On review it was found that some state acts are older than the INC act of 1947. All the state acts are similar in content which includes the profile of members, key definitions, process of becoming a member, information for professional registration, re-registration and clauses under which a practitioner can lose registration. The profile of the governing body is not uniform, ranging from seven members in Odisha to fifteen in Bihar. Every council has a set number of members who are doctors and some members are non-nursing/ midwifery administrators. The ex-officio members, four to seven in every council, can be elected multiple times as long as they hold the position by virtue of which they have been elected. There is no system of direct application unless through nomination, followed by election. None of these Acts have been amended since they were introduced way back in the 1930’s and 40’s. Bihar shared a council with Odisha at the time of its creation (in 1935) but did not amend the Act even though soon after its creation Odisha started a separate council (1938).
The language of the Acts is not gender sensitive and all the Acts refer to the registrar as ‘he’ or ‘his’ even though historically the position of registrar in most nursing councils is held by women, including at present when four out of five SNC’s registrars interviewed in this study are women. The curriculum is not part of the act. It is centrally designed and implemented with some variation in the states.
The content varies a little for some Acts. The Rajasthan Nurses, Midwives, Health visitors and Auxiliary Nurse Midwives Act of 1964 is the most detailed Act entrusting the power of council through eight activities, including grounds on which the state government has the right to dissolve the Council and the Act. The language of the RNC Act is comparatively gender sensitive. Odisha and Rajasthan’s Act and Council include ‘midwives’ in the title. None of the other Acts mention anything about independent midwifery practice. Odisha is the only state that registers dai’s (traditional birth attendants). The Central provinces Nurses Registration Acts of 1936, in Madhya Pradesh discourages private practice even though it does not mention what it means for nurses working in the private health care provision and education.
All six Acts regulate education and none of them mention regulating practice or maintaining and updating the knowledge and skills of practicing professionals. There are no separate Acts at the state or centre that regulates nursing and midwifery practice. The Acts also do not mention INC’s role in supervising the SNCs. This could be because the state Acts, except Rajasthan, were formed before the INC Act of 1947 - although Rajasthan’s Act also does not mention INC’s role. INC’s key activities are maintenance of registers for all nursing and midwifery courses, registration at the national level, licencing of nursing training institutes, setting the curriculum for every course and maintaining uniformity. The INC website has information on the National Registration Tracking System (NRTS), which was recently launched to maintain a database of nurse-midwives in the country from every state, to enable tracking and regulate placement. As of August 9th 2020, there are 9,90,524 professionals enrolled under NRTS (INC, 2020).
The council Acts do not provide any guidance on nurses’ domestic or overseas migration clarifying the terms of registration while serving in a foreign country, practice in India on return, higher education in nursing and midwifery or other health-related education in other countries.
The INC is the main body that regulates nursing and midwifery education in India. The SNCs manage regulation at the state level. Regulation of nursing and midwifery education covers certificate, diploma and degree courses in public and private sector. Every council has positions of President and Registrar as the key administrators. Routine administration is in the purview of the Registrar. One participant from at the centre objected to the processes and terms of reference of administrators at the councils.
Most council participants mentioned a lack of human resources as a key challenge to managing the councils work such as admission, examination, inspection, registration and re-registration in each state. The role of the INC is different from the SNCs. The INC sets the national curriculum, oversees registration, implements the NRTS and conducts inspections in all the states. Some of these services overlap, such as institutional inspections which are carried out both by the SNCs and the INC independently when starting and maintaining a new institution. The reason for this was not clearly explained by the participants. One respondent from Rajasthan commented that this duplication of activity was unnecessary and should be handled solely by the respective SNCs.
