR) by 1900, much ahead of the United Kingdom and United States. The decline in maternal mortality was more pronounced in the 19th century and early 20th century – before the advent of modern technology such as surgery, blood transfusion and antibiotics. The overall reduction in MMR in Sweden was from 900 deaths per 100,000 live births in 1750 to only six deaths per 100,000 live births in 1980;⁶ the figure is now only1-2 per 100,000 live births.

More recently, Sri Lanka reduced its MMR in a relatively short period. From a level of over 1500 per 100,000 live births in 1940-45, maternal mortality fell to 555 per 100,000 in 1950-55, 239 per 100,000 within another 10 years, and to 95 per 100,000 by 1980. The figure is now 30 per 100, 000.⁷ These improvements followed the introduction of a system of health facilities around the country, mainly an expansion of midwifery skills and the spread of family planning.⁸

This paper looks at how Sweden historically and Sri Lanka more recently reduced their maternal mortality and what lessons India can learn from their experience. We also briefly present what progressive states like Tamil Nadu, Gujarat and some NGOs are doing in this regard.

 

Sweden was one of the first European countries to establish a reliable vital registration system as early as 1750. In 1749 the office of the Registrar General was founded which compiled national statistics such as census and causes of death. Reasonably reliable data is available in Sweden on maternal mortality from the 17th century onwards, which helped measure progress in reducing the maternal mortality ratio (MMR).

 

The rapid decline in the maternal mortality rate in rural Sweden after 1875 was mainly due to improved standards of maternal care associated with increased numbers of well-trained midwives.⁹ Midwives were part of a developing public health system in Sweden, which had a political commitment to equity reaching the poor and rural population, and to quality of services through adequate training of physicians and midwives and surveillance of outcomes.¹⁰

Sweden is a vast country with a sparse population making the availability of doctors to rural populations difficult in the past; hence, a midwifery based maternal care system was developed. In the early 18th century, the government decreed that midwives undergo a two-year training and pass the Collegium Medicum (equivalent of the Medical Council) examination. By the late 19th century, midwifery became a legitimate profession – separate from nursing. Table 1 gives a list of events which led to the establishment of an efficient midwifery system in Sweden.

To make midwives acceptable to the community, strong, healthy and respectable women were selected and trained to become midwives. These new midwives were better trained, hence safer than traditional midwives. The maternal mortality in Sweden declined from 400 to 100 as the deliveries by trained midwives increased from 30 to 70% between 1861 to 1894.

The early reduction in maternal mortality in Sweden was mainly because of teamwork of physicians and highly competent midwives. This fact is reflected in a remark by an American physician, ‘Scandinavian midwives are proud of being associated with important community work and whose profession is recognized by medical men as an important factor in the art of obstetrics, with which they have no quarrel.’¹¹ He attributed the lower mortality rates in Sweden to a carefully supervised system of instruction and practice of midwifery.

In Sweden normal deliveries in the 18th and 19th century were done by midwives under supervision of doctors. This midwife-doctor cooperation was facilitated by the population distribution where 90% of the population was in rural areas and without doctors, but had locally accessible trained midwives. Most of the home deliveries were undertaken by midwives who also performed instrumental delivery in the absence of doctors. This was respected by the state and sanctioned by the law (see Table 1).¹²

The two year long midwifery training in Sweden was detailed and involved considerable theoretical and practical instruction. Under supervision of the head midwife or trained sister, the student midwife was required to deliver 100 to 125 women during the training period, which gave high degree of skills and confidence to conduct childbirth. The final approval came after a month’s trial period. For instrumental deliveries, a local medical officer supervised the midwife. Until the age of 50, midwives were required to undertake regular review courses. From its inception, the midwifery system has been under the firm control of the state and medical profession. The strict regulation came at the beginning of a midwife’s career, but she was independent once she was trained and satisfied the examiners who were also doctors.

Community midwifery in Sweden was based on regular review and close supervision. The midwives were required to report to general practitioners through a detailed diary. The report provided information about all the deliveries attended, interventions done, reasons for interventions, follow up including temperature chart of woman, outcome of the mother and child and so on. The report was signed by the county physician and registered at the national health bureau. The Swedish midwifery association exercised control over the professional conduct of midwives. The standardized protocols for management of birth complications were strictly enforced.

Thus, over the last 300 years, Sweden created a system of high quality training, deployment and supervision of highly skilled midwives which lead to a decline in MMR.

