Women and Birth xxx (xxxx) xxx

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Women and Birth

journal homepage: www.sciencedirect.com/journal/women-and-birth

Contextual factors influencing the implementation of midwifery-led care

units in India
Malin Bogren a, *, Paridhi Jha b, Bharati Sharma c, Kerstin Erlandsson d
a
Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Arvid Wallgrens backe 1, 413 46 Gothenburg, Sweden
b
Foundation for Research in Health Systems, Bangalore, Karnataka, India
c
Indian Institute of Public Health Gandhinagar, Gujarat, India
d
Institution for Health and Welfare, Dalarna University, Falun, Sweden

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The Government of India has committed to educate 90,000 midwives functioning in midwifery-led
Midwifery-led care care units (MLCUs) to care for women during labour and birth. There is a need to consider local circumstances in
Hospital setting India, as there is no ‘one size fits all’ prescription for MLCUs.
Maternal and new-born health
Aim: To explore contextual factors influencing the implementation of MLCUs across India.
India
Low- and middle-income countries
Method: Data were collected through six focus group interviews with 16 nurses, midwives, public health experts
Implementation research and physicians, representing six national and international organisations supporting the Indian Government in its
midwifery initiative. Transcribed interviews were analysed using content analysis.
Findings: Four generic categories describe the contextual factors which influence the implementation of MLCUs in
India: (i) Perceptions of the Nurse Practitioner in Midwifery and MLCUs and their acceptance, (ii) Reversing the
medicalization of childbirth, (iii) Engagement with the community, and (iv) The need for legal frameworks and
standards.
Conclusion: Based on the identified contextual factors in this study, we recommend that in India and other similar
contexts the following should be in place when designing and implementing MLCUs: legal frameworks to enable
midwives to provide full scope of practice in line with the midwifery philosophy and informed by global stan­
dards; pre- and in-service training to optimize interdisciplinary teamwork and the knowledge and skills required
for the implementation of the midwifery philosophy; midwifery leadership acknowledged as key to the planning
and implementation of midwifery-led care at the MLCUs; and a demand among women created through effective
midwifery-led care and advocacy messages.

1. Background local circumstances, opportunities, and necessities in India, as there is

no ‘one size fits all’ prescription for MLCUs.
By 2030, maternity services in India will need to respond to The impact of midwives, who are educated and regulated according
approximately 35 million pregnancies per year [1]. As a response out­ to international standards [5,6] in improving maternal and new-born
lined in its National Guidelines for Midwifery Services, the Government health outcomes is well documented. These outcomes in turn have a
of India has committed to educating 90,000 midwives, who will be positive influence on the Sustainable Development Goals (SDGs) and are
called Nurse Practitioners in Midwifery and function in midwifery-led critical to the achievement of universal healthcare [7–9].
care units (MLCU) to care for women during labour and birth [2]. A Cochrane review that included 15 trials involving 17,674 women
MLCUs, in which the midwife is the primary healthcare professional from high-income countries shows a range of positive outcomes for
caring for low-risk pregnant women, represent one model of how to women who receive midwife-led continuity of care compared to other
integrate midwifery-led care during birth into existing health systems, to models of care [10]. Midwife-led continuity of care has midwives as the
improve maternal health [3,4]. This introduces the need to consider lead professionals to support women in the planning, organisation, and

Abbreviations: MLCU, Midwifery-led care units; SDG, Sustainable Development Goals.

* Corresponding author.
E-mail address: malin.bogren@gu.se (M. Bogren).

https://doi.org/10.1016/j.wombi.2022.05.006
Received 24 February 2022; Received in revised form 24 May 2022; Accepted 24 May 2022
1871-5192/© 2022 The Author(s). Published by Elsevier Ltd on behalf of Australian College of Midwives. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

Please cite this article as: Malin Bogren, Women and Birth, https://doi.org/10.1016/j.wombi.2022.05.006
M. Bogren et al. Women and Birth xxx (xxxx) xxx