Workload challenges were repeatedly mentioned particularly because the number of training institutes increased rapidly. Table 3 shows the number of nursing and midwifery educational institutes in each study state (along with seats) and total institutions in India. Between 2005 to 2018, the total ANMTCs increased from 254 to 1564, the total GNMTCs from 979 to 2812 and the total colleges of nursing from 349 to 1761. Bihar has the lowest number of institutes and admission capacity in comparison to the rest, while Madhya Pradesh has the highest. Bihar has 8.6% of India’s population but only 0.5% of total colleges of nursing. The capacity of bachelors degree in nursing education has increased four times and post graduation in nursing by eleven times in India between 2005 and 2018. This increase has been disproportionate. The number of institutes providing GNM education increased from 22 to 324 in Madhya Pradesh but remained low in Bihar (13 to 21) between 2005 to 2018. The range of 991 to 12,970 GNM places for admission is disproportionately high especially given that the population coverage is highest in Bihar followed by West Bengal, Madhya Pradesh, Rajasthan and Odisha. Bihar does not provide any higher education prospects for its graduating nurse-midwives in the state. Each of the states have between 20-100 seats for GNM and BSc Nursing per institute. Within the states, the number of training institutions are not proportionate with the state’s population. There is no data available from the INC that disaggregates distribution of institutes and admission capacity by public and private sector.
Table 3
Nursing and midwifery training institutions in selected states (2018)
|
State
|
Year
|
BSc Nursing
|
MSc Nursing
|
General Nursing and Midwifery
|
Auxiliary Nursing and Midwifery
|
Population (2011 Census)
|
|
Bihar
|
2018
|
9
|
0
|
21
|
90
|
10,38,04,637
|
|
2011
|
0
|
0
|
11
|
29
|
|
2005
|
0
|
0
|
13
|
25
|
|
Madhya Pradesh
|
2018
|
140
|
50
|
324
|
71
|
7,25,97,565
|
|
2011
|
101
|
29
|
135
|
82
|
|
2005
|
19
|
2
|
22
|
9
|
|
Rajasthan
|
2018
|
169
|
26
|
164
|
12
|
6,86,21,012
|
|
2011
|
149
|
5
|
176
|
11
|
|
2005
|
3
|
0
|
57
|
8
|
|
Odisha
|
2018
|
29
|
11
|
78
|
127
|
4,19,47,358
|
|
2011
|
16
|
5
|
48
|
67
|
|
2005
|
4
|
0
|
10
|
16
|
|
West Bengal
|
2018
|
23
|
12
|
72
|
6
|
9,13,47,736
|
|
2011
|
16
|
7
|
49
|
59
|
|
2005
|
2
|
2
|
28
|
20
|
|
All India
|
2018
|
1,761
|
590
|
2,812
|
1,564
|
1,21,08,54,977
|
|
2011
|
1,570
|
450
|
2,351
|
935
|
|
2005
|
349
|
54
|
979
|
254
|
The regulatory challenges in education are different in public and the private institutions. Although the curriculum being taught is uniform in every state, the respondents argued that quality of education is not the same in the public and private sector. Respondents from every state shared that regulation of education was comparatively poorer in private sector institutions.
“Practical experience (for students) is zero in private sector” (Bihar)
“Private sector regulation is poor. No one sees that.” (Bihar)
Health facilities have affiliations to medicine and nursing education institutes, from public and private. It is difficult for the hospital authority/ staff to ensure that every student receives required amount of practice as recommended for successful course completion. A respondent from Bihar shared from her experience of working in a government tertiary level teaching hospital.
“Head of the Department (doctor) says my medical students will practice first (in the labour room). The nursing (and midwifery) students observe cases but can only request to give them a chance to practice. 100% cases (births) are conducted by medicine students… thecouncil inspected, yet did nothing to change this.” (Bihar)
Such issues were shared from every state except West Bengal. The most common challenge mentioned was private institute students not getting an opportunity for practical experience during pre-service education. Students often filled up their case books with fabricated cases as a way to pass the course. This practice goes unchecked, though well acknowledged. Even more alarming is the illegal procurement of fake certificates by untrained persons. To address this, the councils take precautions before registering candidates from other states. However, the Registrars do not have sufficient resources to tackle such challenges which represents a major barrier in councils’ functioning.
The lack of practical exposure for students in private institutes leads to a lack of knowledge and skills in comparison to those from government-led institutes. This challenge is acknowledged in private hospitals. Most private hospitals have their own education institutes but reportedly they do not have confidence in their own students because of their lack of skills. A participant from Rajasthan reflected on the poor training quality of students from private institutes and acknowledged that the state council is aware of the problem.
“The (state) council knows about it and does nothing” (Rajasthan)
The participant further shared that students sometimes pay bribes to the professors after practical examination or even inside their answer sheets during examination for theory papers to score well when the scorer finds the bribe inside it. Many teachers succumb to this practice, but not all surrender to the pressure as mentioned by a participant.
