Implementing Professional Midwife-Led Maternity Care in India for Healthy Pregnant Women: A Community Case Study

En Route to Midwifery Professionalisation: Contextualising Midwifery Care in the Indian Public Health System

BackgroundThe 'Guidelines on Midwifery Services Initiative, 2018' introduces the Nurse Practitioner in Midwifery (NPM) cadre to improve maternal mortality rates, quality of care, and reduce overmedicalisation in the Indian public health system. The paper examines how the NPM cadre is envisioned in the guidelines, positioned within the medical hierarchy, and aligned within the existing maternal health context. It also looks at how existing midwives and midwifery advocates perceive the changes introduced and the accompanying professionalisation process.MethodologyThe study employed two methods: (a) qualitative document analysis (QDA) of the midwifery guidelines and (b) semi-structured in-depth interviews with 14 nurse-midwifery leaders and advocates.FindingsThe QDA uncovers the underlying themes of task shifting and institutional deliveries as dominant, discussions on professional autonomy and primary health care receiving less importance and even less reflection on the history of midwifery in India. The interview findings highlight (a) tensions around carving out a separate profession, (b) the implications of midwifery at the primary healthcare level and (c) the need for an enabling environment for midwives. This paper reveals how the guidelines frame midwifery as a cost-effective, specialised nursing care within the institutional delivery framework and distanced from its traditional connotations.DiscussionIt elucidates tensions around autonomous midwifery involving professional boundaries, negotiations with medical professionals, institutional perceptions, and historical stereotypes. It builds on the broader literature on 'professions' in sociology by identifying aspects of 'professional boundary work' embedded in policy documents and experiences of participants - thereby unpacking the midwifery professionalisation process in the Indian context.

National Nursing and Midwifery Commission Act, 2023 in India: Issues and the Way Forward

With the recent enactment of the National Nursing and Midwifery Commission (NNMC) Act, 2023, significant changes are anticipated in the scope of practice and autonomy for registered nurses and midwives in India. However, alongside these anticipated advancements, concerns have emerged regarding various aspects of the Act, necessitating critical examination. In this article, we aim to explore expected changes in nursing education and service and concerns about the NNMC Act, providing insights into the implications of the NNMC Act on the regulation and advancement of the nursing and midwifery profession in India. The Act is anticipated to introduce uniform standards, implement entry and exit examinations, recognize midwifery as a distinct discipline, and determine the scope of practice for nurses and midwives. Moreover, the implementation of the Nurse Practitioner Program and guidelines for its limited prescribing authority is anticipated. Concerns exist regarding the composition of the commission and board members, adequate stakeholder representation, lacking provisions for ensuring continued competence, working conditions of nurses and midwives, nomenclature, integrating new terms, and clearly defining roles. These concerns emphasize the need for viable career pathways, uniform cadres, and a streamlined registration system, crucial for advancing nursing and midwifery profession in India. The coexistence of concerns and anticipation highlights the complexity of enacting regulatory reforms in nursing and midwifery. Policymakers can lay the foundation for a comprehensive, inclusive regulatory system that promotes excellence in nursing and midwifery practice, ultimately benefiting both healthcare providers and patients.

Strengthening midwifery in the South-East Asian region: A scoping review of midwifery-related research

Improving sexual, reproductive, maternal, newborn, and adolescent health outcomes necessitates greater commitment to, and investments in, midwifery. To identify future research priorities to advance and strengthen midwifery, we conducted a scoping review to synthesise and report areas of midwifery that have been explored in the previous 10 years in the 11 countries of the World Health Organization's South-East Asia region. Electronic peer-reviewed databases were searched for primary peer-reviewed research published in any language, published between January 2012 and December 2022 inclusive. A total of 7086 citations were screened against the review inclusion criteria. After screening and full text review, 195 sources were included. There were 94 quantitative (48.2%), 67 qualitative (34.4%) and 31 mixed methods (15.9%) studies. The majority were from Indonesia (n = 93, 47.7%), India (n = 41, 21.0%) and Bangladesh (n = 26, 13.3%). There were no sources identified from the Democratic People's Republic of Korea or the Maldives. We mapped the findings against six priority areas adapted from the 2021 State of the World's Midwifery Report and Regional Strategic Directions for Strengthening Midwifery in the South-East Asia region (2020-2024): practice or service delivery (n = 73, 37.4%), pre-service education (n = 60, 30.8%), in-service education or continuing professional development (n = 51, 26.2%), workforce management (n = 46, 23.6%), governance and regulation (n = 21, 10.8%) and leadership (n = 12, 6.2%). Most were published by authors with affiliations from the country where the research was conducted. The volume of published midwifery research reflects country-specific investment in developing a midwifery workforce, and the transition to midwifery-led care. There was variation between countries in how midwife was defined, education pathways, professional regulation, education accreditation, governance models and scope of practice. Further evaluation of the return on investment in midwifery education, regulation, deployment and retention to support strategic decision-making is recommended. Key elements of leadership requiring further exploration included career pathways, education and development needs and regulatory frameworks to support and embed effective midwifery leadership at all levels of health service governance.