delivery of care, from the initial visit to the postnatal period. Positive hospitals conducting more than 600 births a year. The first phase entails
outcomes include greater satisfaction, fewer interventions, such as a national and state-level training cascade in which midwifery-training
epidural analgesia, episiotomies or instrumental births, and lower rates institutes are strengthened to educate existing midwifery educators so
of adverse outcomes such as perinatal mortality. Different models of that they are competent to educate the Nurse Practitioner in Midwifery
midwife-led care have been reported to be effective at improving cadre at the state level. In the second phase, the Nurse Practitioners in
maternal and new-born outcomes in high-income countries [7,10,11]. Midwifery will then lead the midwifery care of women with low-risk
Midwife-led care has also emerged as an effective model across low- and pregnancies in MLCUs.
middle-income countries [11–14], and could be an alternative model
not only for providing safe and cost-effective childbirth care for low-risk 2.2.2. Childbirth in India
women but also to improve the efficiency of the health system [11]. Intrapartum care in India is institutionalized, with public hospitals
However, a lack of enabling factors may compromise the quality of care accounting for only 10 %, approximately, of the total number of hos­
that midwives can provide [14]. More research about midwife-led care pitals throughout the country [21]. India has a maternal mortality rate
in low- and middle-income countries has been recommended to under­ of 145 per 100,000 live births and a neonatal mortality rate of 23 per
stand the elements of successful implementations of midwife-led care 1000 live births. Eighty nine percent of all births in 2019 were assisted
models, their feasibility, effectiveness, and sustainability [14,15]. by skilled birth personnel (nurse-midwives, auxiliary nurse-midwives
Similarly, the World Health Organization recommends implementation and physicians) [22]. With a population of more than 1.3 billion [23],
of and research into midwife-led care models to improve the quality of the current birth rate is 17.163 births per 1000 people [24]. The
maternal and new-born care in low- and middle-income countries [16]. caesarean section rate is 11,9 % in public hospitals and 40,9 % in private
However, no specific care model is effective in every context, which hospitals [22]. Childbirth care is standardized by the Ministry of Health
means that the same intervention may have different effects in different and Family Welfare, which has regulatory power over most health policy
contexts. decisions but is not directly involved in health care delivery in the Indian
Context includes anything internal and external to an intervention states. At the state level the State Departments of Health and Family
that may act as a barrier or facilitator in its implementation or may Welfare implement National policies in accordance with the health
modify its effect [17]. Healthcare contexts, in particular, are influenced profile of the state; they may even implement locally developed models
by stakeholder values and behaviours, organisational boundaries, over and above implementing national policies [21]. Physicians or
external pressures, and environmental factors [18]. Hence, under­ specialists in obstetrics and gynaecology are primarily responsible for
standing context – including identifying what the contextual factors are the care of pregnant and birthing women, characterized by a hierar­
and how they influence the implementation of evidence-based inter­ chical structure in a medical model. Trained nurse-midwives assist the
ventions– is essential. As part of an implementation project aimed at women during pregnancy, labour, and childbirth under a physician’s
improving the health of mothers and new-borns [19], this study’s aim supervision. Nurse-midwives are estimated to manage only about 25 %
was to explore contextual factors influencing the implementation of of all institutional births [25]. Reports of disrespect, abuse, and
MLCUs across India. The evidence it provides is crucial for the design, mistreatment during facility-based childbirth in India have been docu­
targeting and implementation of effective policies and interventions in mented [26,27]. Nurse-midwifery education is via a diploma (3.5 years)
relation to the implementation of a midwifery-led care model during or an academic degree (4 years plus 6 months internship) constructed
childbirth. The lessons learned from the results are presumed also to be around the medical care model [28]. An academic degree in nursing is
useful in other similar contexts when designing and implementing required before the 18-month education programme to become a Nurse
MLCUs. Practitioner in Midwifery [2] can be entered.
The trained Nurse Practitioners in Midwifery are being absorbed into
2. Method the public sector healthcare facilities [2]. These include the 763 District
Hospitals (highest referral health facility in a district/province catering
2.1. Design to 3–4 million population on average [29]) and the 542 Medical College
Hospitals (regional referral centres providing tertiary level and reha­
Based on the process evaluation framework suggested by Moore et al. bilitative care for all health needs). Here the labour rooms have been
[17], the contextual factors influencing the implementation of MLCUs in renovated for optimal quality of care under the Government of India’s
India were explored using a qualitative research design [20]. To un­ labour room quality improvement initiative guidelines, known as
derstand the contextual factors, data were collected from six focus group LAQSHYA [30].
interviews (FGI) with staff representing national and international or­
ganisations across India involved in the setup of MLCUs in India. The 2.3. Study participants and data collection
Institutional Review Board of the Foundation of Research in Health
Systems approved the study (IORG0007693). National and international organisations who were supporting the
Indian Government in its midwifery initiative (n = 10) were invited by
2.2. Setting email in July 2021. The first author provided written information about
the study, including the fact that participation was voluntary and that
2.2.1. The midwifery initiative in India they had the right to withdraw at any time without explanation. The
In 2018, the Government of India took an historic policy decision to second author sent two to three reminders. Eight organisations agreed to
improve the quality of care and ensure respectful care for women and participate, one organisation declined due to organizational policies,
new-borns through high-quality midwife-led care. Through the and one did not respond. Because of delayed internal processes at two
“Midwifery Service Initiative” released in 2018, India’s Government has organisations, they had to be excluded. As a result, a total of six orga­
committed to educating 90,000 midwives informed by international nisations participated in the study. The six organisations themselves
standards, with a focus on setting up (i) a midwifery education system selected staff working in the capacity of supporting the government in
and (ii) midwifery-led care units [2]. preparing for the set-up of midwifery-led care units. All participants (n
The initiative has two aims. The first is to create a cadre of Nurse = 16) were either nurses, midwives, public health experts or physicians
Practitioners in Midwifery by educating existing Nurse Midwives who who had programmatic responsibilities. The participants gave their
have a General Nursing and Midwifery diploma or a Bachelor’s or consent to participate by connecting to a digital meeting at an agreed-
Master’s degree and who are currently working in a hospital. The second upon time.
is to establish MLCUs in Government Medical College and district All interviews were conducted during July and August 2021 by three

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M. Bogren et al. Women and Birth xxx (xxxx) xxx