 

Let us now turn to Sri Lanka, a low income country, that established a civil registration system way back in 1867.¹³ The system is based on village level registration by an honorary registrar designated by government. Maternal death reviews began in the 1980s. The purpose was to identify preventable factors/causes and take corrective measures; it was not a fault-finding exercise.¹⁴ In 1989, maternal death was declared a notifiable event. Overall, an efficient vital registration system helped Sri Lanka identify the magnitude of maternal mortality, trace the progress and work towards its reduction.

 

Sri Lanka was perhaps the first country in Asia to establish a government maternity hospital as early as 1879, followed by the first training school for midwives in 1881. Legislation passed in 1887 required the registration of all midwives. From the beginning efforts were made to provide quality midwifery services at the community level.¹⁵

In 1906, Sri Lanka appointed six trained midwives to Colombo municipality hospitals. After 1926, with the establishment of health units, training of public health midwives (PHM) commenced. They were part of the community and provided home-to-home antenatal, natal and postnatal care.¹⁶ These midwives were backed by a good referral system for timely management of maternal complications. During the 1950s, most births in Sri Lanka took place at home with the assistance of untrained birth attendants. By the end of the 1980s though, over 85% of all births were attended to by skilled personnel, mainly community-based midwives.¹⁷ The number of trained midwives increased from 347 in 1941 to 7394 in 2000 – a 20-fold increase¹⁸ (Table 2).

In Sri Lanka, social policies such as free health services, subsidized transport, recruitment and training of public health midwives instead of traditional birth attendants (TBAs or dais) played a significant role in reduction of maternal mortality.¹⁹

Training of public health midwives commenced in 1928.²⁰ At present they are trained for 18 months of which six months is at the community level. The training is highly practical and hands-on. However, unlike her Swedish counterpart, the Sri Lankan midwife is not allowed to use instruments and has to refer such cases to higher facilities. She keeps a record of her activities and reports performance and vital events to a medical officer. In Sri Lanka, the Medical Officer of Health supervises a public health midwife.²¹

Sri Lanka has a systematic posting and transfer policy that ensures the posts of public health midwife and doctor are filled regularly in remote areas. The government also ensures that staff stays at the place of posting and provides free services. The basic needs of staff and their family are taken care of alongside assurance of career advancement.²² Supervision by various levels of managers is fairly strict and systematic to ensure accountability and quality of work.

Thus multiple factors were responsible for a rapid decline of maternal mortality in Sri Lanka.

 

India has yet to achieve its goal of reducing maternal mortality despite a long history of programmes to improve maternal health, mainly due to lack of consistent policies and an absence of focus on evidence-based interventions.²³ Although efforts were made to establish midwifery practices in India even in British times²⁴ (see Table 3), midwifery is not recognized as a separate profession by law, society, medical and paramedical professionals even today. Unsurprisingly, India has a very low nurse-midwife to population/patient ratio compared to Europe.

Though midwifery and nursing are regarded as paramedical professions to support doctors, midwives are not given due recognition by medical professionals and the state. Unfortunately, even the nursing profession resists accepting the separate identity of midwives; this despite efforts by the British to promote midwifery for delivery care in the pre-independence era. As a result, the midwives do not have a separate professional body, nor are they represented in the Nursing Council or the Trained Nurses Association of India (TNAI). A Society of Midwives was only recently formed in India.

There are no official job/positions of community or institution-based midwives. The Auxiliary Nurse Midwives (ANM) who are community midwives are not trained to use life-saving drugs and procedures in case of an obstetric emergency, although the government has recently liberalized the drug policy and allowed them to administer the first dose of certain life-saving drugs for birth complications. There are no career advancement prospects for midwives.

The original training course for ANMs was for two years, which had a midwifery component of six months. From 1980, however, the training duration was reduced to 18 months with reduced emphasis on midwifery, specifically the practical component. Not only are there no separate midwifery schools in India, most of the ANM training schools lack good midwifery teachers and training facilities.²⁵ The nursing courses have a 3-6 months posting in the labour rooms of a hospital, but a student nurse does not get any hands-on experience of midwifery. Unlike in Sweden, midwifery training in India does not include management of birth complications. After training, the ANMs are registered with the Nursing Council as there is no separate registering body for midwives.