Perceived Gaps in Academic Training and Expectations From Refresher Training in Primary Care Nurses at an Urban Metropolis in Northern India: A Qualitative Study

Background Nursing professionals, comprising the largest workforce engaged in the primary healthcare system, play a pivotal role in addressing population health needs. However, gaps in the training of nurses and midwives in lower-middle-income countries may undermine their performance and necessary skill development for fulfilling key population health needs. Substantial challenges exist in improving the regular curricular and refresher training of diplomate nurses and midwives working in primary care facilities and supporting both clinical care and health promotion functions. The study objective was to conduct a gap analysis in the present nursing curriculum and training profile of general duty midwives working in urban primary health facilities and understand their expectations and preferences from the planned refresher training course.  Methods We conducted a qualitative explorative study among General Nursing midwives (GNMs) working in urban primary health facilities in the Gurugram district of Haryana, India to conduct a gap analysis in their present curriculum and training preferences.  Results A total of 17 nurses with a mean (SD) age of 33.52 (4.75) years and an average nursing work experience of 5.35 (0.56) years were interviewed in-depth. Lack of practical applicability, complex study material, inexperienced tutors, and weak English language comprehension were key barriers in the existing nursing curriculum. The nurses expressed willingness to participate in refresher training with varied expectations, although there existed a distinct preference for short, flexible, and blended online-offline modes of training.  Conclusions Strengthening GNM nursing education should be prioritized in Indian health settings with the focus on improving student comprehension through vernacular instruction when feasible, and capacity building of tutors, with avenues for continued training and education. There is also a need for strengthening the curriculum related to key emergent public health challenges related to non-communicable diseases and mental health, as also skills for client and patient counseling and communication.

Translation and validation of the Hindi-Indian version of the Birth Satisfaction Scale-Revised

AIM

Critical to maternal outcome and development of a healthy and relationship between mother and baby, is the woman's perception of her birth experience. The Birth Satisfaction Scale-Revised (BSS-R) has been demonstrated to be psychometrically robust, easily administered, and scored self-report measure of birth experience. Aim of the study was to translate the UK-BSS-R into Hindi, collect data, and psychometrically validate an Indian (Hindi)-BSS-R.

METHODS

Psychometric assessment of the Indian (Hindi)-BSS-R was undertaken following translation using a cross-sectional design. Evaluation of known-groups validity was undertaken using an embedded between-subjects component. Data were collected from (n = 312) postnatal Hindi speaking women in India. Measurement characteristics were assessed using confirmatory factor analysis, divergent validity and internal consistency analysis.

RESULTS

The measurement properties of the Indian (Hindi)-BSS-R were observed to be equivocal, with the established tri-dimensional measurement model not achieving best fit to data. Instead, an alternative two-factor model offered an excellent fit to data. Significant differences were observed between Indian (Hindi)-BSS-R scores and family type and gestation term status, which highlights the relevance of these contextual aspects to the Indian birth experience. Internal consistency was observed to be low on some sub-scales, indicating the potential need for future revision.

CONCLUSIONS

The Indian (Hindi)-BSS-R is a measure of birth experience, which accepting some measurement caveats, is acceptable for use with Hindi speaking women in India. Further research is required to determine if modification of some of the items is required to improve internal consistency.

A case study on the use of Public Narrative as a leadership development approach for Patient Leaders in the English National Health Service

Background

In 2016 the National Health Service (NHS) England embraced the commitment to work for maternity services to become safer, more personalized, kinder, professional and more family-friendly. Achieving this involves including a service users' organizations to co-lead and deliver the services. This article explores how Public Narrative, a framework for leadership development used across geographical and cultural settings worldwide, can enhance the confidence, capability and skills of service-user representatives (or Patient Leaders) in the National Health Service (NHS) in England. Specifically, we analyse a pilot initiative conducted with one cohort of Patient Leaders, the Chairs of local Maternity Voices Partnerships (MVPs), and how they have used Public Narrative to enhance their effectiveness in leading transformation in maternity services as part of the NHS Maternity Transformation Programme.

Methods

Qualitative two-phase case study of a pilot training and coaching initiative using Public Narrative with a cohort of MVP Chairs. Phase 1 consisted of a 6-month period, during which the standard framework was adapted in co-design with the MVP Chairs. A core MVP Chair Co-Design Group underwent initial training and follow-up coaching in Public Narrative. Phase 2 consisted of qualitative data collection and data analysis.

Results

The study of this pilot initiative suggests two main ways in which Public Narrative can enhance the effectiveness of Patient Leaders in service improvement in general and maternity services in specific. First, training and coaching in the Public Narrative framework enables Patient Leaders to gain insight into, articulate and then craft their lived experience of healthcare services in a way that connects with and activates the underlying values of others ("shared purpose"), such that those experiences become an emotional resource on which Patient Leaders can draw to influence future service design and decision-making processes. Second, Public Narrative provides a simple and compelling structure through which Patient Leaders can enhance their skills, confidence and capability as "healthcare leaders," both individually and collectively.

Conclusions

The Public Narrative framework can significantly enhance the confidence, capability and skills of Patient Leaders, both to identify and coalesce around shared purpose and to advance genuine co-production in the design and improvement of healthcare services in general and maternity services in specific.