of the authors (MB, PJ, KE). There were two to three participants in each Table 2
group. The interviews were conducted in English, based on an interview Generic Categories and Subcategories describing contextual factors influencing
guide consisting of open-ended questions related to contextual factors the implementation of midwifery-led care units across India.
influencing the implementation of midwifery-led care units in India. See Generic Category Subcategory
Appendix 1. The interviews were audio-recorded, and each lasted Perceptions about and acceptance of the Understanding and recognition of the
around 60 min. Nurse Practitioner in Midwifery and Nurse Practitioner in Midwifery is
the MLCUs uncertain
Lack of awareness of MLCUs
2.4. Data analysis Creating a demand for care provided by
Nurse a Practitioner in Midwifery is
The verbally transcribed interviews were analysed using qualitative needed
inductive analysis [20]. First, all 300 pages of transcripts were read Reversing the medicalization of The prevailing medical paradigm is
childbirth strong
several times to get an understanding of the content. Next, in new
Creating a culture in line with
readings, meaning units were identified that answered the following international midwifery philosophy
research question: What are the contextual factors influencing the Infrastructure and care level under
implementation of midwifery-led care units in India? Content related to debate
midwifery education was removed and will be presented elsewhere. The Engagement with the community Women need to be involved
Respectful care for a positive birthing
meaning units were then compared and sorted into codes based on experience motivates utilization
similar content, which were thereafter compared and clustered into The need for legal frameworks and Legal frameworks are required
subcategories and generic categories. The analysis process was standards Lack of standards
completed jointly by MB and KE in collaboration with PJ and BS. An
example of the analysis process is shown in Table 1.
Practitioner in Midwifery, both nurses and the Nurse Practitioner in
Midwifery have been thought of as synonymous, with both roles being
3. Results
subordinate to the physicians. No differences could be discerned be­
tween the philosophies and core values of nurses and Nurse Practitioners
Contextual factors identified as influencing the implementation of
in Midwifery, and the new cadre was therefore perceived as competitors
midwifery-led care units across India were sorted into four generic
not only to the nurses but also the obstetricians. Thus, there was a
categories with respective subcategories. For an overview, see Table 2.
reluctance among the nurses and physicians to let the Nurse Practitioner
in Midwifery emerge as a profession in its own rights.
3.1. Category 1. Perceptions about and acceptance of the Nurse It is not very easy to carve out a place for midwives, because it is so ob­
Practitioner in Midwifery and the MLCUs stetrics led until now. There are fear factors which are there, like, you know, if
midwives will do everything, what will the obstetricians do? (FGI 2)
3.1.1. Understanding and recognition of the Nurse Practitioner in
Midwifery is uncertain 3.1.2. Lack of awareness of MLCUs
There was an expressed uncertainty among the participants about In general, the participants found it difficult to envision the function
the term Nurse Practitioner in Midwifery, as the term and function are of MLCUs as they have been made functional only very recently in India.
confused with the term and function of a traditionally untrained birth In addition, there seemed to be a lack of awareness among the women,
attendant (commonly called the Dais) among the public and other nurses, educators, and physicians about MLCUs and how they differed
healthcare providers. Though the Dais have become obsolete in the from labour rooms with care provided by nurses and physicians. The
current scenario of institutionalized childbirth in India, the participants stigma of the Nurse Practitioner in Midwifery being equated with Dais
were concerned that women and the community might conceptually seems to have spilled into their perception of what MLCUs are and what
equate the Nurse Practitioners in Midwifery with the Dais. Participants their function is.
stated that this misperception has led to the Nurse Practitioner in The acceptance of the name midwifery-led care unit derives from the
Midwifery being perceived as of a ‘lesser’ cadre compared to nurses and history to be run by a not fully qualified care provider staying with the woman
obstetricians. Unless the term and function of the Nurse Practitioner in from the community giving birth. What has happened from the past in India,
Midwifery becomes accepted, it may be a long time before women seek the term midwife has been demoted, that they’re not fully qualified or
their services willingly. something like that kind of thinking. (FGI6)
The thing is acceptance from the community because there is apprehen­
sion that as soon as community gets to know the word midwifery, there is a 3.1.3. Creating a demand for care provided by a Nurse Practitioner in
thinking that, Oh, they are, not as good as doctors, they are less qualified, so Midwifery is needed
whether communities would like to have child birth or deliveries conducted by Creating a demand for the care provided by a Nurse Practitioner in
midwives, that is to be seen. (FGI 5) Midwifery requires that they be promoted as the primary caregiver
To add to the confusion about the term and function of the Nurse during the intrapartum period. The internationally accepted core phi­
losophy of professional midwifery, namely, “keeping what is normal,
Table 1 normal”, needs to be accepted by women, the community and health
Example of the data analysis process from meaning unit to generic category. care providers. It was anticipated that the demand for MLCUs would
Meaning Unit Code Subcategory Generic Category suffer without this acceptance.
The medical model of Unnecessary The prevailing Reversing the
Participants suggested several advocacy approaches for promoting
care treats pregnancy interventions medical medicalization of the acceptance of the Nurse Practitioner in Midwifery and creating a
and childbirth as a paradigm is childbirth demand. These included community-based awareness programmes,
disease and strong engaging the media for mass media campaigns, motivating local polit­
interventions after
ical leaders, and creating champions.
interventions are
performed when it’s I think they are still working on how to brand and position a Nurse
not required. So, Practitioner in Midwifery, and how to create that demand in the society, I
that’s a huge think that’s all happening, because recently we had a meeting, partner co­
problem. ordination meeting, and they did share some updates. (FGI3)

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M. Bogren et al. Women and Birth xxx (xxxx) xxx