There is no provision for continued education for midwives. The Indian Nursing Council (INC) has limited powers over state nursing councils to ensure quality nursing/midwifery training and adherence to protocols in practice in the country.

 

There is no data on practicing midwives in India. Not only are the records of delivery in India very scanty, there is no verification of records by supervisors. Since ANMs are monitored only for family planning and immunization, they have neglected delivery care. At present only 11% of deliveries in India are conducted by ANMs. Worse, the outcome of deliveries is not monitored – unlike in Sweden and Sri Lanka. Lady health visitors and district public health nurses who supervise ANMs, are not trained for delivery care and do not have facilities to carry out field supervisions. At the state and national level there are hardly any nursing/midwifery management posts.

Since the country has paid little attention to development of the vital registration system, the maternal mortality data in India remains unreliable. It is likely that the projected maternal mortality rates at state and national level are an underestimate. It is thus difficult to both judge the magnitude of the problem and the progress made.

 

Over the last few years some states and NGOs in India have developed interesting models of midwife-nurse based maternal health care services supported by needed emergency obstetric care services. For example, in Tamil Nadu, the government has developed a model of primary health care centres staffed by three nurses to provide a 24-hour service for childbirth. Tamil Nadu has also established a good system of recording all maternal deaths and conducting a maternal death inquiry to find preventable factors. It has also developed centres for emergency obstetric care throughout the state.

Similarly, the Academy of Nursing Studies, Hyderabad has developed a nurse-based model of maternal care in the Medak district through the government health system. Arth, an NGO has developed a nurse-based model in rural and tribal areas of Udaipur district by appointing its own nurses for a cluster of villages. The Swedish Sida-assisted midwifery and maternal healthcare development project coordinated by IIM Ahmedabad, is also trying to help develop midwifery training, practice and research in five states in India through teacher training, skill training of ANM and networking with Swedish partners. The Indian Nursing Council has also developed a one-year curriculum for training nurses to become practitioners of midwifery. CEDPA with help from Jhpeigo has developed a model of skill-based training of midwives in rural Jharkhand.

 

International evidence, especially from Sweden and Sri Lanka, shows that midwifery-based maternal health service, backed by referrals and emergency obstetric care services, was successful in reducing maternal deaths in resource poor settings during the 19th and 20th century. Based on the review of midwifery in India, and the experience of Sweden and Sri Lanka, we offer some specific recommendations.

The ANM should be upgraded to Public Health Midwife as in Sri Lanka. As done in Sweden and Sri Lanka, training young, strong, highly motivated and healthy women from urban and rural areas, giving them quality midwifery training (at least two to three years) and having strong regulations will help improve the status of midwives in society. Medical professionals should work as a team with midwives for increasing accessibility of quality delivery care. Providing care only through obstetricians for 70% of India’s rural population is not possible even in the medium term, which is in the next 20-30 years. The status of midwifery as a profession should be improved in India. Separate registering and regulation bodies (councils) for midwives will help establish it as an independent profession.

Standardization of protocols for midwives to manage common obstetric emergencies and interventions needs to be established along with a good reporting system. Close supervision and regular refresher training would help enhance skills of community midwives and maintain quality delivery services in rural areas. Detailed reports of work done by midwives will help in monitoring skills and outcomes.

Training of midwives should be of adequate duration (at least two years) with a strong practical component. Competency-based training should be given in both institutional and community set-ups to give midwives the required skills and confidence to manage delivery care in a rural situation. The training should be given under supervision of senior nurse/midwife for normal and abnormal labour and management of basic emergencies. Certification of the midwife must be done after a trial period in the field where they conduct at least say 50 deliveries. Regular refresher courses should be mandatory for midwifery practitioners.

Institutional and community-based midwife posts should be created in both government and private hospitals to look after normal deliveries and basic EmOC. A regulating body consisting of senior midwives and medical professionals should oversee both sectors. The midwife’s role should be expanded to include family planning, menstrual regulation, abortion, STD and HIV counselling, adolescent health, women’s reproductive health outside of pregnancy and childbirth, and so on.

India needs to urgently establish a reliable vital registration system and maternal outcome monitoring system to provide an accurate picture of the maternal health situation. This will also help assess the work of midwives on maternal mortality and morbidity.

