Return of the Daimaa: A game changer in saving lives of pregnant women and newborns

Despite rapid progress in medical education and installing good healthcare facilities in India, it is a matter of grave concern that the country still has an unacceptably high Maternal Mortality Ratio and stands next only to Nigeria in terms of the number of deaths due to pregnancy.

Ideally, we should have a low MMR of single-digit that Western nations boast of, but it is a long distance away, going by the disturbing figures on this score. In India, this figure is upwards of 100. But things have begun to change.

Fortunately, the efforts of a largely women-driven initiative in Hyderabad, the capital city of Telangana, is proving to be the game-changer — of reviving and using midwifery as the means of providing superior healthcare for the pregnant women that is saving the lives of mothers and new-borns. Telangana is becoming the flagbearer for midwifery — for giving full maternity care with dignity and respect that a pregnant mother deserves. It reminds us of the daimaas and mantrasaanis of the yore, who used to be the caregivers to pregnant women and delivered their children.

But this preference for enabling normal deliveries is still low in hospitals given the preponderance of caesarean operations for child delivery, that has become the norm owing to a variety of reasons. Even in cases where it is absolutely unnecessary.

Ironically, the very medical and healthcare advances made by India became a bane for pregnant women as the shockingly huge number of caesarean operations (C-Section procedures) posed an ever-present danger to the lives of pregnant women and new-borns, especially when these operations were not needed at all.

Yes, caesarean operations do have life-saving capabilities but only in cases where it is needed, and unnecessary preponderance to this procedure, almost making operations become the norm in deliveries, led to avoidable deaths of pregnant women and infants. Telangana in 2015 had the highest percentage of C-Section deliveries — at 60.7 per cent of all deliveries. Even government-run hospitals had a high figure of 41 per cent and in the private sector, this was even higher at 75 per cent.

In India, nearly 60 per cent of all deliveries take place in the private sector. It is here that the midwives can play a crucial role — wherein the medical doctors deal with high-risk critical cases and midwives can take care of all the low-risk cases so that the doctors are not overstretched.

Telangana, more or less, reflected the situation in the country where unnecessary C-section interventions became the rule, rather than an exception for a variety of reasons. Other than the hospitals preferring it as a ‘good business avenue’, even people and their craze for childbirths at good muhurthams (auspicious time) for a good future for the infant also had its contribution to the high number of operations for child deliveries. C-Section procedures can save lives but can endanger them when used unnecessarily.

This is why those engaged in maternal healthcare always prefer, advocate and encourage natural, normal delivery, something that most pregnant women desire. In ancient times, the daimaas or mantrasaanis (midwives) in villages were in attendance but over the years, the spread of medical health facilities saw the disappearance of the midwives altogether.

But the world over, midwifery is a proven, globally acclaimed intervention that can prevent most maternal and newborn deaths. And this is exactly what the Telangana government initiative is all about — adopting, encouraging and promoting the concept of midwifery as a healthcare initiative and creating a new cadre of midwives as healthcare service providers.

In a first in India, the Telangana government has established a new cadre of healthcare professionals — midwives — and teamed up with Fernandez Foundation, a private sector non-profit healthcare services provider, to train midwives from the nursing staff of Telangana government hospitals. This initiative began in 2017, with just 30 trainees; today, it has grown to 400 trainees, with the state government bearing all the cost of the training programme.

It is an 18-month certificate training programme in midwifery and the first cohort were trained in 2017 and since then two more cohorts have taken place and eventually the government has plans to increase the number of trained midwives and post them at district level hospitals and even down the ladder in the government-run hospitals, and most importantly, at primary health centres that are the most easily accessible to the women in rural and remote areas.

Today, the Telangana government has absorbed newly trained professional midwives into its healthcare services delivery staff and posted them in area hospitals in districts. A health department official said that it was envisaged to post midwives in primary healthcare centres in all the 33 districts of the state so that the entire village population could be covered.

Now, the small pilot project of training 30 nurses as midwives of 2017 has grown into a full-fledged national programme with the Central government endorsing it and supporting midwifery as a game-changing initiative in saving the lives of pregnant mothers and newborns.

“Today, the government programme has 400 trainees and we are looking at 1,000 midwive trainees in the next five years,” said Vakati Karuna, Commissioner, Health and Family Welfare and Mission Director, National Health Mission, Telangana. One of the drivers of the programme, since its inception, Karuna felt that it was going to be a game-changer when it came to saving the precious lives of pregnant mothers and infants.

“In Telangana government hospitals now, 50 per cent of all deliveries are being carried out by midwives, trained under the new government initiative,” she said and added: “Today we have a C-section audit in every government hospital.”

Karuna said it was a matter of great pride that this initiative had now been taken up at the national level and was being funded by the National Health Mission.

Now the Telangana government’s efforts to start a special cadre in the healthcare delivery system centres around raising an army of midwives. The results of the pilot project, and the performance of the new inductees — nurses trained as midwives — has been so encouraging that many other states are also looking at taking it up in their respective states.

More importantly, the Telangana government is also working with the Indian Nursing Council and the Central government education department to make changes in the curriculum of medical sciences to include midwifery in the MBBS Gynaecology subject.

After it has been observed in Telangana that its midwifery initiative had led to an improvement in the key health indicators and decreasing dependence on unnecessary interventions other state governments too have evinced keen interest in the programme. Andhra Pradesh, Maharashtra, Uttar Pradesh, Odisha and Karnataka are among the states that have begun participating in the programme and want to send their trainees to Telangana institutes.

The Central government has noted that 85 per cent of pregnancies and births do not require specialised obstetric intervention and that midwifery-led care can play a crucial role in promoting physiological births and reducing excessive medicalisation. This is why, the Centre has stepped in support to the midwifery and has come out with guidelines for starting midwifery services, as a separate cadre, across India.

The author is a senior journalist tracking social, economic, and political changes across the country. He was associated with the Press Trust of India, The Hindu, Sunday Observer and Hindustan Times. Views expressed are personal.

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