To gain acceptance and create a demand for normal birth, the 3.2.3. Infrastructure and care level under debate
women, and nurses with experience from the MLCU could act as According to the participant it was being debated nationally whether
champions and agents for change. the MLCUs should be free standing or alongside midwifery units within
There are not enough mass communication happening about midwifery. existing medical college hospitals. Under consideration was MLCUs
The general populations do not even know what care provided by a Nurse being established at the district hospitals closer to the community in
Practitioner in Midwifery is about. (FGI 1) which a woman lives. The participants argued that establishing MLCUs
near communities at lower care levels in rural and tribal areas will
3.2. Category 2. Reversing the medicalization of childbirth reduce overcrowding at higher-level hospitals and increase accessibility
for women in underserved areas. Establishing MLCUs at the medical
3.2.1. The prevailing medical paradigm is strong college hospitals could provide a more women-friendly and relaxing
The legal accountability for childbirth lies with the physicians, atmosphere in existing labour rooms. Further, they argued that MLCUs
meaning that the physicians are responsible for triaging all maternity should not necessarily look the same everywhere. They could be free
services, performing interventions such as caesarean sections, and con­ standing or alongside midwifery units, and not uniform across the
ducting and supervising vaginal births. This legal authority further country.
strengthens the prevailing medical paradigm around labour and birth. To reduce unnecessary medicalization and unnecessary caesarean sec­
The medical paradigm seems to assume that normal birth is time tions MLCUs are very helpful. But we need midwives even at the lower levels
consuming and because of the possible legal implications if something and just not only at the higher levels where it is not going to make much
goes wrong, caesarean sections are preferred over normal births. Par­ impact on the desire you know. (FGI6)
ticipants stressed that if the MLCUs are to be successfully implemented,
there will need to be a concurrent reversal of medicalization of child­
birth, to which the MLCUs will contribute. The Nurse Practitioner in 3.3. Category 3. Engagement with the community
Midwifery has to be recognized and authorized as an autonomous
practitioner and allowed to provide normal birth care in their own right. 3.3.1. Women need to be involved
This recognition will help to give physicians confidence to refer women It was stressed that the implementation of MLCUs will depend on
to MLCU care and know that they will be safe. whether women and community members and leaders are involved the
…for a country that is so obstetric led as India, I think women need planning for the MLCUs.
permission from their physician to say giving birth cared by a midwife is okay, Getting stakeholders involved and women involved. When women start
first, and then when more women have been through the process, then word of shouting out loud, people will hear. Women’s voices are very powerful. (FGI
mouth will go out to tell others about it. Once they see what the midwives are 3)
capable of, and birthing in different positions of choice, and interest will be In the communities, Auxiliary Nurse Midwives can play a critical role
generated. (FGI3) in referring women to the MLCUs. With support from the Auxiliary
According to the participants, the medical profession in India uses an Nurse Midwives, the image and demand for care at the MLCUs can be
obstetric risk perspective on birth as an argument against the function of strengthened in the community. Thus, the Nurse Practitioner in
the MLCUs and a normal birth perspective. It was mentioned that it is Midwifery will need to promote their ability to provide women with
easier for a woman to go for a planned caesarean section than to wait for high-quality respectful care at the MLCUs, thereby establishing their
a spontaneous onset of labour. The perception was that these ideas were reputation as experts in normal labour and birth.
deeply rooted in the medical paradigm. I know that in the beginning they (the Nurse Practitioner in Midwifery)
The medical model considers pregnancy as a disease, an adverse condi­ may face problems but within a short time the attitude of the community will
tion, and everything happens in a hospital is medical and iatrogenic because change. (FGI 4)
intervention after intervention is initiated and applied when it’s not required. There was a concern that unless the engagement with the community
So, that’s the problem. (FGI 5). entails a co-creation with women, there will be no women champions in
the communities who can advocate for the care provided by the Nurse
3.2.2. Creating a culture in line with international midwifery philosophy Practitioner in Midwifery at the MLCUs.
Through the “India Midwifery Initiative” India is moving towards a
paradigm shift in which normal childbirth has become facility-based and 3.3.2. Respectful care for a positive birthing experience motivates utilization
the Nurse Practitioner in Midwifery is being introduced as the most The importance of respecting women’s choices and empowering
appropriate care providers for childbearing women. If MLCUs are to be them was discussed among the participants. They believed that when
established and sustained, the international midwifery philosophy needs the Nurse Practitioners in Midwifery provide respectful care it will
to be understood by the Nurse Practitioner in Midwifery and respected create an expectation of a positive birthing experience that will support
in terms of the division of roles between healthcare professionals. the establishment and utilisation of MLCUs.
As pregnancy and childbirth are normal physiological processes, the They (the women) need to see, you know, how they (Nurse Practitioner in
participants stated that the Nurse Practitioner in Midwifery plays a Midwifery) make decisions, and how they run the MLCU, and how they talk
critical role in upholding a woman’s right to a positive birth experience. to mothers, and give them informed choices, so they can birth in…you know,
A shift is needed from a medical paradigm, in which pregnancy and birth whichever position of choice they want to. (FGI3)
can be considered normal only after the event when nothing has gone The participants believed that the provision of respectful care at the
wrong, to a physiological pregnancy and birth considered as a normal MLCUs by the Nurse Practitioners in Midwifery would give a sense of
life event in which all will be well until something goes wrong. This security for the women giving birth. Respectful care was defined by the
different view was seen as the core of midwifery philosophy; according participants as: not using a loud voice, having a warm manner, main­
to the participants it meant promoting, protecting, and supporting taining privacy and confidentiality, preserving the woman’s dignity,
women’s reproductive rights. providing information and informed consent, engaging through effec­
I am sure midwife led units are going to make a huge impact once we have tive communication, respecting a woman’s choices, and thereby
the philosophy of care right. Because lot of women don’t know their rights, strengthening her ability to give birth, making available competent,
they don’t know, you know, I mean consent is not sought. Things happen motivated Nurse Practitioners in Midwifery.
because they just surrender themselves to the doctor. (FGI 1) Ultimately only happy mothers will sustain MLCUs. Positive experiences
during the birth okay, mother will be happy, all men will happy during in the
antenatal period, so this is our another. (FGI 4)

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M. Bogren et al. Women and Birth xxx (xxxx) xxx

