Challenges and Reforms in Midwifery and Nursing Regulatory Systems in India: Implications for Education and Practice

Abstract Background: Quality of maternal healthcare is determined by the strength of the regulatory framework in which health workers practice. Nursing regulation is poor and midwifery coexists with nursing in India, where 88% of midwifery and nursing education is provided by the private sector. The Indian health system faces major challenges for maternal health provision, with a 12% share of total maternal deaths globally, poor quality, indeterminate regulatory functions and lack of reforms. Methods: We undertake a qualitative investigation to understand the experiences and perceptions of nurse-midwife leaders on midwifery and nursing regulatory systems in India and further examine their influence on midwifery education and development. Thirty-four in-depth interviews were conducted with senior midwifery and nursing leaders representing administration, advocacy, education, regulation, research and service provision. Results: Our findings shows a lack of importance accorded to midwifery roles within the nursing system. The councils and statutes do not adequately reflect midwifery practice, and hence they are a barrier to good quality care provision. The lack of amendment of Acts and lack of representation of midwives and nurses in key governance positions in councils and committees have restrained or undermined leadership positions, which in turn has also impaired the growth of the profession. The regulatory framework standards for midwifery and nursing education in private institutions appeared imprudent with lack of opportunities for practice and unfair assessment practices. Discrimination against midwifery and nursing students was rampant in the education system in public and private institutions, with limited opportunities for clinical practice when compared to medical students. Conclusions: The study concludes with a reform measure including a recommendation for implementing direct-entry midwifery education, empowering midwives and nurses with autonomy, decision-making powers within health care and workforce governance.