Why Transforming Birthing Requires Systemic Change

India’s maternal health story is one of genuine progress and persistent gaps. Maternal mortality has declined steadily over two decades. Institutional deliveries have risen to 90.6% of all births, according to NFHS-6 (NFHS-6 2023–24). More women are reaching facilities than ever before. 

What they encounter once they arrive, however, remains deeply variable. And the gap between reaching a facility and receiving quality care is where the next chapter of India’s maternal health story must be written. 

 

How the System Gets Here 

Consider what a typical birth looks like in a busy private hospital. A doctor managing multiple patients, a family waiting anxiously for hours, and a health system where intervention is better reimbursed than observation. In that environment, a C-section can feel like the safest, most responsible choice for everyone involved, even when the clinical picture does not call for it (World Health Organization 2015). 

In private hospitals, financial incentives shape clinical decisions in ways that are well documented: intervention is better reimbursed than observation, and the system responds accordingly (World Health Organization 2015). In public facilities, the pressures run differently: overstretched staff, under-resourced wards, and institutional cultures shaped by decades of established practice. The constraints differ, but the underlying dynamic is the same in both settings. 

Both sectors, in different ways, reflect the same underlying reality: outcomes are shaped by the systems people work inside, not only by the choices they make within them. 

 

What Women Have the Right to Know 

A significant proportion of women giving birth in India have never been told that they have the right to a birth companion beside them through labour, and that informed consent, real consent, with explanation, time, and the freedom to ask questions, is a clinical and legal standard, not a courtesy (Bohren et al. 2015). Their voice in the room is a right, not an interruption. 

When women know what good care looks like, they seek it, they ask for it, and over time they create the conditions in which institutions must provide it. Demand and supply move together. A health system designed around women’s needs becomes sustainable when women know what those needs are and expect them to be met. Building that awareness among women, families, and communities is therefore inseparable from building the systems that honour it. 

 

Why One Reform at a Time Falls Short 

Most efforts to improve maternal healthcare work on one part of the system at a time. Better clinical training. New guidelines. Awareness campaigns for women. All of these matter. 

But a system holds its shape because all its parts are connected. A healthcare worker trained in evidence-based care returns to a facility not yet structured around it. A woman who learns to expect respectful care walks into an environment still finding its way to deliver it. A policy that looks excellent on paper meets a ward where the conditions to implement it are still being built. 

Real change in maternal care requires movement on multiple fronts: what the workforce knows, what institutions make possible, and what women and families have come to expect (Renfrew et al. 2014). Each part supports the others. That is what makes this work systemic rather than incremental. 

 

What Systemic Change Looks Like in Practice 

Systemic change does not announce itself. It accumulates through the compounding of reforms that reinforce each other over time. 

In Karnataka, Aastrika Foundation’s support for the Government of India’s NPM Programme has created a cascade of training, from National and State Midwifery Training Institutes to Midwifery-Led Care Units embedded in public hospitals, where skilled midwives practise the model of care they were trained to deliver (Aastrika Foundation 2026). Alongside this, Aastrika Sphere strengthens the broader workforce through digital capacity-building, extending professional development to healthcare workers across geographies at the pace and scale that a system as large and diverse as India’s demands. Advocacy work runs alongside both, building public demand for respectful, evidence-based care and giving facilities a reason to sustain their standards. 

None of these reforms works in isolation. Together, they create the conditions in which better care becomes the norm rather than the exception. 

 

The Way Forward 

Transforming maternity care in India is a long undertaking. It asks something of institutions, of health workers, of policymakers, and of women themselves, and it asks for all of these things together. A workforce reform without institutional change cannot hold. Institutional change without demand from women and families lacks the pressure to sustain it. Demand without the systems to meet it goes unmet. 

That is how standards shift. That is how systems change. 

Aastrika Foundation works to strengthen India’s maternal health system through midwifery education, health workforce capacity building, and advocacy for respectful, evidence-based care. 

 

References 

Aastrika Foundation. 2026. NPM Programme Karnataka Data. Bengaluru: Aastrika Foundation. Internal programme data. 

Bohren, Meghan A., Joshua P. Vogel, Erin C. Hunter, Olha Lutsiv, Suprita K. Makh, João Paulo Souza, Carolina Aguiar, et al. 2015. “The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review.” PLOS Medicine 12 (6): e1001847. https://doi.org/10.1371/journal.pmed.1001847. 

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

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