Improving maternal-neonatal outcomes through implementing Quality Midwifery Services in India: a case study of facilitators and barriers

Approximately 45,000 women die of pregnancy-related causes each year in India, and global evidence shows that 83% of these death can be prevented if competent midwives provide skilled birth attendance. India does not have independent midwives. Indian nurses, who have studied midwifery as part of their nursing studies work as the nurse-midwives in most of the health facilities in public and private sectors. Since India is striving to bring the maternal deaths down from 130 to 70 per 100,000 live births by 2030; the Government of India has acknowledged that introducing and strengthening midwifery in line with the international standards could be an effective strategy to achieve the target.
The Government of India has supported additional training of some nurse-midwives to prepare them as Nurse Practitioners in Midwifery in the states of Gujarat and Telangana. These Nurse Practitioners in Midwifery have been posted in public health facilities serving remote/rural/difficult-to-access geographical areas. In Gujarat, some Nurse Practitioners in Midwifery have been posted in Urban Family Welfare Centers too.
An Indo-UK consortium of researchers have developed this research proposal titled "Improving quality of care through implementing quality midwifery services in India: a case study of facilitators and barriers". This project will be implemented over a period of 12 months. The aim of this study is to document the perceptions and experiences of women, families, community influencers; the Nurse Practitioners in Midwifery, other nurse-midwives, and obstetricians about midwifery; and the facilitators and barriers for establishing independent midwifery in India. The study will also highlight gaps in the quality of care and identify important outcomes that could be used assess whether midwifery is effective.
Our research work will involve qualitative in-depth interviews/focus group discussions/group interviews with women, and community influencers (40 in total) and also with Nurse Practitioners in Midwifery, other nurse-midwives, and obstetricians (40 in total). Reviews of Indian and international literature will be carried out to identify the key maternal-neonatal outcome indicators; and 5 maternal and neonatal deaths from each state will be reviewed to see if reviews of death are a good way to identify gaps in care.
This study will pave the way to do further research to evaluate the impact of midwifery care on maternal and neonatal outcomes in the coming years; and lay the foundation to develop interventions to strengthen rolling-out midwifery care in India. The project will also train early-stage Indian researchers in research skills.

The Indian Government's key strategy to improve the quality of maternal and newborn care and to reduce preventable mortality and morbidity is to implement high quality midwifery services. This preliminary study will investigate the lessons that can be learned from the first sites to implement professional midwifery to inform future scale-up across India.
The study uses ecological systems theory and quality care frameworks to analyse barriers and facilitators to the integration of the new cadre of Nurse Practitioners in Midwifery into the health system, and to highlight gaps in the quality of care. The study design combines community-based participatory research using human-centred design with case study methods to address three objectives: 1). to assess women's perceptions of current maternity services and the acceptability of midwives as key providers; 2) to identify barriers and facilitators to integrating professional midwives into current maternity services; and 3) to identify important outcomes measures that could be used in future research and to explore if review of maternal and newborn deaths is feasible to highlight gaps in care quality. The two case studies in Gujarat and Telangana comprise interviews and focus groups with a total 40 women and community influencers; in-depth interviews with 40 health providers including midwives, nurses and doctors; and exploratory case reviews of maternal and newborn deaths. We will conduct a systematic review to identify potential outcome measure for future research.
Aspects of the study, including an integrated knowledge transfer plan will be co-designed by a stakeholder working group that includes women, healthcare providers and policymakers to ensure outputs are relevant. The key outputs of the study is policy options to strengthen implementation of midwifery across India and a plans for future research to test feasibility of conducting a cost-effectiveness study of professional midwifery in India.

The ultimate aim of this research is to contribute significantly to the implementation of quality midwifery services in India, thereby helping to reduce maternal and neonatal mortality and morbidity. This preliminary study will inform existing Government Policy to roll out midwifery across India. It aims to learn from the experiences of the first sites to implement professional midwifery in order to inform future research that will develop and test potential solutions to improve implementation across India. It has been identified that midwives, when providing the full package of care, fully trained to international standards and well integrated into the existing health care system, have the potential to reduce maternal deaths, stillbirths and neonatal deaths by as much as 83%. Such improvements in maternal and neonatal health will not only benefit women but also their families and communities.

A major impact from this study will be to accelerate progress towards the roll out of high quality professional midwifery in India by enabling policy makers and health practitioners to learn from the experiences of the first sites to implement professional midwifery. The study will co-produce significant new understandings of women's views of current maternity services and of midwives as key providers of maternal and neonatal care, and will identify actionable knowledge of barriers and facilitators to integrating professional midwives into current maternity services. It will also identify relevant and important outcomes and indicators that could be used to measure the impact of professional midwifery services on the quality of maternity care provision. Through involving users of maternity services and the full range of stakeholders responsible for the provision of care to mothers and newborns (e.g. a range maternity care providers, Ministry of Health and Family Welfare, WHO, UNICEF, UNFPA), these activities will produce knowledge that will directly inform modifications and interventions for future scale-up of midwifery services. This will ultimately benefit users of the services, a range of health professionals and health system functioning at district, primary care and facility levels. This learning will also inform policy makers and service planners to ensure the evidence informed roll out of midwifery is as effective and resource efficient as possible - providing not only coverage but high quality midwifery services.

The study will also continue to build research capacity in India and UK researchers will gain further experience of working in a LMIC developing strong partnerships for future work. Researchers recruited to work on the project will receive training in participatory approaches and case study methodology and will be mentored through working in partnership with experienced researchers from within India and the UK. They will also develop skills in data analysis and dissemination and importantly implementation science. Through the use of participatory approaches this research will empower women and health professionals, ensuring their voices and expectations are incorporated. Inclusion of women and health professionals' opinions also keeps the study grounded to the reality of maternity service delivery experienced by both groups, making it context-specific and relevant. This will lead to community level acceptance and utility.

This study will also have impact more broadly producing knowledge and insights of benefit not only to other areas in India, but also transferable to other low and middle income countries in the South East Asia Region e.g. Bangladesh, Pakistan, Nepal, that are looking to strengthen or introduce high quality professional midwifery and that may face similar challenges.