This document provides an overview of midwifery and obstetrics in India. It discusses the history and development of midwifery in India from ancient times through independence and into the present. Key topics covered include the roles of dais and midwives, the establishment of midwifery training programs, changing perspectives and approaches over time, contemporary midwifery roles and cadres, and statistics on maternal and infant mortality rates.

1. Introduction
to Midwifery

2. • Introduction to concepts of midwifery and obstetrical nursing
Obstetrics word came from a Latin word "OBSTETRIX" means
"MIDWIFE".
Midwifery, as known as obstetrics, is a health science and health
profession that deals with pregnancy, childbirth and the
postpartum period (including care of newborn), besides sexual
and reproductive health of women throughout their lives.

3. Terminology
• Midwifery is the knowledge necessary to perform the duties of a midwife.
• Obstetrics is that branch of medicine, which deals with the management of pregnancy, labor
and puerperium.
• Gynecology is that branch of medical science, which treats diseases of the female genital
organs.
• Reproduction means process by which a fully developed offspring of its kind is produced.
• Pregnancy is a state of carrying fetus inside the uterus by a woman from conception to
birth.
• Gestation means pregnancy.
• Gravida is state of pregnancy irrespective of its duration.
• Multipara refers to a woman who has given birth more than once.

4. • Nullipara is the woman who has not given birth before.
• Primigravida is a woman carrying first pregnancy.
• Multigravida is a woman carrying pregnancy more than once.
Healthy women are the key to the health of any nation, primarily because of their vital role in co-
creating healthy infants and co-caring for the family.
Providing health care to women is not only a health issue but a matter of human rights issue.
In women's life childbirth is a special event.
A mother will never forget a 'midwife' who delivered her baby, and who was 'with the woman'
during childbirth, which is the very essence and identity of a midwife.
Hence a midwife is an obvious catalyst in providing safe motherhood in the fabric of our society.

5. Midwifery in India before independence
In ancient India, care of women and practice of midwifery were totally in the hands of indigenous
village 'Dias'.
• These indigenous dais, not only helped during childbirth but also acted as consultants for any
condition of the mother related to birth.
When medical missionary women from England came to India, the first striking observation they made
was that, since mothers were unable to deal with difficult deliveries and pregnancies, the maternal and
neonatal mortality were very high.
The first training school for dais was started in 1877 by Miss Hewlett, an English missionary of the
Zenana Missionary Society.
However, the training of dais was not taken up by Government of India till 1900 when a fund was
established by Lady Curzon to improve the conditions of childbirth in the country.

6. But before that, in 1872, a handful of Indian Christian nurses were trained for two years at Delhi.
In 1899 the Zenana Bible and Medical Mission started the training of nurses, but until 1893 there was
no generally accepted scheme of training in the hospitals.
In 1918 with the help of Dufferin Fund, Lady Reading Health School was established to train Auxiliary
Nurse Midwives (ANMs).
In 1926 the Madras Registration of Nurses and Midwives Act was passed to promote the role of a
registered midwife for service during childbirth.

7. • In 1936 Dufferin fund sanctioned grant to a number of Dufferin hospitals to build hostels,
supply teaching materials and employ qualified sisters in nursing schools.
Thus Dufferin fund helped in raising the standards of nursing and midwifery in India.
• In fact prior to independence, midwifery training started as a separate course, in India.
Young girls at the middle school level (8th) were selected to undergo this training

8. Midwifery in independent India
• In 1946, the Bhore committee laid stress on the need for qualified
midwives, health visitors and the training of nurses.
• In 1955, the Shetty Committee recommended the training of Auxiliary
Nurse Midwife (ANMs) in health centers for maternal and child health
services, provided there were adequate health visitors to supervise them.
In 1959 Bishoff, a technical consultant supported the training of two types of
nursing personnel ANM and General Nurse Midwife (GNM Nursing - 3 years
and Midwifery - 1 year).
In 1947, the first step the Indian Nursing Council took after its inception was
to combine the nursing and the midwifery courses into a single course.
• The course was designed to be of three and a half years duration, with the
entry qualification being 10th class

9. • In 1975 the Kartar Singh Committee recommended shortening
the two year course of ANM to one and a half years and entry
after class 10th.
• These ANMs were designed as female health workers. They
were specially trained in midwifery and child health care
services. Government of India also invested heavily in the
training of dais.