3.4. Category 4. The need for legal frameworks and standards Midwifery and a lack of recognition for the role. It can be argued
whether part of the uncertainty of perceptions and acceptance among
3.4.1. Legal frameworks are required the women and their families and hospital health care staff, might be
Getting the appropriate legal frameworks in place was considered that the proposed new cadre will be called ’Nurse Practitioners in
critical for successful implementation of the MLCUs. Several re­ Midwifery’ rather than ’midwives’. The birthing woman is at the centre
quirements were identified to facilitate the role and function of the in this ecological model, positioned as an active rather than a passive
Nurse Practitioners in Midwifery and to provide safe, effective, actor in the choice of birth environment, with the woman influencing
respectful midwifery care in line with the expectations of women, that birthing environment, namely the MLCU, as much as the birthing
communities, and other healthcare professionals. They included better environment has an effect on her. Consistent with Bronfenbrenner’s
coordination between the parties involved to prevent unnecessary argument that the contexts and processes in which women actively
duplication of work and wastage of resources and ensuring the participate have a greater influence on them [31], the care at the MLCUs
involvement of the Indian Nursing Council in the setup. However, par­ seeks to respect and empower women and their birth supporters. As
ticipants stressed the need for additional work around developing legal described by Coxon et al., if a woman’s first experience of birth is in a
frameworks addressing issues such as the lack of a separate licensure for health facility, she is likely to choose the same for subsequent births
Nurse Practitioners in Midwifery, directives of scope of practice, au­ [32], especially if the experience is positive. From an Indian perspective,
tonomy, responsibilities, and consequences, along with an action plan. it can be argued that once women have given birth at an MLCU, they are
I think when the midwifery led units are set up in a state, there will have to likely to return for subsequent births. As supported by research [10–14],
be guidance or an office order from the state directory somebody senior the women in India at all socioeconomic levels would thus benefit from
official saying that this has been established and the midwives allowed to do midwifery-led care, and the Government of India would get closer to
A, B, C and D functions independently. (FGI 6) meeting the SDGs [33], especially the goal on health, by improving
With legal frameworks in place, the Federation of Obstetric and maternal and new-born health outcomes.
Gynecological Societies of India could, according to the participants, act At an Institutional and organizational level according to the ecological
as advocates in collaboration with the Society of Midwives to accelerate model [31], the prevailing medical paradigm in this study was shown to
the implementation of the MLCUs. be strong at the hospitals and within their organisational structure.
So once the professional bodies are convinced, they have a binding. It is Nurse Practitioners in Midwifery were described as ‘specialists of the
easy to influence the attitude and acceptance of other obstetrician and gy­ normal birth’ but were too new as a cadre to be acknowledged as such.
necologist. (FGI 5) Creating a culture in line with midwifery philosophy was deemed
important if MLCUs were to be established. In a recent systematic review
3.4.2. Lack of standards of barriers to, and facilitators of, the provision of high-quality midwifery
The need for standards that could be used by any hospital for setting services in India, several were identified [34]. For example, having
up, running, and assessing quality in the MLCUs was stressed. Such educated midwives free to practice to their full scope was a facilitator
standards would allow for better utilization of resources by the MLCUs. that would improve women’s experiences of maternity care. In line with
The specific standards mentioned were for clinical care services, scope of McFadden et al., participants in our study also engaged in the debate
practice, administrative and care-delivery protocols, logistic support, going on within the health system on the infrastructure required for
supplies, career pathways, essential staffing such as a core staff team MLCUs, and the level of health facility at which the Nurse Practitioner in
with a Nurse Practitioner in Midwifery and midwifery leadership on site Midwifery should be absorbed for care provision. Another ongoing
to promote high standards, philosophy of care, standards for continuing discussion was on the type of midwifery care unit whether freestanding
training, mentoring and supervision. But such standards would require or alongside a care unit, a concept that has also been discussed by [35] in
funding in national plans, and according to the participants that was their investigation of freestanding and alongside midwifery units in
currently not the case. According to the participants, these standards England. Walsh et al. have shown how development in health services is
would secure a birthing environment that supported the needs of the influenced by factors that protect the status quo, such as the medicali­
woman and the baby in all stages during normal labour and birth and zation of childbirth, leadership, the economy, and institutional norms
ensured that interventions would be offered when clinically necessary. [35]. Walsh et al. point out that alongside midwifery units have
Guidelines exists for freestanding private midwife-led care units, encountered less resistance than freestanding units among the care
which, according to the participants, could also be used in the public professionals in a maternity unit [35]. India has chosen alongside
sector. There was discussion as to whether the standards used in the midwifery units, a choice that suggests India is moving towards a lower
freestanding private MLCUs would also be used in public MLCUs. conflict situation, certainly less than with freestanding units. Similar to
The word midwifery led unit is used very liberally. For a midwifery led countries such as Sweden that has alongside units, the relationship be­
unit, you need to have an autonomous midwife, you need to have guidelines tween physicians and midwives in these units has been characterized
on the ethos of what a midwifery led unit is. So, the definitions of midwifery more by teamwork than conflict [36]. Midwives in Sweden are the
led units needs to be defined, and standards needs to be in place. (FGI 3) primary care providers for normal pregnancy and childbirth. Their
practice is guided by a non-interventionist ideal, i.e., wait and see rather
4. Discussion than intervene. Physicians take over the medical responsibility from the
midwife when complications occur during labour and childbirth [36]. In
The study identified four contextual factors that influence the contrast, the medical model of care found in this study is consistent with
implementation of MLCUs in India: (i) Perceptions about and acceptance what has been described in a study on risk, theory, social and medical
of Nurse Practitioners in Midwifery and MLCUs; (ii) Reversing medi­ models, where birthing is a risk needing medical interventions and
calization of childbirth; (iii) Engagement with the community; and (iv) considered normal only in retrospect [37]. For reversing the medicali­
The need for legal frameworks and standards. These findings can be zation of childbirth in India, teamwork and a non-interventionist prac­
interpreted at four interrelated contextual levels of influence: Interper­ tice as the ideal must guide both the Nurse Practitioner in Midwifery and
sonal, Institutional and Organizational, Community, and Public Policy, physicians to create a culture in line with the midwifery philosophy. The
similar to the ecological model of Bronfenbrenner [31]. Our discussion is Nurse Practitioners in Midwifery can probably avert about 65 % of
situated within an ecological model to offer a broader contextual un­ maternal and neonatal deaths and stillbirths, according to data from 88
derstanding related to the implementation of MLCUs in India. low-and middle-income countries. [9]. At the same time, the findings
At an Interpersonal level, a critical contextual factor was the uncertain from this study reveal a prevailing sense of apprehension among the
understanding, in general, of the function of the Nurse Practitioner in physicians as well as the nurses working as staff nurses in labour wards

