In 2005, for the first time, the Indian government incentivized institutional deliveries by launching the Janani Suraksha Yojana (JSY), an intervention under the National Rural Health Mission (NRHM) that promised cash assistance to mothers delivering at a medical facility. While the implementation of JSY increased the number of institutional deliveries from 40.8% in 2005–2006 (National Family Health Survey (NFHS) III) to 88.6% in 2019–2021 (NFHS V), there is a recognition that the maternal and newborn health indicators did not improve commensurately. Further, there are huge variations in levels of maternal and newborn mortality across different parts of the country and are higher than in other similar economies.
Apart from the absence of a proportionate decrease in maternal and infant mortality ratios in tandem with the overall increase in institutional childbirths, there is also a growing concern about rising cesarean section (C-section) rates. Overall, the C-section rates in India have crossed the World Health Organization’s (WHO) threshold of 15%. On the one hand, there are districts, regions, and states where C-section facilities are not available even when required; on the other hand, there are states and regions where most childbirths occur through C-sections. In the state of Telangana, for example, 60% of the total deliveries in 2021 occurred by a C-section. Such an “over-medicalization” of childbirth is likely to result in increased costs and higher risks of childbirth.
Respectful maternity care is another cornerstone of quality care. However, reports of ill-treatment, abuses, and negative experiences associated with institutional birth are common in hospitals across India. A study conducted at public and private maternity facilities in Uttar Pradesh reveals that physical violence was often used while performing fundal pressure. Slapping often occurred when fundal pressure was applied. Verbal abuse included speaking down to the expecting woman, using insulting language, and threatening to perform a C-section if expectant mothers did not stop screaming or weeping. Despite the advantage of readiness to manage obstetric complications, many women are mistreated throughout pregnancy and childbirth in hospital births, including the conduction of vaginal examination without their permission, labor induction, and epidural anesthesia.
Decentralized maternal care
Primary health care is a comprehensive, equitable, cost-effective, and efficient approach to improving people’s physical and mental health and social well-being. There is a pervasive and growing need for primary health care, especially in low- and middle-income countries (LMICs) like India, where primary health centers (PHCs) are the bedrock of rural health service, often being the first point of contact with the healthcare system. Maternal and infant health services are an essential component of the service package provided by the PHCs. To this end, PHCs could be the ideal setting for low-risk pregnancies, as they are safe, cost-effective, and treat women with the lowest degree of complexity. Research from underdeveloped regions in developed countries shows that decentralization of maternal health care during pregnancy and childbirths, provided by skilled attendants, can indeed lower maternal and infant mortality, is less expensive, and is more responsive and respectful to women.
However, only a small fraction of deliveries occur at PHCs in India. There is also a growing discourse in policy circles in India that childbirths are safest if conducted in hospitals by obstetricians as opposed to doctors or nurses/midwives in primary care facilities. This argument is partly based on the evidence from the studies, largely from affluent countries, which evidence a volume–outcome linkage for deliveries, with lower mortality for births occurring at hospitals equipped with superior-level neonatal intensive care units (NICUs).
Decentralized maternal care is effective, equitable, and respectful
We recently concluded a review of evidence and experience across developed and developing countries to compare the effectiveness, costs, equity, and acceptability of maternal care in primary care settings, delivered by nurses/midwives (decentralized maternal care) versus hospital-based care delivered by doctors and obstetricians. The review revealed that decentralized care delivered by nurses/midwifes improves maternal and newborn outcomes at significantly lower costs. Not surprisingly, being closer to communities, decentralized maternal care also improves access of marginalized communities to maternal care, enhancing equity. We also found strong evidence that decentralized care by nurses/midwives reduces unnecessary interventions and potentially harmful practices. For example, episiotomy rates are much lower among women whose deliveries are conducted by midwives.
In this review, we also examined why only a small proportion of all childbirths occur in PHCs in India. We found out that this is largely on account of PHCs not being adequately equipped and PHC teams not being adequately supported and skilled. In the state of Tamil Nadu, where PHCs are well equipped and PHC teams are skilled and supported, a large proportion of births do take place in PHCs and community health centers (CHCs).
A call for decentralized maternal care in India
Based on the review and on our own experience of delivering maternal–newborn care in primary care settings in rural Rajasthan, we call for an urgent shift to decentralized maternal care in India. This would require three actions: First, it would require strengthening primary care facilities to deliver maternal–newborn care. The example of Tamil Nadu shows that when such investments are made, a large proportion of childbirths occur in PHCs and CHCs, and there is a proportionate decline in maternal–newborn mortality. Second, we need to strengthen the training, skilling, and supportive supervision of nurses (general nurse midwives and auxiliary nurse midwives) and that of the new cadre of midwives. Third, the linkage of primary care facilities with secondary and tertiary hospitals for emergency obstetric care will need to be strengthened so that women who develop complications can be timely and appropriately referred for emergency obstetric care.
This study is inspired by the tireless efforts of all nurses and midwives who provide respectful and skilled care to women in remote and rural areas. The policy brief on which this editorial is based was financially supported by the United Nations Children’s Fund (UNICEF) India Country Office. Dr Evita Fernandez and Dr Kirti Iyengar reviewed the draft manuscript and provided useful inputs.
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