10. Present and future of midwifery in India
The presence of a skilled midwife at birth is the single most
important factor for achieving safe motherhood (WHO).
The number of midwives available as per population is an important
indicator of the maternal health status in a country.
The maternal health status of women and maternal mortality are
closely related to the presence of trained attendants at birth.
As the percentage of births attended by trained personnel goes up,
the maternal mortality ratio goes down.

11. In India there are the following cadres of midwives
1. The trained nurse midwife (RN, RM): Who has undergone a diploma
(Diploma in General Nursing and Midwifery), which is of three and a half
years duration. Or A degree nurse who has done B.Sc. (Honors)
Nursing, which is of four years duration.
2. The ANM, who is designated as the Multi worker (female), is registered
as a midwife. purpose health
Presently, this is a two year course with entry classification being 12th
class.
India has a huge cadre of ANMS who are educated and trained in
Midwifery.

12. 3. Skilled Birth Attendant (SBA) refers exclusively to people with
midwifery skills (e.g. doctors, nurses, midwives) who have been
trained to get proficiency in the skills necessary to manage normal
deliveries and to diagnose, manage or refercomplications to all levels
of health care settings.
Midwifery skills are defined as a set of cognitive and practical skills
that enable the individual to provide basic health care services
throughout the natal continuum period and also to provide prompt
actions in emergencies including life saving measures, when
required.

13. • Need for midwifery as a profession in India
1. To achieve safe motherhood.
2. To avoid duplication of services.
3. To give health education.
4. To participate in country's concern i.e. maternal and child
welfare.
5. To get status and recognition in the society.

14. Trends in midwifery and obstetrical nursing
Changes in social structure, variations in family lifestyle
It has altered health care priorities for maternal and child health
nurses. Today, client advocacy, an increased focus on health education
and new nursing roles are ways in which nurses have adapted to these
changes.
Cost containment
Cost containment refers to systems of health care delivery that focus on
reducing the cost of health care by closely monitoring the cost of
personnel, use and brands of supplies, length of hospital stays, numbers
of procedures carried out, and number of referrals requested.

15. • Expanded roles for nurses
• Increasing nursing responsibility for assessment and professional
judgment and providing expanded roles for nurse practitioners, such
as the nurse - midwife.
Family centered care
More natural childbirth environment where partners, family members
can remain in a homelike environment and participate in the childbirth
experience.
By adopting a view of pregnancy, childbirth as a family event, nurses
can be instrumental in including family members in care and consult
family members about a plan of care and provide clear health
teaching so that family members can monitor their own care.

16. • Access to health care
• Strong predictors of access to quality health care include having
health insurance, a higher income level and a regular primary care
provider or other source of ongoing health care. Use of clinical
preventive services, such as early prenatal care, can serve as
indicators of access to quality health care services.
The objectives selected to measure progress in this area are: o
Increase the proportion of persons with health insurance.
- Increase the proportion of persons who have a specific source of
ongoing care.
-Increase the proportion of pregnant women who begin prenatal
care in the first trimester of pregnancy.