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M. Bogren et al. Women and Birth xxx (xxxx) xxx

towards the Nurse Practitioner in Midwifery, who seems to be perceived 4.1. Strengths and limitations
as encroaching on their territory. This latent friction within the health
system may undermine the effectiveness of the function of the Nurse The key strength of this study is that it is the first of its kind, to the
Practitioner in Midwifery at MLCUs. The situation may be compounded best of the authors’ knowledge, to address contextual factors influencing
by the fact that Nurse Practitioners in Midwifery were originally nurses, the implementation of midwifery-led care units across India. Insider and
who have traditionally always worked under the supervision of physi­ outsider perspectives benefited the whole research process. The research
cians, creating a power imbalance if not properly addressed. This phe­ group consists of senior researchers from India and Sweden who have
nomenon has been described in other studies as well [27,38]. Taken all extensive expertise in India and South-East Asia contexts. The study is
together, there is a clear call for attention to be paid to a potential threat not without limitations. The small number of participants could be
to the implementation and sustainability of the MLCUs. In line with a questioned; however, the participants were all experts, sharing their
recent systematic review on strategies for implementing primary care extensive expertise in the field. For the international researchers, lan­
models in maternity care [39], we suggest that these threats can be guage issues were sometimes a barrier, but were compensated for by the
mitigated by a number of measures: holding conversations about the national researcher. The participants were selected based on their
changes and the extent of the changes envisaged in establishing MLCUs: involvement with the setup of MLCUs in India, and they may or may not
advocating for interdisciplinary teamwork: and moving ahead strategi­ have worked with women in the communities. But given their extensive
cally with in-service training and education related to the midwifery experience within the field of midwifery and maternal health, this study
philosophy of care. benefits from the different professional lenses brought up in the in­
Community level comprises engagement with women, leaders, and terviews. Despite the limitations, the information obtained from the
community members that can influence planning for the MLCUs. participants generated rich and comprehensive data, which will be of
Although the birthing woman in the community may not be directly use in India. However, other countries and settings must interpret these
involved at this level, women can become champions in their own in light of their own context when designing and implementing MLCUs.
community advocating the use of the MLCUs to other women. The
findings from this study refer to the larger social and cultural environ­ 4.2. Conclusion
ment in which this care model is considered alien and against the Indian
tradition. A tradition encompasses the wider environment and draws Contextual factors influencing the implementation of midwifery-led
heavily on attitudes, ideologies, culture, and beliefs that have indirect care units in India include the following: (i) Perceptions of the Nurse
effects on the individual. Thus, as found in our study, auxiliary nurse- Practitioner in Midwifery and MLCUs and their acceptance, (ii)
midwives in India play a critical role in supporting the idea of the Reversing the medicalization of childbirth, (iii) Engagement with the
MLCU and creating demand for care at them by referring women. These community, and (iv) The need for legal frameworks and standards.
results reflect those of Renfrew (2021) who also commented that local Together, these contextual factors are critical for the design, targeting
community knowledge and resilience, and an equitable, individualised and implementation of effective policies and interventions in relation to
midwifery model of care responds to clinical, psychological, social, and the implementation of a midwifery-led care model during childbirth.
cultural needs [40]. The community level in the ecological ecosystem Based on the findings from this study, and in agreement with worldwide
positively influences the family and the woman and the baby. As found evidence on midwife-led care [10–15,39], we recommend that in India
in our study, there exists a challenge in creating a brand of Nurse and other similar contexts, it is important to ensure that:
Practitioner in Midwifery that is free of the social shadows of traditional
birth attendants and is seen as an alternate to physicians rather than • Legal frameworks are in place to enable midwives to provide full
subservient to them. These perceptions have previously been described scope of practice in line with the midwifery philosophy and informed
as a common stigma historically attached to the professions of nursing by global standards.
and midwifery in India [41]. • Interdisciplinary teamwork and the knowledge and skills required
At a Public Policy level, another critical contextual factor is the need for the implementation of the midwifery philosophy is optimized
for legal frameworks for midwives to practice, which needs to be in place through pre- and in-service training.
as India moves towards professionalising the Nurse Practitioner in • Midwifery leadership is acknowledged as playing a key role in the
Midwifery. Unless legal frameworks for practice are in place at the planning and implementation of midwifery-led care at the MLCUs.
policy level, the Nurse Practitioner in Midwifery will remain unregu­ • A demand among women is created through effective midwifery-led
lated and unable to autonomously provide an entire scope of practice care and advocacy messages.
during normal pregnancy and childbirth. These findings suggest that
they will remain under the jurisdiction of the physicians at the MLCUs if Ethical statement
legal frameworks for practice are not in place. It was also found that
there is a lack of standards for midwifery practice. Thus, a full set of Ethical approval was obtained from the Institutional Review Board of
global standards for practice, contextualized into national policies and the Foundation of Research in Health Systems with the reference num­
plans, is required when setting up midwifery services [42]. Neigh­ ber IORG0007693.
bouring countries in South East Asia have recognised the importance of
legislation for midwifery practice [43]. Consistent with findings pre­ Financial support
sented in a recent study on the challenges and legal midwifery reforms
needed in India [44], for India to succeed with its impressive midwifery This study was conducted with financial assistance from Aastrika
initiative, legislation cannot be overlooked. Legislation and standards in (Aastar Urmika Health Systems Pvt. Ltd.).
place provide strength to the midwifery profession [45]. There is a link
to midwifery leadership in that it is essential to drive change and CRediT authorship contribution statement
well-run functioning midwifery-led units are characterized by high
quality leadership [35]. If restrictions for Nurse Practitioners in MB and KE designed the study. Data were collected by MB, KE and
Midwifery remain unaddressed, the status quo will remain in India as PJ. All authors analysed the data and MB and KE prepared the first draft
only strong midwifery leaders can challenge the status quo. of the paper to which all authors contributed important revisions. All
authors have read and approved the final manuscript.

