Are midwives India’s answer to 1 million fewer C-sections a year?

In the quiet labour room of a hospital, a young mother in the final stages of labour clenched her midwife’s hand as she breathed through a contraction—the same hand that guided her through the pregnancy. The midwife encouraged her, “You’re doing good”, while helping her take a more comfortable position. Her support made the mother feel in control of her birthing experience. This is the kind of care the Midwife-led Care model (MLC) emphasises—no blaring equipment, no unnecessary interventions, no unfamiliar health workers walking in and out of the labour room–just a constant reassuring presence.

Midwife-led care emphasises minimally medicalised natural birthing while being vigilant for complications, ensuring that women’s voices and choices are central to the birthing experience. Midwives provide continuity of care in a respectful manner. Global data suggests that midwives reduce avoidable Caesarean sections (1,2). Midwifery presents an opportunity to improve maternal outcomes in low and middle income settings such as India, where after a continuous increase over the years, caesarean section rates stand at 21.5 per cent today—an alarming 47.4 per cent in private facilities—far exceeding the WHO threshold of 15 per cent (3). Our estimates based on the Lancet series on Midwifery projections for 2030 suggest that midwifery could save 220,000 babies (77.4  per cent neonatal deaths) (F1), 12,000 mothers (69.8 per cent maternal deaths) (F1) and 1.1 million unnecessary C-sections (22 per cent of total C-section   deliveries) (F1) every year in India.

Hyderabad-based Fernandez Hospital, a National Midwifery Training Institute (NMTI) is pioneering Midwifery practice and education in the state of Telangana. Through ongoing patient monitoring and sustained commitment to minimally invasive maternal, the hospital has achieved a significant reduction in C-section rates for women in Robson Group 1. This is a promising precedent in India as it grapples with what can be described as an epidemic of Caesarean sections.

Childbirth is a normal physiological process and established sans complications in majority of women. However, unnecessary labour interventions are widespread, especially in low- and middle-income regions. WHO emphasises the need to prioritise individualised supportive care that encourages shared decision making.(4)“Women know their bodies and are naturally equipped to get through birthing. We are here to help them trust their instincts and ensure open communication to help mothers make informed decisions”, a midwife reiterates the core tenets of midwife-led care as she marvels at the strength of the women she supports.

Midwife-led care involves showing up, staying present and doing less–empowering more. They spend more time with pregnant women during consultations, addressing physical and emotional needs. Their constant care and presence in the labour room helps women confidently navigate natural labour progression, reducing the demand for surgical (C-section) and pain relief interventions (epidurals) thus improving maternal outcomes.

Poor outcomes are expensive. (5) Midwifery boosts healthcare access and efficiency, particularly in resource-constrained regions, with an ability to generate a 16-fold return on investment. (6) Evidence from Fernandez Hospital highlights the significant impact of midwife-led care (MLC) in comparison to obstetrician-led care (OLC) in lowering Caesarean section rates, preventing invasive procedures like episiotomies by 27 per cent and reducing instances of postpartum haemorrhage, the leading cause of maternal deaths, by more than 4 per cent. Besides, significant decline in pharmacological pain relief measures such as epidurals by 18 per cent, lower neonatal and birth injuries, increased vaginal birth after caesarean rates enhance the overall cost efficiency. As a result, midwives economise maternal care by reducing unnecessary interventions and avoidable complications. In the long run, they can help healthcare systems optimise resources and save costs.

World Health Assembly Resolution 77.5, adopted in 2024, also recommends scaling the midwifery model of care. (7) In India, through the ‘Midwifery Service Initiative’, the Government has committed to train about 90,000 midwives informed by International Code of Ethics for Midwives (ICM) standards. The initiative focuses on establishing a robust midwifery education system and a scalable model of midwifery-led care units. (8) Sheetal Samson, a seasoned midwifery educator and ardent advocate of midwifery practice says, “Investing in midwifery education and support is crucial for addressing global maternal health challenges and ensuring every woman has access to safe childbirth experiences.” The authors of this article are involved in ongoing research on cost effectiveness of midwifery in India which will further inform the scaling up of midwifery in private and public sectors.

Embracing the midwife-led model can ensure better outcomes and cost-effective care for mothers and newborns, offering a sustainable solution to controlling unnecessary Caesarean sections. Integrating human touch with well-trained healthcare providers, the midwife-led model is a paradigm shift from the medicalised birthing process, transforming the labour room into a respectful and dignified environment that restores agency to women. It fosters a nurturing milieu where women and midwives work in tandem to redefine birthing or rather reinstate it to its original unmedicalised version. Strategic expansion of midwife-led models promises a safe, respectful, and empowering birthing experiences, realising the goal of healthier mothers and healthier babies for a healthier nation.

References:

1. Hanahoe, M. (2020). Midwifery-led care can lower caesarean section rates according to the Robson ten group classification system. European Journal of Midwifery, 4(March). https://doi.org/10.18332/ejm/119164
2. Fikre, R., Gubbels, J., Teklesilasie, W., & Gerards, S. (2023). Effectiveness of midwifery-led care on pregnancy outcomes in low- and middle-income countries: a systematic review and meta-analysis. BMC Pregnancy and Childbirth, 23(1). https://doi.org/10.1186/s12884-023-05664-9
3. Pandey, A. K., Raushan, M. R., Gautam, D., & Neogi, S. B. (2023). Alarming Trends of Caesarean Section-Time to Rethink: Evidence from a Large-Scale Cross-sectional Sample Survey in India. Journal of medical Internet research, 25, e41892. https://doi.org/10.2196/41892
4. World Health Organization: WHO. (2018a, February 15). Individualized, supportive care key to positive childbirth experience, says WHO. who.int. Retrieved April 29, 2025, from https://www.who.int/news/item/15-02-2018-individualized-supportive-care-key-to-positive-childbirth-experience-says-who
5. World Health Organization: WHO. (2018, July 5). Low quality healthcare is increasing the burden of illness and health costs globally. who.int. Retrieved April 24, 2025, from https://www.who.int/news/item/05-07-2018-low-quality-healthcare-is-increasing-the-burden-of-illness-and-health-costs-globally
6. World Health Organization: WHO. (2014, November 4). The State of the World’s Midwifery 2014 launched in China to call for greater investment in midwifery to save lives of women and newborns. WHO News. https://www.who.int/china/news/detail/04-11-2014-the-state-of-the-world-s-midwifery-2014-launched-in-china-to-call-for-greater-investment-in-midwifery-to-save-lives-of-women-and-newborns
7. Accelerate progress towards reducing maternal, newborn and child mortality in order to achieve Sustainable Development Goal targets 3.1 and 3.2, World Health Organization. (28 May 2024).
8. International Day of the Midwife: the missing piece in India’s maternal health. (n.d.). UNFPA India. https://india.unfpa.org/en/news/international-day-midwife-missing-piece-indias-maternal-health.