“No one fails students… it is all hidden. Student goes to drop the examiner at the train station to pass on an envelop. I have never taken that envelop. I have heard 5000 rupees is minimum per student for BSc and GNM… Everyone wants to be an examiner for private institute, for that extra income and no one wants to go to government institutes cause government students wont pay to pass.” (Rajasthan)
Corruption is the underlying reason for such malpractice which is kept in place by promoting nurses who are party to it.
“When nurses raise their voice, government removes them from their position. They are not scared of us as we don’t have any power. We are dominated from above. We know everything but can do nothing” (Rajasthan)
A participant from Madhya Pradesh commented on the issue of student’s non-attendance. Instead of sitting through the classes, students work in smaller nursing homes as assistants for an extra income. These training centres are usually affiliated to big private hospitals, so in terms of requirement, their ‘papers’ are always complete which means the non attendance goes undocumented. Even though these nursing institutes undergo inspections from the SNC, INC and the state government, they often don’t face any regulatory action. Figure 1 shows the current responsibilities of state and central council, along with the overlap in their role and the gaps in regulatory functions.
3.3. Gender and power influencing midwifery and nursing regulation
The states face some unique gender-based challenges. In a female dominated profession, the leadership is male dominated in India and Rajasthan. In Rajasthan, the curriculum is regulated under the leadership of a male Nursing Registrar and practical experience is overseen by a male nursing administrator from the state health ministry. Rajasthan and Madhya Pradesh are amongst the few states that allow male students to take up nursing and midwifery education. Although, Rajasthan historically had both men and women candidates in diploma and degree level courses, due to lesser girls opting to do nursing owing to professional stigma, the inability to ensure the required practical experience in midwifery for male candidates has been a persistent challenge. In some institutions the midwifery professor or clinical instructor is a man, yet there is a strong possibility that he has never assisted a single birth. The issue of the lack of practical midwifery education for male candidates has not been addressed. A participant from Rajasthan, who teaches midwifery, raised this issue faced during his own training.
“I asked them why are you giving us this training when you won’t let us practice during the training. What is the point of doing this training?... They (regulatory bodies) are not even thinking in those lines.” (Rajasthan)
The INC recommends for students to assist 25 births each in BSc Nursing and MSc Nursing in Obstetrics. A male participant who teaches midwifery assisted only five births including his BSc in Nursing and Masters in Obstetrics degrees, even though 650 hours of study is required in total for an MSc. Even getting a chance to assist those five births was fraught with difficulties involving persistent efforts to win the trust of the labour room’s team of care providers.
“There is stigma for men to work in labour room. Families don’t encourage it, so the scope is less.” (Rajasthan)
“This gender related problem has existed for over 30 years but INC is not doing anything to address it… the state nursing councils can not do anything about this. Now INC is implementing an 18 months course in midwifery but not looking into the challenges of men in midwifery… INC needs to take a stand… States can not do anything. INC tells, we do. State council can write to INC, but they don’t care about the quality of education”. (Madhya Pradesh)
The nursing and midwifery leaders representing education, administration and service provision brought up similar issues regarding male students lacking practical midwifery exposure. However, the participants representing regulatory bodies shared no such concerns. West Bengal has recently started enrolling male candidates for nursing and midwifery education. The issue of gender is not just about getting a chance to practice midwifery. A participant mentioned that the apparent gender imbalance in the profession is also a reason for the lack of leadership for women in nursing and midwifery.
“People in West Bengal used to think men in nursing won’t be accepted by society, but that was a myth. There are two colleges with 50 seats each for male candidates who are also learning midwifery. The 1st batch training is on and it is very exciting.” (West Bengal)
The role of doctors, who are usually men, is explored in different ways. They are held responsible for the lack of female representation and growth of the profession. There is frustration about doctors holding key positions in nursing councils.