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M. Bogren et al. Women and Birth xxx (xxxx) xxx

Acknowledgement [16] WHO. WHO recommendations Intrapartum care for a positive childbirth
experience. Geneva; 2018.
[17] G.F. Moore, S. Audrey, M. Barker, L. Bond, C. Bonell, W. Hardeman, et al., Process
We would like to express our sincere appreciation to all the organi­ evaluation of complex interventions: medical research council guidance, BMJ:
zations and the participants who took part in this study. British Med. J. (2015) 350.
[18] S.A. Li, L. Jeffs, M. Barwick, B. Stevens, Organizational contextual features that
influence the implementation of evidence-based practices across healthcare
Conflict of interest settings: a systematic integrative review, System. Rev. 7 (1) (2018) 72.
[19] M. Bogren, K. Erlandsson, Aastrika Midwifery centre, a model for midwifery-led
The authors declare that they have no conflict of interest. The au­ care in India, J. Asian Midwives 8 (1) (2021) 3–5.
[20] S. Elo, H. Kyngas, The qualitative content analysis process, J. Adv. Nurs. 62 (1)
thors alone are responsible for the views expressed in this publication, (2008) 107–115.
which do not necessarily represent the decisions or policies of the [21] The Commonwealth Fund. International Health Care Systems Profile India 2020
funder. [Available from: 〈https://www.commonwealthfund.org/sites/default/files/2020
–12/2020_IntlOverview_INDIA.pdf〉.
[22] Ministry of Health and Family Welfare GoI. National Family Health Survey (NFHS-
Statement of significance 5), 2019–21. Mumbai: International Institure for Population Sciences; 2022.
[23] United Nations DoEaSA, Population Division,. World Population Prospects 2019.
New York; 2019.
Problem or Issue: Midwifery-led care is known to improve maternal [24] Macrotrends. India Birth Rate 1950–2022 2022 [Available from: 〈https://www.
and new-born health outcomes, but little is known about factors influ­ macrotrends.net/countries/IND/india/birth-rate〉.
encing implementation of this care model in low- and middle-income [25] UNFPA, ICM, WHO,. The State of the World’s Midwifery 2021. New York: United
Nations Population Fund; 2021.
countries.
[26] K. Mayra, Z. Matthews, S.S. Padmadas, Why do some health care providers
What is Already Known: The Government of India has committed disrespect and abuse women during childbirth in India? Women Birth 35 (1)
to educate 90,000 midwives, who will be called Nurse Practitioners in (2022) e49–e59.
Midwifery and will function in midwifery-led care units to care for [27] N. Madhiwalla, R. Ghoshal, P. Mavani, N. Roy, Identifying disrespect and abuse in
organisational culture: a study of two hospitals in Mumbai, India, Reprod. Health
women during labour and birth. Matters 26 (53) (2018) 36–47.
What this Paper Adds: Knowledge about the contextual factors [28] M. Chhugani, Midwifery in India and its roadmap, J. Asian Midwives 1 (1) (2014)
critical for the design, targeting and implementation of effective policies 34–40.
[29] Directorate General of Health Services Ministry of Health & Family Welfare
and interventions in relation to the implementation of a midwifery-led Government of India, Indian Public Health Standards (IPHS) Guidelines for District
care model during childbirth. Hospitals (101 to 500 Bedded), Directorate General of Health Services Ministry of
Health & Family Welfare Government of India,, New Delhi, 2011.
[30] National Health Mission, LAQSHYA: Labour Room Quality Improvement Initiative,
References Ministry of Health and Family Welfare India,, New Delhi, 2017.
[31] U. Bronfenbrenner, Environments in developmental perspective: theoretical and
[1] UNFPA, WHO, ICM. The state of the world’s midwifery 2014: a universal pathway. operational models, in: S.L. Friedman, T.D. Wachs (Eds.), Measuring Environment
A woman’s right to health. New York; 2014. Across the life Span: Emerging Methods and Concepts, American Psychological
[2] Ministry of Health and Family Welfare Government of India. Guidelines on Association Press, Washington, DC, 1999, pp. 3–28.
Midwifery Services in India. 2018. [32] K. Coxon, A. Chisholm, R. Malouf, R. Rowe, J. Hollowell, What influences birth
[3] J.R. Stevens, C. Alonso, Commentary: creating a definition for global midwifery place preferences, choices and decision-making amongst healthy women with
centers, Midwifery 85 (2020), 102684. straightforward pregnancies in the UK? a qualitative evidence synthesis using a
[4] J.K. Edmonds, J. Ivanof, U. Kafulafula, Midwife led units: transforming maternity ‘best fit’ framework approach, BMC Pregnancy Childbirth 17 (1) (2017) 103.
care globally, Ann. Glob. Health. 86 (1) (2020) 44. [33] United Nations. Transforming our world: The 2030 agenda for sustainable
[5] ICM. Essential Competencies for Midwifery Practice: International Confederation development New York, USA; 2015.
