The Role of Midwives in Strengthening Maternal Healthcare

India has made significant progress in maternal health over the past two decades. More women are birthing at healthcare facilities. Maternal mortality has declined. These are genuine achievements, hard-won through sustained public health investments. 

And yet, for millions of women giving birth in India today, the quality of that care remains deeply uneven. Survival is no longer the only measure that matters. What happens during the journey of pregnancy, labour, and childbirth, whether a woman is informed, supported, and treated with dignity, shapes not just her experience but her outcomes, and those of her child. 

This is where professional midwifery enters the picture. In a country where a dignified standard of care is still the exception, building a midwifery workforce is one of the most evidence-backed structural reforms available. 

 

What Is Midwifery 

Midwifery is a clinical specialisation focused on normal, physiological birth. A midwife is trained specifically to support low-risk pregnancies through antenatal, labour and birth, to identify and escalate complications early, to reduce unnecessary interventions, and to ensure that the woman in her care is informed and central to every decision. 

This is a distinct skill set, and it produces distinct outcomes. 

The 2014 Lancet Series on Midwifery, a comprehensive review of evidence across 58 countries, found that scaling up midwifery care could prevent up to 83% of maternal and neonatal deaths globally (Renfrew et al. 2014). A subsequent Lancet Global Health modelling study reinforced this, estimating that full-scale midwifery could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths annually (Nove et al. 2021). The WHO further notes that quality midwifery care improves more than 50 health outcomes, extending well beyond mortality to include breastfeeding rates, newborn health, and the mental wellbeing of mothers (WHO et al. 2019). 

Where skilled midwives practise, care improves. The evidence on this is consistent and global. 

 

What the Numbers Show in Karnataka 

India’s overall C-section rate has risen sharply to 27.2% nationally, according to NFHS-6 (NFHS-6 2023–24). In the private sector, the rate now stands at 54.1%, which is more than triple the WHO’s recommended ceiling of 10 to 15% (World Health Organization 2015). Karnataka recorded the sharpest increase in C-section rates of any major state in India between the two surveys, rising from 31.5% in NFHS-5 to 45.7% in NFHS-6, a jump of 14.2 percentage points (NFHS-6 2023–24; The South First 2026). In Karnataka’s private hospitals, the rate has reached 63.8%. 

These numbers reflect a care model that has drifted significantly from what evidence supports as clinically appropriate. They also set the context for what a different model of care, one centred on women and evidence-based practices, can produce in comparison. 

In Karnataka, Aastrika Foundation supports the Government of India’s Nurse Practitioners in Midwifery (NPM) Programme in collaboration with the Department of Health and Family Welfare. The programme trains professional midwives through an 18-month curriculum aligned with International Confederation of Midwives (ICM) global standards and places them in Midwifery-Led Care Units at high-volume public hospitals (International Confederation of Midwives 2021). 

The outcomes from 5,731 births facilitated under the NPM programme, based on data updated through 31 March 2026, reflect what a well-designed care model can produce (Aastrika Foundation 2026). 95% of women had a birth companion present throughout labour. The episiotomy rate was 21%, compared to rates that approach 80 to 100% in many standard obstetric settings across India. Skin-to-skin contact was initiated in 96% of births. These outcomes are the direct result of a facility structured to support physiological birth, where evidence guides every decision and the woman remains at the centre of her care. 

 

Building the Architecture for Midwifery at Scale 

What makes the NPM Programme a structural intervention is its cascade architecture. 

It builds the institutional infrastructure for midwifery to exist and function at scale. National and State Midwifery Training Institutes create the educational backbone. Nurse Practitioners in Midwifery Educators (NPMEs) are trained at NMTIs, and they in turn train Nurse Practitioners in Midwifery (NPMs) at State Midwifery Training Institutes. Midwifery-Led Care Units, embedded within public hospitals, provide the practice environment in which that training becomes sustained clinical competency. 

In Karnataka, the NMTI was established at Vani Vilas Hospital, Bengaluru in 2023. The first cohort of 29 educators have since created State Midwifery Training Institutes in Bengaluru, Mysuru, and Belagavi, training 62 practising NPMs, who are now practicing across 12 midwifery sites, in Karnataka (Aastrika Foundation 2026). The programme’s national ambition is to build a recognised cadre of 90,000 midwives and establish 8,000 MLCUs across the country. 

Countries that have invested in building and sustaining professional midwifery workforces within their public health systems have seen sustained reductions in maternal mortality that no single programme achieved in isolation. 

The Netherlands, where midwives support majority of low-risk births, consistently records among the best maternity outcomes in Europe (Euro-Peristat Network 2022). New Zealand’s integration of professional midwifery as the lead maternity carer has been associated with high rates of physiological birth and low intervention rates: 94% of people giving birth in 2023 received care from a community-based Lead Maternity Carer (Health New Zealand | Te Whatu Ora 2024). In Sri Lanka and Malaysia, midwifery-led primary care was central to dramatic reductions in maternal mortality across the second half of the twentieth century (ten Hoope-Bender et al. 2014). Ethiopia’s community midwifery programme, rolled out at scale from 2009, is credited with significant contributions to the country’s MMR reduction (United Nations Population Fund–Ethiopia, n.d.). 

