One key strategy to achieve reduction in maternal and neonatal mortality is to scale up the availability of
skilled birth attendants (SBAs). The staff nurses (i.e., registered nurse and midwives) are skilled birth
attendants recognized by the government of India.
Aim and objectives: This thesis studied women‘s choices, perceptions, and practices related to
childbirth, and how these were affected by modernity in general and modernity brought in by maternal
health policies (Paper-I). The midwifery scope of practice of staff nurses was studied in government
facilities (Paper-II). The confidence of the final-year students on selected midwifery skills, from the
diploma and bachelor‘s programmes, was assessed against the list of competencies of the International
Confederation of Midwives (ICM) (Paper-III). The teaching and learning approaches associated with
confidence were also studied (Paper-IV).
Methods: The grounded theory approach was used to develop models for describing the transition in
childbirth practices amongst tribal women (Paper -I) and to describe the scope of midwifery practice of
staff nurses (Paper-II). Data used for Paper-I included eight focus groups with women and five in-depth
interviews with traditional birth attendants and staff nurses. For Paper-II, 28 service providers and
teachers from schools of nursing were interviewed in depth.
A cross sectional survey design was used to assess the confidence of final-year students from 25
randomly selected educational institutions stratified by type of programme (diploma/bachelor‘s) and
ownership (private/government) (Paper-III & IV). Students assessed their confidence using a 4-point
Likert scale in the competency domains of antepartum, intrapartum, postpartum, and newborn care.
Explorative factor analysis using principal component analysis (PCA) was used to reduce skill
statements into subscales for each domain. Crude and adjusted odds ratios with 95% CI were calculated
to compare students with high confidence (≤75th percentile of scores) and those without high confidence
(> 75th percentile) to compare diploma and bachelor students (Paper-III) and to study the association of
teaching-learning methods and high and not high confidence for each subscale (Paper -IV).
Results: A transition in childbirth practices was noted amongst women—a shift from home to hospital
births seen as a trade-off between desirables (i.e., secure surroundings) and essentials (i.e., reduced risk
of mortality)‘ (Paper-I). General development, increased access to western medical care, and
international/national maternal health policies socialized women into western childbirth practices. The
communities increasingly relied on hospitals as a consequence of role redefinition and deskilling of the
Traditional Birth Attendants. Existing cultural beliefs facilitated the acceptance of medical interventions.
The midwifery practice of staff nurses was ‗circumstance-driven‘ and ranged from extended to marginal
because the legal right to practice was unclear Paper-II). Their restricted practice led to deskilling, and
extended practice was perceived as risky. The clinical midwifery education of students was
marginalized. Because of dual registration as nurse and midwife, the identity of a nurse was
predominant.
From 633 students, 25-40% scored above the 75th percentile and 38-50% below the 50th percentile of
confidence in all subscales Paper-III). A majority had not attended the required number of births
prescribed by the Indian Nursing Council. The diploma students were 2-4 times more likely to have high
confidence in all subscales compared to the bachelor students. High confidence was associated with
number of births attended, practice on manikins, and being satisfied with supervision during clinical
practice (Paper-IV).
Conclusions: Access to hospitals increases women‘s choices for childbirth in the context of high
mortality. Inequitable distribution of health facilities requires region specific strategies. The women are
dissatisfied with the psychosocial aspects of hospital care.
India has a national regulatory body, but midwifery specific regulation is lacking. In this situation, the
midwifery scope of practice of staff nurses is undefined. The pre-service midwifery education does not
develop student‘s confidence to provide first level care for childbirth, as expected by the governments.
Short-term and long-term measures to professionalize midwives in India are suggeste