17. • Shortening hospital stays
Women who have begun preterm labor stay in the hospital while
labor is halted and then are allowed to return home on medication
with continued monitoring.
Routine hospital stay for mothers and newborns after an
uncomplicated birth is now 2 days or less.
Short term hospital stays require intensive health teaching by the
nursing staff and follow up by home care or community health
nurses.
Increased use of alternative treatment modalities
There is a growing tendency to consult alternative forms of therapy,
such as acupuncture or therapeutic touch, in addition

18. to, or instead of, traditional health care providers. Nurses have an
increasing obligation to be aware of complementary or alternative
therapies.
Increased use of technology
The field of assisted reproduction (e.g. in vitro fertilization), seeking
information on the internet and monitoring fetal heart rates by Doppler
ultra sonography are another examples.
In addition to learning these technologies, maternal and child health
nurses must be able to explain their use and their advantages to
clients. Otherwise, clients may find new technologies more frightening
than helpful to them.

19. Technological advances
As the technology has revolutionized and increasingly sophisticated
computers in today's world, it has become necessary for the nursing
personnel to have thorough knowledge of the new technology being
used.
• Due to this advancement, 'the hands on care' of the client is reduced,
so is the, quality nursing care.
Today fetal monitoring has progressed from the use of fetoscope to
electronic fetal monitors. It can be used both, directly and indirectly
stimulate men to take interest in obstetrics.

20. Historical development in obstetrics
In 1739, in London, William Smellie and his student William Hunter became
obstetricians and worked for the same.
• In 1744, William Smellie introduced steel lock forceps.
In 1752, William Smellie published 'Textbook of Obstetrics'.
In 1760, Puerperal fever was on peak in London in Lying-in hospital.
On Jan 14th 1794 first Cesarean operation was performed by Dr. Jesse
Bennett of Virginia on his wife.
• First school of midwives was established at Pare's instigation at the hotel
Dieu in Paris.
In 18th century National regulation of education and practice of midwifery
began.

21. • In 1807, Samuel Bard published the first book on obstetrics on four stages
of labor.
In 1847, Semmelweis, in Vienna, demonstrated that washing hands in
chlorine of lime solution before examining women in labor reduces
puerperal fever. Chloride of lime used as antiseptic.
- Obstetrical forceps was developed by Dr. Peter Chamberlain. In the
past only Greeks used variety of hooks and tractors to deliver dead fetus.
In 1853, Dr. James Y. Simpson of Glasgow succeeded in introducing the
use of Chloroform anesthesia as an aid in obstetrics called "ERA OF
MODERN OBSTETRICS".
Then, Pinard Fetoscope was developed and Lan Donald from Glasgow
introduced Ultrasound in Obstetrics.
In 1950, Fritz Fuch of Copenhagen performed Amniotomy identified the
fetal cells present in it which identify sex of the

22. • 1974 - Family Planning Services Incorporated In MCH Care
• 1977 - Renaming Family Planning To Family Welfare
• 1978 - Expanded Program on Immunization
1985 - Universal Immunization Programme
1992 - Child Survival & Safe Motherhood Programme
1996 Target Free Approach
1997 RCH Program Phase-1 (15-10-1997) -
• 2005 - RCH Program Phase-2 (01-04-2005)

23. Contemporary perspective of obstetrics
• In current view all the focus from obstetrics care shifted to perinatal care.
Advancement in Obstetrics care has reduced the MMR.
Govt. has started program to identify high risk mothers.
Training of health personnel, Allocation of facilities & equipment decreases MMR.
MMR can be reduced:
Early registration of pregnancy.
o At least three antenatal check-ups.
o Dietary supplements can correct anemia.
o Prevention of infection and haemorrhage during puerperium.
o Prevention of complications e.g. Eclampsia, Malpresentation, ruptured uterus.
o Treatment of medical conditions e.g. hypertension, DM, TB.

24. • Anti-malaria and tetanus prophylaxis.
o Clean delivery practice.
o Institutional deliveries for women with bad obstetric history and risk
factors.
o Promotion of family planning.
MCH services have started which aims at reduction in morbidity and
mortality rate of mother and baby.
Baby friendly hospital scheme has been launched in 1993 for
effective breastfeeding to children.
. Genetic counseling to the couples.
Screen the mother for HIV.