The midwifery workforce is the infrastructure through which system-level change becomes possible. 

 

Why This Matters Beyond Midwifery 

Respectful, evidence-based care is the responsibility of every healthcare professional, across every cadre, in every setting. The challenges of disrespect, unnecessary intervention, and poor-quality care exist throughout the system and require solutions throughout the system. 

What midwifery contributes is demonstration; at scale, in real public health facilities, that a different standard of care is possible and measurable. Every MLCU that is operational is a proof point. Every midwife who supports a woman through labour with skill and attentiveness is evidence that the system can function differently. 

In a health system where over-medicalisation has become normalised, a functioning alternative is precisely what shifts the standard of what anyone believes is achievable. 

Transforming maternal healthcare in India requires building a workforce trained to place women at the centre of care. Midwifery is one of the most evidence-backed ways to do that. The infrastructure is being built. The outcomes are already visible. What comes next is the commitment to take it to scale. 

Aastrika Foundation supports the Government of India’s Nurse Practitioners in Midwifery (NPM) Programme in Karnataka, in collaboration with the Department of Health & Family Welfare. 

 

References 

Aastrika Foundation. 2026. “Introduction of Professional Midwives with ICM Competencies: A Case Study from Karnataka, India.” Data updated through March 31, 2026. Bengaluru: Aastrika Foundation. Internal programme data. 

Euro-Peristat Network. 2022. European Perinatal Health Report: Core Indicators of the Health and Care of Pregnant Women and Babies in Europe in 2015–2019. Paris: Euro-Peristat. 

Health New Zealand | Te Whatu Ora. 2024. Report on Maternity 2023. Wellington: Health New Zealand. 

International Confederation of Midwives. 2021. ICM Global Standards for Midwifery Education (Revised 2021). The Hague: International Confederation of Midwives. 

International Institute for Population Sciences (IIPS) and ICF. 2021. National Family Health Survey (NFHS-5), India, 2019–21. Mumbai: IIPS. 

Ministry of Health and Family Welfare. 2024. National Family Health Survey-6 (NFHS-6), India, 2023–24. New Delhi: Government of India. 

Nove, Andrea, Ingrid K. Friberg, Luc de Bernis, Fran McConville, Allisyn C. Moran, Maria Najjemba, Petra ten Hoope-Bender, Sally Tracy, and Caroline S. E. Homer. 2021. “Potential Impact of Midwives in Preventing and Reducing Maternal and Neonatal Mortality and Stillbirths: A Lives Saved Tool Modelling Study.” Lancet Global Health 9 (1): e24–e32. https://doi.org/10.1016/S2214-109X(20)30397-1. 

Office of the Registrar General of India. 2023. Sample Registration System (SRS), India, 2021–23. New Delhi: Office of the Registrar General of India. 

Renfrew, Mary J., Alison McFadden, Maria Helena Bastos, James Campbell, Andrew Amos Channon, Ngai Fen Cheung, et al. 2014. “Midwifery and Quality Care: Findings from a New Evidence-Informed Framework for Maternal and Newborn Care.” Lancet 384 (9948): 1129–1145. https://doi.org/10.1016/S0140-6736(14)60789-3. 

ten Hoope-Bender, Petra, Luc de Bernis, James Campbell, Soo Downe, Vincent Fauveau, Helga Fogstad, Caroline S. E. Homer, Holly Powell Kennedy, Zoe Matthews, Alison McFadden, Mary J. Renfrew, and Wim Van Lerberghe. 2014. “Improvement of Maternal and Newborn Health through Midwifery.” Lancet 384 (9949): 1226–1235. https://doi.org/10.1016/S0140-6736(14)60930-2. 

The South First. 2026. “NFHS-6 Reveals Southern States Dominating C-Section Landscape, Telangana Tops Nation.” The South First, May 29, 2026. https://thesouthfirst.com/health/nfhs-6-reveals-southern-states-dominating-c-section-landscape-telangana-tops-nation/. 

United Nations Population Fund–Ethiopia. n.d. “Maternal Health.” UNFPA Ethiopia. https://ethiopia.unfpa.org/en/topics/maternal-health. 

World Health Organization. 2015. WHO Statement on Caesarean Section Rates. Geneva: World Health Organization. WHO/RHR/15.02. 

World Health Organization, United Nations Population Fund, United Nations Children’s Fund, and International Confederation of Midwives. 2019. Strengthening Quality Midwifery Education for Universal Health Coverage 2030: Framework for Action. Geneva: World Health Organization.