Highlighting Success: The Fernandez Midwifery Initiative in India 

Origins and Rationale

The Fernandez Foundation, a private healthcare group led by obstetrician Dr Evita Fernandez, began exploring the midwifery model of care in 2011.

As a tertiary perinatal referral centre, the Foundation often received women with complex health needs. Many tragically suffered from multi-organ failure by the time they arrived, making it too late to save them. This situation in Telangana reflected the state of maternal health across India. With around 25 million births each year, 2.7 million babies are stillborn. The burden of loss is even higher, with approximately 35,000 women dying from pregnancy-related complications annually (WHO 2020), resulting in a maternal mortality rate of 103 per 100,000 live births.

Inspired by countries who have successfully implemented midwifery-led care, the Fernandez Foundation made midwifery a cornerstone of its healthcare strategy. Dr Evita Fernandez, familiar with midwifery in the UK, collaborated with a public health consultant to assess health challenges in Telangana. The assessment revealed significant disparities in care, widespread disrespect and abuse, and a lack of knowledge among women about their birthing options. Telangana also had an exceptionally high caesarean birthrate of 60.7%.

By introducing midwifery-led care, the Fernandez Foundation aims to address these issues, providing compassionate, respectful, and effective maternity care to improve outcomes for mothers and babies alike.

Developing the Midwifery Model

The need to humanise childbirth and provide woman-centred care for those without clinical indications for interventions during labour was evident. Drawing inspiration from the UK’s Albany Midwifery Practice, known for its high home birth rate in an area of high socio-economic disadvantage in London, the Foundation developed a comprehensive curriculum for midwifery education and training, aligning with the ICM standards.

Professional Midwifery Education and Training (PMET) Programme

Launched as a pilot in 2011, the PMET Programme aimed to train highly skilled nurses as midwives, providing respectful maternity care and establishing collaborative care between obstetricians and midwives. Initially, in-house nurses were trained through classroom teaching and clinical experience and mentored by a UK midwife for an 18 month period.

Students gained practical experience by assisting expectant women throughout labour and observing senior obstetricians in Fernandez changing childbirth practices to align with the philosophy of promoting normal birth and minimising unnecessary intervention.

The decision to unlearn and relearn paved the way for building new working relationships. Midwives and obstetricians began to work as colleagues with mutual respect and trust. This process involved open communication, mutual respect, and a shared commitment to improving maternal and neonatal health outcomes. Ultimately leading to the successful integration of midwives.

Following continuous assessments, trainees cleared exams and after six months of supervised clinical practice, were offered contracts as midwives, at the Fernandez Foundation’s hospital. Over the years, midwives became integral to the hospital’s framework, contributing to the continuous refinement of the PMET programme. From August 2011 to October 2021, midwives led 15,237 (41%) of the total births at Fernandez, showing positive trends with clinical indicators. The incidence of episiotomy, need for epidural analgesia and caesarean birth rates decreased. Positive feedback from mothers also increased.

Scaling Up and National Impact

PMET programme’s success caught the Telangana government’s attention. In 2017, together with UNICEF, Fernandez was invited to pilot the 18-month midwifery training programme with a cohort of 30 senior and experienced obstetric nurses. The integration helped reduce caesarean births significantly and increased vaginal births in the district hospital where the training programme was conducted.

The Telangana model led the Government of India to establish midwifery led care across its public institutions. This formal announcement was made at the Partners’ Forum, an international conference that was hosted by India in December 2018.

The move strengthened the existing model of midwifery at Fernandez and in 2019, the Indian government recognised the Fernandez School of Nursing as the first National Midwifery Training Institute (NMTI). In collaboration with the WHO, the Fernandez NMTI then trained 72 midwifery educators from 12 states.

   Training Programmes 

Central to Fernandez Midwifery Initiative is the Nurse Practitioner in Midwifery (NPM) programme developed in partnership with UNICEF and the Telangana government. This programme includes theoretical and clinical training in maternal and newborn care, emphasising evidence-based communication with doctors. It also trains midwifery educators under its midwifery educator programme.  

Currently, 353 NPMs across 32 districts are providing quality midwifery care, significantly increasing normal birth rates. By 2019, two Fernandez hospitals recorded 70.2% and 86% midwife-led births, respectively. 

Partnerships and Research 

The Fernandez Foundation has fostered significant partnerships with UNICEF, WHO, the Aastrika Foundation, Laerdal, Pronto International, the Government of Andhra Pradesh, and the University of Birmingham. These collaborations have been instrumental in transforming midwifery education and clinical practice standards. 

Fernandez is also part of the C-Safe programme, collaborating with the Government of Andhra Pradesh, the University of Birmingham, and representatives from WHO, UNICEF, Jhpiego, the Global Surgery Foundation, and others to reduce unnecessary caesareans. The goal is to improve maternal and perinatal outcomes through the appropriate use of caesareans in low- and middle-income countries. 

The five-year programme focuses on improving clinical decision-making to perform caesareans only when medically indicated, enhancing safety, and promoting respectful care in labour. Currently in a pilot stage in Tenali, Andhra Pradesh, the documented evidence will form the basis of a clinical trial in India and Tanzania.