25. • Morbidity in obstetrics occurs from any cause related to
pregnancy or its management, any time during antepartum,
intrapartum or the post partum period.
Causes :
• Direct causes, such as APH, PPH, sepsis, rupture uterus, ectopic
pregnancy, eclampsia, obstructed labor etc.
Indirect causes, which consist of those conditions which were
present earlier also, but aggravated in pregnancy, such as
anemia, tuberculosis, hepatitis, malaria etc.

26. Maternal fertility-
According to the Health Population Policy 2000, India was supposed to
achieve replacement level of fertility by 2010, but experts find it a tall
order.
According to a Professor of Population Research Centre, Institute of
Economic Growth, "Although fertility decline has set in all over India, its
slow pace in some parts of the country remains a serious concern for
population and development planners. As such, the target is likely to be
achieved by 2018,”
According to a latest data from the National Family Health Survey-III, an
increasing number of couples want a maximum of 2 children. This data
caused the fertility rate to drop from 2.9 in the year 2000 to 2.7 in the
year 2006.

27. Year FERTILITY RATE
2008 2.76
2007 2.81
2006 2.73
2005 2.78
2004 2.85
2003 2.91
2002 2.98
2001 3.11

28. Definition of Total fertility rate:
This entry gives a figure for the average number of children that
would be born per woman if all women lived to the end of their
childbearing years and bore children according to a given fertility
rate at each age.

29. The total fertility rate (TFR)
• It is a more direct measure of the level of fertility than the crude birth rate,
since it refers to births per woman.
• This indicator shows the potential for population change in the country.
• A rate of two children per woman is considered the replacement rate for a
population, resulting in relative stability in terms of total numbers.
• Rates above two children indicate populations growing in size and whose
median age is declining.
• Higher rates may also indicate difficulties for families, in some situations,
to feed and educate their children and for women to enter the labor
force. Rates below two children indicate populations decreasing in size
and growing older. Global fertility rates are in general decline.

30. According to Registrar General of India
Total fertility rate, 1970
Total fertility rate, 1990
Total fertility rate, 2006
Under-5 mortality rate, 2006
Infant mortality rate (under 1), 2006
Neonatal mortality rate, 2000
Annual no.of births(thousands), 2006
Annual no.of under-5 deaths(thousands), 2006
5.4
4
2.9
76
57
43
27195
2067

31. PERINATAL MORTALITY AND MORBIDITY RATES
Definition-
It is defined as deaths among the fetuses weighing over 500gm or
more at birth who die before and during delivery or within the first 7
days of delivery.
It is expressed in terms of such deaths per 1000 total births.
Perinatal morbidity implies the illness of the neonate from birth to first
four weeks of life. Its results mainly due to birth trauma are asphyxia,
prematurity and congenital malformations.

32. • Perinatal and neonatal deaths are largely the consequences of
inadequate and inappropriate care during pregnancy, during the
crucial first few hours after delivery.
The causes of perinatal and neonatal mortality are
multi-factorial and include
• low birth weight,
• neonatal asphyxia,
• birth injury,
• congenital malformations and infections.

33. Infant Mortality Rates in Asia
China
Pakistan
India
Bangladesh
Thailand
Sri Lanka
41
74
72
79
29
18

34. Causes-
1. Clinical conditions related to perinatal deaths- main clinical conditions
causing mortality are related to prolonged labor and difficult labor, any
pregnancy complications.
2. Direct causes of death- Under direct causes, the deaths are due to
prematurity, asphyxia and intracranial haemorrhage.
Babies who have an increased risk of dying before their first birthday fall
into three broad categories:
• those born to very young mothers,
• those born to women past their prime childbearing years and
• those born too soon after a previous birth.

