Four months after having established a 24×7 delivery & newborn care service in a rural health centre located 55 km from Udaipur, Rajasthan, two nurse-midwives on duty encountered a woman with severe pre-eclampsia. Following protocol, they treated her, carefully injecting Magnesium Sulfate. Then one of them accompanied her to the hospital in the city, for emergency admission. The doctor on duty was visibly upset that a nurse had administered a dose of Mag-Sulf and harshly reprimanded her for “trying to become a doctor”. It took us some effort to console the visibly shaken nurse-midwife, that she had done right and saved a life. ARTH’s team of nurse-midwives nevertheless carried on undeterred, and over 26 years attended 18,466 deliveries of which 1451 (8%) were referred. The most critical skill required of a professional midwife working in a primary care setting, is to know when to refer a woman or newborn for a complication, and to provide basic emergency care in the interim. This life-saving role has been acknowledged by this year’s theme for International Day of the Midwife.
Diploma and degree qualified nurse-midwives who join ARTH receive induction training based on standard guidelines, to perform their roles effectively. Early in 1999, we realised that timely referral of those with complications would be an essential part of our Basic Midwifery Model. Hence we developed a safe-threshold protocol for emergencies, that included simple referral criteria, telephone consultation with a doctor, provision of basic emergency obstetric care, empanelled transport vehicles, detailed referral cards, accompanying critical patients and a helpline worker at the government hospital, to expedite admission and provide daily support until discharge. Results of this model published in 2009 showed that nurse-midwives were able to promptly and accurately detect, stabilize and refer those with complications1. During 2024-25, nurse-midwives referred 113 (12% of deliveries) comprising 96 women and 17 newborns. The commonest maternal complications were non-progression or prolonged labour, pre-eclampsia and fetal distress, major neonatal complications included preterm – low birth weight, and birth asphyxia.
India has progressed with midwifery training by starting a course on Nurse Practitioner in Midwifery at national and regional institutes in 20182. This will help to professionalise midwifery and give due stature, even though the training will take several years to generate midwives at scale. Meanwhile, the 1.25 million strong existing cadre of nurse-midwives can effectively be trained to provide basic midwifery care, including emergency care for women and newborns during a crisis.