“Nursing association wants the nursing directorate to be separate so their demands can be addressed. Any demand from a nursing or midwifery association is usually shelved when a doctor policy-maker comes in the picture.” (Rajasthan)
“The president of Bihar Nursing Council is a Doctor…there is a lot of politics in all of this. There is pressure from the (Health) Secretary as well.” (Bihar)
An interesting rationale came from a participant in West Bengal on the lack of leadership quality in nurse-midwives. According to her, the issue is that “lesser doctors are falling in love with nurses” as more women are being trained as doctors. Given that more recently male doctors are getting married to female doctors, nurses seem to be falling further down in the hierarchy of healthcare. The position of nurses, therefore, diminishes in society because doctors do not consider them their equal anymore. The involvement of men in nursing is deemed to uplift of the image of nursing in the country to reduce the gender based stigma.
“As women, we are ruled by our father, brother, husband and son at different stages of our life… It is our lack of confidence and attitude that only if men are there will we succeed. There is a dependence… we surrender too easily.” (West Bengal)
3.4. Midwifery under nursing as a regulatory challenge
Participants were asked about their opinion on the midwives current role in India, which is not a direct entry education and is usually practiced on rotation with other nursing roles. Direct entry midwifery is a 3 years degree course recommended by ICM that provides a license of Registered Midwife (RM). Participants responded with mixed opinions on the requirement and future of midwifery in India as an independent profession. While most participants seemed to be in favour of independent midwifery, there were limited and unclear responses on the regulatory challenges it entails. A respondent from Odisha could relate to working independently in the periphery and yet working harder, as the best phase of her career.
“ANM is our independent midwifery practitioner who is assisting deliveries in rural areas as good as doctors are doing independently in the urban areas.Some ANM’sconductdeliveriesmuchbetterthandoctorsandareveryfamousfortheirwork,peoplespeciallyrequestthemtoassistwiththeirdelivery.” (Rajasthan)
Medical domination is reported as a key barrier for independent midwifery practice as the respondent mentioned “we can not work independently in the tertiary level as the (medical) professors are there” or that “we can not work without their permission”. Multiple respondents mentioned not being ‘allowed’ to do much as a key issue in the tertiary level of care though they have been entrusted with larger responsibilities at the primary and secondary level.
“I have done spinal anaesthesia, caesarean section and abortion, under supervision. If a policy is made that we can work independently, it will be uplifting for the profession (of midwifery).” (Odisha)
“Independent midwifery is key to address the situation with disrespect and abuse during childbirth everywhere.” (Bihar)
“Nurse and midwife should be separate cadres, like medicine. Rotation is not helping” (National)
Another participant mentioned the lack of a legal framework as a key challenge for independent midwifery in India. This is due to a lack of legal protection for midwifery practitioners, unlike with doctors. At the national level, participants felt that the INC should take charge of regulating nursing and midwifery services. Participants have reported these challenges from every state.
“If the INC is the (only) regulatory body (in the country) then that should look after practice. In the 10 years that I have been superintendent, no one has come to check the competency level of my nurses”. (National)
“ Nothing is happening in terms of nursing regulation. There is no regulation of service.” (Bihar)
There are challenges of underfunding as well, which were identified by a participant from Switzerland.
“All of them are badly underfunded. INC has managed to get some funds but given the size of India, its peanuts. It would be effective if they had many more resources. They could really meet, coordinate, re-educate, train, get the evidence and really understand what’s going on. Its sad that what’s all happening at states is registering and re-registering.” (Switzerland)
Respondents felt that the councils should work in favour of midwifery and protect midwives right to practice in an independent profession. The need for a midwifery Act was mentioned a few times, which could encompass the unique challenges that midwives face. A participant stated that a Nursing and Midwifery Practice Act of India is being drafted without any assurance of when it will be enacted. Meanwhile another participant commented that the lack of a midwifery model of care is due to the vested interests of national leaders “… they do not want independent midwifery in India”. The independent status of midwifery is expected to bring in more recognition and a boost in salary as is seen in many other countries. A participant from the United Kingdom suggested a way forward,
“I think it would change the status if the public sees that this is a midwife, this is her level of skills. Someone who practices independently, not dependent on doctor. Its straightforward. It automatically shifts the status of the profession. It is fundamental to have that independent status. I know its not easy to organize and make happen. But it’s the way forward… Changes in policies will of course support the midwives but also part of what’s needed is to get midwifery leaders in the profession who sit there at those tables. There are policies being made about midwifery and maternity care without them at the table. We have got to get ourselves at those top tables… There is strong evidence on midwifery with the lancet series. Its doesn’t happen overnight.” (United Kingdom)