35. Births to adolescents.
Many adolescent women, especially in poor countries, are physically immature, which increases their risk of suffering from
obstetric complications.
• For example, malnourished young women may not have developed sufficiently for the baby's head to be able to pass safely
through the birth canal. Teenage mothers also have an increased risk of giving birth to an infant who is premature or low-
birth-weight-conditions that reduce the resilience and stamina babies need to overcome infection or trauma early in
life. Additionally, pregnant adolescents are less likely than older women to receive good prenatal care and skilled medical
care at delivery, and to be able to provide adequate care for an infant.
For these reasons, babies born to teenage women are more likely to die than those born to women in their 20s and 30s.
• The infant mortality rate averages 100 deaths per 1,000 births among mothers younger than 20, compared with 72-74
deaths per 1,000 births among mothers 20-29 and 30-39. Moreover, among the developing countries studied here, the
higher risk of babies born to young mothers is found at every income level.

36. Births to older women.
At the other end of the reproductive spectrum, many poor women in
their 40s suffer from anemia, malnutrition, damage to their
reproductive systems from earlier births and the sheer physical
depletion associated with frequent childbearing all conditions known
to increase the likelihood of having a baby at increased risk of dying.
The average infant mortality rate among women giving birth in their
40s-94 per 1,000 live births-is much higher than the rate among
women in their 20s and 30s and almost as high as the rate among
teenage mothers.
As with adolescent mothers, high infant mortality rates among babies
born to women in their 40s occur in countries at every income level.

37. Closely spaced births.
Babies born less than two years after a prior birth are much more
likely than those born after a longer interval to be premature or low-
birth-weight.
As a consequence, the infant mortality rate is 117 per 1,000 live
births when the interval is less than two years, compared with 64
per 1,000 when births are spaced 2-3 years apart and 47 per 1,000
when births are four or more years apart.
This effect is found in every developing region.

38. YEAR 2000 2001 2002 2003 2004 2005 2006 2007 2008
Infant
mortality
rate
(deaths/
1,000
births
64.9 63.19 61.47 59.59 57.92 56.29 54.63 34.61 32.31

39. Definition of Infant mortality rate:
• This entry gives the number of deaths of infants under one year old in a
given year per 1,000 live births in the same year; included is the total
death rate, and deaths by sex, male and female.
• This rate is often used as an indicator of the level of health in a country.

40. • It is estimated that about 7 percent of new-born infants perish within a year.
• Poor maternal health results in low birth weight and premature babies. Infant
and childhood diarrheal diseases, acute respiratory infections and malnutrition
contribute to high infant mortality rates.
• Additionally, in India, across the board (rural or urban areas), there are more
female deaths in the age group of 0-14 than elsewhere.
• Although the Infant Mortality Rate (IMR) has decreased from 146 per 1000 births
in 1951 to 72 per 1000 births (1997), and the sex differentials are narrowing,
again there are wide inter-state differences recorded in 1998.

41. Prevention-
Regular antenatal care.
Screening of high risk cases and
Counseling during pregnancy. pre-pregnancy state.
Genetic counseling in early pregnancy to detect abnormalities.
Correction of nutritional deficiencies and prevention of anemia, pre
eclampsia.
Immunization for tetanus.
Avoiding traumatic delivery and careful monitoring of labor.
Educating birth attendants.
Updating hospital services as well as equipments for premature babies

42. To improve health status of population, countries like India have two
general options;
(1) increase the level of resources available to health and/or
(ii) improve the efficiency of health resources being used.
In a resource poor country like India, increasing total resource availability in the
health sector will be relatively difficult and slow, Irrespective of the level of
resources available, it is important to use the existing resources in a more
efficient manner.
Substantial progress could be accomplished with better efficiency, both at
national and sub-national levels.
It is also possible that improving efficiency of the health system (in terms of
child health outcome) may help lower socio-economic disparities in health.

43. PREVENTION OF INFANT MORBIDITY & MORTALITY
Well equipped hospitals to care premature babies
Regular antenatal care
Screening of high risk cases
Counseling during pregnancy & pre-pregnancy state
Correction of nutritional deficiencies
Immunization of baby
Training of birth attendants
Careful deliveries by avoiding trauma