of Midwives; 2019 [Available from: 〈https://www.internationalmidwives.org/asse [34] A. McFadden, S. Gupta, J.L. Marshall, S. Shinwell, B. Sharma, F. McConville, et al.,
ts/files/general-files/2019/02/icm-competencies_english_final_jan-2019-update Systematic review of barriers to, and facilitators of, the provision of high-quality
_final-web_v1.0.pdf〉. midwifery services in India, Birth issues Perinatal Care 47 (4) (2020) 304–321.
[6] International Confederation of Midwives. Global Standards for Midwifery [35] D. Walsh, H. Spiby, C. McCourt, C. Grigg, D. Coleby, S. Bishop, et al., Factors
Regulation 2011 [Available from: 〈https://www.internationalmidwives.org/ influencing the utilisation of free-standing and alongside midwifery units in
assets/files/general-files/2018/04/global-standards-for-midwifery-regulation-eng. England: a qualitative research study, BMJ Open 10 (2) (2020), e033895.
pdf〉. [36] Berg M. Bogren M., Erlandson E., Hök G., Lindgren H., Osika Friberg I. The Swedish
[7] M.J. Renfrew, A. McFadden, M.H. Bastos, J. Campbell, A.A. Channon, N.F. Cheung, Midwifery report 2021: The midwif’e role in implementing the Sustainable
et al., Midwifery and quality care: findings from a new evidence-informed Development Goals of the UN 2030 Agenda. Protect and invest together.
framework for maternal and newborn care, Lancet 384 (9948) (2014) 1129–1145. Stockholm; 2021.
[8] P. ten Hoope-Bender, L. de Bernis, J. Campbell, S. Downe, V. Fauveau, H. Fogstad, [37] H. MacKenzie Bryers, E. van Teijlingen, Risk, theory, social and medical models: a
et al., Improvement of maternal and newborn health through midwifery, Lancet critical analysis of the concept of risk in maternity care, Midwifery. 26 (5) (2010)
384 (9949) (2014) 1226–1235. 488–496.
[9] Nove A., Friberg IK, de Bernis L., McConville F., Moran AC, Najjemba M., et al. [38] M. Bogren, K. Erlandsson, U. Byrskog, What prevents midwifery quality care in
Potential impact of midwives in preventing and reducing maternal and neonatal Bangladesh? a focus group enquiry with midwifery students, BMC Health Services
mortality and stillbirths: a Lives Saved Tool modelling study. The Lancet Global Research 18 (1) (2018) 639.
health. 2020. [39] L. Batinelli, E. Thaels, N. Leister, C. McCourt, M. Bonciani, L. Rocca-Ihenacho,
[10] J. Sandall, H. Soltani, S. Gates, A. Shennan, D. Devane, Midwife-led continuity What are the strategies for implementing primary care models in maternity? A
models versus other models of care for childbearing women, Cochrane Database systematic review on midwifery units, BMC Pregnancy Childbirth 22 (1) (2022)
Syst. Rev. (4)) (2016). 123.
[11] Q. Long, E.R. Allanson, J. Pontre, Ö. Tunçalp, G.J. Hofmeyr, A.M. Gülmezoglu, [40] M.J. Renfrew, A.M. Malata, Scaling up care by midwives must now be a global
Onsite midwife-led birth units (OMBUs) for care around the time of childbirth: a priority, Lancet Glob. Health 9 (1) (2021) e2–e3.
systematic review, BMJ Glob. Health 1 (2) (2016), e000096. [41] M. Healey, ‘Regarded, paid and housed as menials’: nursing in colonial India,
[12] B. Mortensen, M. Lukasse, L.M. Diep, M. Lieng, A. Abu-Awad, M. Suleiman, et al., 1900–1948, South Asian Hist. Cult. 2 (1) (2010) 55–75.
Can a midwife-led continuity model improve maternal services in a low-resource [42] M. Bogren, K. Erlandsson, Opportunities, challenges and strategies when building a
setting? a non-randomised cluster intervention study in Palestine, BMJ Open 8 (3) midwifery profession. Findings from a qualitative study in Bangladesh and Nepal,
(2018), e019568. Sexual Reprod. Healthcare 16 (2018) 45–49.
[13] S. Hailemeskel, K. Alemu, K. Christensson, E. Tesfahun, H. Lindgren, Midwife-led [43] M.U. Bogren, A. Wiseman, M. Berg, Midwifery education, regulation and
continuity of care improved maternal and neonatal health outcomes in north Shoa association in six South Asian countries–a descriptive report, Sexual Reprod.
zone. Amhara Regional State, A quasi-experimental study. Women and Birth.,, Healthcare Off. J. Swed. Assoc. Midwives 3 (2) (2012) 67–72.
Ethiopia, 2021. [44] K. Mayra, S.S. Padmadas, Z. Matthews, Challenges and needed reforms in
[14] M. Michel-Schuldt, A. McFadden, M. Renfrew, C. Homer, The provision of midwife- midwifery and nursing regulatory systems in India: implications for education and
led care in low-and middle-income countries: an integrative review, Midwifery. 84 practice, PLoS One 16 (5) (2021), e0251331.
(2020), 102659. [45] ICM, Global Standards for Midwifery Regulation (2011), International
[15] B. Mortensen, M. Lieng, L.M. Diep, M. Lukasse, K. Atieh, E. Fosse, Improving Confederation of Midwives, Den Haag, 2011.
maternal and neonatal health by a midwife-led continuity model of care - an
observational study in one governmental hospital in Palestine, EClinicalMedicine
10 (2019) 84–91.