 

The present maternal health situation in India is similar to the one that prevailed in Sweden during the 18th century and Sri Lanka in the early 20th century. Seventy per cent of India’s population is rural and thus it is not possible to have doctors for all births. Reforming maternal health services by developing quality midwifery services, backed by referrals and emergency obstetric services, will help provide locally accessible skilled assistance for all births and significantly reduce maternal mortality. Establishing midwifery training schools, an independent regulating body, and standardizing midwifery practice through protocols, requires continuous effort on the part of government, medical and nursing professional bodies and society. Creating posts for midwives at institutional and community levels with scope for career advancement will help to attract bright women which in turn will help improve the status of midwifery as a profession.

Sri Lanka’s experience shows that when public health midwives, supported by doctors and a referral system, provide maternal health, it is possible to rapidly reduce maternal mortality with modest public expenditures.²⁶ If India still neglects midwifery development and keeps focusing on ineffective strategies of TBA training, training community volunteers (ASHA) or half-baked efforts through short training of ANMs without fundamental restructuring of rural midwifery services, maternal mortality is unlikely to decline rapidly. Adopting a skilled cadre of midwives backed up by referral and EmOC will help India to achieve the goal of rapidly reducing maternal mortality with the existing resources.

 

* The authors are thankful to Swedish International Development Agency (Sida) for partial support for this work and to Professor K.V. Ramani (Indian Institute of Management, Ahmedabad), Dr Prakasamma (Academy of Nursing Studies, Hyderabad), Dr Kyllike Christianson (Karolinska Institute) and Ms Aana (Swedish Midwifery Association) for the support and inputs provided for this paper.

Footnotes:

1. M.A. Koblinsky, Reducing Maternal Mortality: Learning from Bolivia, China, Egypt, Honduras, Indonesia, Jamaica, and Zimbabwe, World Bank, 2003.

2. R.M. Hecht, Foreword, Investing in Maternal Health: Learning from Malaysia and Sri Lanka, World Bank Publication, 2003.

3. I. Loudon, ‘European Midwives’, chapter 24, in Death in Childbirth, Clarendon Press, 1992.

4. R.M. Hecht, op cit.

5. W. Van Lerberghe and V. De Brouwere, ‘Of Blind Alleys and Things That Have Worked: History Lessons on Reducing Maternal Mortality’, in Safe Motherhood Strategies: a Review of the Evidence, 2001.

6. I. Loudon, op cit; U. Hogberg and S. Wall, ‘Secular Trends of Maternal Mortality in Sweden for the Years 1750 to 1980, Department of Obstetrics and Gynaecology, University Hospital of Ume’a, Sweden.

7. N.W. Vidyasagara, ‘Maternal Mortality Reduction in Sri Lanka’, WHO, Sri Lanka, 2003.

8. ‘Maternal Health Services’, chapter 2 in Maternal Mortality Decline: The Sri Lankan Experience, Unicef, Sri Lanka, 2003.

9. I. Loudon, op cit.

10. U. Hogberg, ‘The Decline in Maternal Mortality in Sweden: The Role of Community Midwifery’, American Journal of Public Health 94(8), 2004, 1312-1320.

11. I. Loudon, op cit.

12. U. Hogberg, op cit.

13. Maternal Health Services, op cit.

14. Ibid.

15. Ibid.

16. Ibid. and U. Hogberg, op cit.

17. N.W. Vidyasagara, op cit.

18. Ibid.

19. Hiranthi Wijemane, Maternal Mortality Decline: The Sri Lankan Experience, Unicef, Sri Lanka, 2003.

20. Maternal Health Services, op cit.

21. Ibid.

22. Personal communication with maternal health experts from Sri Lanka.

23. R.R. Ved and A.S. Dua, ‘Review of Women and Children’s Health in India: Focus on Safe Motherhood’. Background paper for Burden of Disease in India. National Commission on Macroeconomics and Health, 2005.

24. M. Chugani, ‘Midwifery in India and its Future’, unpublished. U. Handa, ‘Midwifery Services in India’, unpublished; see Table 3.

25. Dileep Kumar, ‘Nursing for the Delivery of Essential Health Interventions’. Background paper for the National Commission on Macroeconomics and Health, WHO, India, Report, 2005.

26. I. Pathmanathan, et al, ‘Investing in Maternal Health: Learning from Malaysia and Sri Lanka’, Executive Summary, World Bank Publication, 2003. ‘Factors Contributing to the Reduction’, chapter 4 in Maternal Mortality Decline: The Sri Lankan Experience, Unicef, Sri Lanka, 2003.