The Promise of Midwife-led Care: Humanized Births, Empowered Mothers

In a bustling hospital labour room in India, a young mother clenched her husband’s hand as she worked through a contraction during the final stages of labour. Jayshree, an experienced midwife, encouraged her, “You will be okay,” while guiding her into a more comfortable position. Another midwife, Jismy, demonstrated deep breathing to help relax during contractions. Together, they made the mother feel supported and in control of her birthing experience. That was our first encounter with the midwives.

Midwifery embraces compassionate and respectful care for low-risk pregnancies that prioritizes open communication and minimal medical intervention. Jismy says, “Pregnancy is not a disease or a disability, it’s just a special yet natural state of the body. Our job is to simply support women, so they feel confident and cared for.”

The philosophy of midwifery

Midwives fulfil multiple roles- caretaker, collaborator and a comprehensive support system for the expectant mothers. Their extended consultations address physical as well as emotional needs of the women, providing continuous support throughout the care continuum, in contrast to the intermittent presence of the obstetricians.

Midwives act as decision makers. Jismy and Jayshree recall the challenging yet rewarding transition from nurses implementing doctors’ orders to taking charge and being accountable for mother and child both. Although initially overwhelming, the autonomy allows them to deliver holistic care that prioritizes women’s voices and choices in the birthing process. Obstetricians and midwives work closely together, with obstetricians managing interventions and midwives focussing on natural birthing. Dr. Maimoona, an obstetrician corroborates, “Working together, doctors and midwives can provide women quality care and a safe birthing experience.”

The midwife-led model is more than just an innovative healthcare initiative. With women and newborns at the heart of their care, the midwives recognize that childbirth is more than medical stats and clinical outcomes; it’s a profound human experience.

Challenges and Opportunities

Global evidence supports the effectiveness of midwifery model.  The 2014 Lancet Report highlights that midwives can provide about 90% of essential maternal and newborn care, reducing the maternal and newborn deaths by two-thirds.¹ Hyderabad’s Fernandez Hospital, a National Midwifery Training Institute, has noted lower instances of postpartum haemorrhage by more than 4%, epidurals by 18% and episiotomies by 27% through consistent focus on natural birthing. The hospital also reports lower birthing injuries and increased vaginal birth after caesarean rates, along with lowered caesarean section rate from 22.4% in 2020 to 19.1% in 2024 for women in Robson’s Group 1. This seems to be an encouraging precedent in India, where average caesarean section rates are 21.5% and even higher in private facilities (47.4%), well above the WHO threshold of 15%.²

Besides showcasing the potential for improving the maternal and neonatal health outcomes, the midwives also strengthen the healthcare workforce. Through task-sharing and task-shifting, they ease the pressure on other healthcare cadres and enhance resource efficiency, which is crucial for resource-constrained regions. Midwife-led models are projected to generate a 16-fold return on investment.¹ Research indicates that trained midwives can avert 83 per cent of all maternal deaths, stillbirths, and newborn deaths.³ Thus, investing in quality midwifery training and education can be an opportunity to better India’s maternal health system.

India has made significant progress on its maternal and neonatal health indicators vis-a-vis the Sustainable Development Goals over the past 30 years. The country has considerably lowered its Maternal Mortality Ratio by 83%, Infant Mortality Rate by 69% and Neonatal Mortality Rate by 65%,⁴ yet the reports of mistreatment and abuse of women at the hands of healthcare workers continue to emerge.⁵ Despite this, the adoption of respectful care models such as midwifery remains slow in the country. Contrastingly, it’s not uncommon for midwives in the Sub-Saharan Africa, including South Africa, Kenya, Ghana and Uganda, to manage 70-80% of the normal deliveries. While the Indian government recognized the need for 90000 midwives, the current number of midwives in the country is far from the target number, with 70+ Midwifery Educators, 350+ trained Nurse Practitioner Midwives across 32 districts (International Confederation of Midwives, 2024).⁶

Moreover, issues surrounding the regulation of the quality of care, streamlining collaboration, and scaling up sustainably need to be addressed. Apart from the extent of scale up that must be done, midwives face significant challenges in navigating cultural perceptions and gaining patient trust, especially in a system where obstetrician-led care remains the dominant and familiar standard. These perceptions tend to alter the acceptance of midwife-led models despite their ability to offer equivalent quality in care.

The Way Forward

Midwife-led models of care are gaining global attention. Discourse around national scale-up of midwifery, a combination of human touch and evidence-based care, is growing stronger. The Max Institute of Healthcare Management (MIHM) at Indian School of Business is conducting a comprehensive study at Fernandez Hospital to evaluate the cost- efficiency and impact of midwifery care on maternal health outcomes. The findings of the study intend to foster the thoughtful and strategic expansion of maternal healthcare models that ensure respectful and consistent care for women during childbirth and beyond.

References:

1. World Health Organization: WHO. (2014, November 4). The State of the World’s Midwifery 2014 launched in China to call for greater investment in midwifery to save lives of women and newborns. WHO News. https://www.who.int/china/news/detail/04-11-2014-the-state-of-the-world-s-midwifery-2014-launched-in-china-to-call-for-greater-investment-in-midwifery-to-save-lives-of-women-and-newborns. 
2. Pandey, A. K., Raushan, M. R., Gautam, D., & Neogi, S. B. (2023). Alarming Trends of Caesarean Section-Time to Rethink: Evidence From a Large-Scale Cross-sectional Sample Survey in India. Journal of medical Internet research, 25, e41892. https://doi.org/10.2196/41892
3. Midwives – central to providing quality care to mothers and newborns during COVID-19 pandemic and beyond. (2020, May 5). WHO. Retrieved February 17, 2025, from https://www.who.int/india/news/photo-story/detail/midwives—central-to-providing-quality-care-to-mothers-and-newborns-during-covid-19-pandemic-and-beyond#:~:text=Midwives%20are%20the%20trusted%20companions,Auxiliary%20Nurse%20Midwives%20(ANMs).).
4. Update on Maternal and Child Health Indicators under NHM. (2021). Pib.gov.in. https://www.pib.gov.in/PressReleasePage.aspx?PRID=2112476
5. Marathe, S. D., Jungari, S., & Phadake, M. (2023). Dignified motherhood? Women experiences of abusive treatment and condemned care during childbirth in the health facilities of urban India. Journal of Global Health Economics and Policy, 3. https://doi.org/10.52872/001c.117357
6. ICM. (2024, July 31). Highlighting Success: The Fernandez Midwifery Initiative in India | International Confederation of Midwives. International Confederation of Midwives. https://internationalmidwives.org/highlighting-success-the-fernandez-midwifery-initiative-in-india/