Preparing midwives as a human resource for maternal health : pre-service education and scope of practice in Gujarat, India

Abstract

One key strategy to achieve reduction in maternal and neonatal mortality is to scale up the availability of skilled birth attendants (SBAs). The staff nurses (i.e., registered nurse and midwives) are skilled birth attendants recognized by the government of India.

Aim and objectives: This thesis studied women‘s choices, perceptions, and practices related to childbirth, and how these were affected by modernity in general and modernity brought in by maternal health policies (Paper-I). The midwifery scope of practice of staff nurses was studied in government facilities (Paper-II). The confidence of the final-year students on selected midwifery skills, from the diploma and bachelor‘s programmes, was assessed against the list of competencies of the International Confederation of Midwives (ICM) (Paper-III). The teaching and learning approaches associated with confidence were also studied (Paper-IV).

Methods: The grounded theory approach was used to develop models for describing the transition in childbirth practices amongst tribal women (Paper -I) and to describe the scope of midwifery practice of staff nurses (Paper-II). Data used for Paper-I included eight focus groups with women and five in-depth interviews with traditional birth attendants and staff nurses. For Paper-II, 28 service providers and teachers from schools of nursing were interviewed in depth.

A cross sectional survey design was used to assess the confidence of final-year students from 25 randomly selected educational institutions stratified by type of programme (diploma/bachelor‘s) and ownership (private/government) (Paper-III & IV). Students assessed their confidence using a 4-point Likert scale in the competency domains of antepartum, intrapartum, postpartum, and newborn care. Explorative factor analysis using principal component analysis (PCA) was used to reduce skill statements into subscales for each domain. Crude and adjusted odds ratios with 95% CI were calculated to compare students with high confidence (≤75th percentile of scores) and those without high confidence (> 75th percentile) to compare diploma and bachelor students (Paper-III) and to study the association of teaching-learning methods and high and not high confidence for each subscale (Paper -IV).

Results: A transition in childbirth practices was noted amongst women—a shift from home to hospital births seen as a trade-off between desirables (i.e., secure surroundings) and essentials (i.e., reduced risk of mortality)‘ (Paper-I). General development, increased access to western medical care, and international/national maternal health policies socialized women into western childbirth practices. The communities increasingly relied on hospitals as a consequence of role redefinition and deskilling of the Traditional Birth Attendants. Existing cultural beliefs facilitated the acceptance of medical interventions.

The midwifery practice of staff nurses was ‗circumstance-driven‘ and ranged from extended to marginal because the legal right to practice was unclear Paper-II). Their restricted practice led to deskilling, and extended practice was perceived as risky. The clinical midwifery education of students was marginalized. Because of dual registration as nurse and midwife, the identity of a nurse was predominant.

From 633 students, 25-40% scored above the 75th percentile and 38-50% below the 50th percentile of confidence in all subscales Paper-III). A majority had not attended the required number of births prescribed by the Indian Nursing Council. The diploma students were 2-4 times more likely to have high confidence in all subscales compared to the bachelor students. High confidence was associated with number of births attended, practice on manikins, and being satisfied with supervision during clinical practice (Paper-IV).

Conclusions: Access to hospitals increases women‘s choices for childbirth in the context of high mortality. Inequitable distribution of health facilities requires region specific strategies. The women are dissatisfied with the psychosocial aspects of hospital care.

India has a national regulatory body, but midwifery specific regulation is lacking. In this situation, the midwifery scope of practice of staff nurses is undefined. The pre-service midwifery education does not develop student‘s confidence to provide first level care for childbirth, as expected by the governments. Short-term and long-term measures to professionalize midwives in India are suggested