Evita Fernandez has pioneered the professional field of midwifery in India. Focusing on public hospitals, she has established the culture, practice, players, and institutions for midwifery that meet global standards, while revolutionizing maternal and child healthcare for women from the poorest communities. Evita’s efforts have moved the government to propose a new law to mainstream midwives into the public health system of India. This is opening up new and rewarding career pathways for nurse practitioners while placing pregnant women's safety, dignity, and empowerment at the center of India’s maternal health system.
The New Idea
India accounts for 15% of the global maternal death burden annually three women are reported to die every hour due to complications during childbirth caused by the lack of trained service providers and over-medicalization of the birthing process . Public hospitals are also sites of obstetric violence and abuse as pregnant women return scarred and traumatized after childbirth an experience that should ideally be joyous and uplifting. Evita, a senior obstetrician with three decades of experience, is taking on this public health challenge by integrating the professional field of midwifery into India’s government health systems.
Midwifery is a globally recognized practice that offers a skilled, compassionate, safe, and empowered route to child birth and newborn care. Recognizing that childbirth is a normal, not a medical event, midwifery is grounded in a deep appreciation of a woman’s emotional, psychological, and physical experiences during birthing. The practice empowers and respects the woman’s choices and ability to lead the birthing process. Scientific evidence illustrates that midwives trained to global standards can meet 87% of maternal and newborn requirements of any country, reducing pre-term birth, the incidence of C-sections, and the use of pain relief medication during labor.
For the first time in India, Evita is making midwifery a mainstream experience for women with low-risk pregnancies. She is doing so by training and promoting highly-skilled cadres of professional midwives, midwifery educators, and trainers in partnership with the government of India. The midwives are placed in public hospitals where they task-shift most low-risk pregnancies away from skilled obstetricians, reducing the overall pressure on hospital systems. This enables doctors to focus only on the cases that require medical or surgical intervention. This collaborative model of care has demonstrated lower maternal and child mortality rates while reducing the unwarranted increase in cesarean sections.
The midwives and midwifery educators trained by Evita are true champions, spokespersons, and advocates for their field. Across 16 government hospitals in 12 districts of three states, the midwives are making a strong case for their profession by demonstrating its benefits; transforming public hospitals into spaces of dignity, joy and care; instituting robust quality processes and protocols for de-medicalizing pregnancy; while training, handholding and expanding their own peer networks. Most importantly, they are representing their profession in international conferences and government meetings to make a case for its expansion.
Starting with a pilot in 2011, Evita has been able to build a cohort of 322 Midwives and 22 Midwife educators in India across the states of Telangana, Andhra Pradesh, and Odisha. In Telangana, they have screened over 57,111 pregnant women, enabled empowered birth experiences for 10,919 women, and independently assessed 11,038 newborns. Between 2011 and June 2022, the midwives at Fernandez Hospitals performed 42.5% of the spontaneous vaginal deliveries while lowering the rates of episiotomies from 40% (2011) to 27.3% (2021) and bringing down the use of epidurals from 70% in 2011 to 40.5% in 2021. All across the state, the rate of C-sections is reported to have fallen. One such example is Karimnagar, where C-sections reportedly dropped by 10% in 6 months, from an alarming level of 77% to 67%.
Evita believes that the field of midwifery can best be shaped and steered by the midwives themselves. At Fernandez Hospitals, she has developed two training programs: Nurse Practitioner Midwifery (NPM) and The Nurse Practitioner Midwifery Educator (NPM-E). Both draw from global best practices and are helmed by midwives educators themselves, who are now building a nationwide momentum, where a group of 3 midwife educators trains 30 peers.
Based on the demonstrated success of the training curriculum, Evita was invited by the Ministry of Health to the national steering committee rolled out by the Indian Nursing council, which involved several important health sector stakeholders such as WHO, UNICEF, and BMGF. Evita’s efforts have given new momentum to the efforts of the Indian government to draft new legislation (the National Nursing and Midwifery Bill 2020) to establish midwifery across government hospitals in India. The government has also established the National Midwifery Guidelines to create an India-wide infrastructure of National Midwifery Training Institutes (NMTIs) and the Indian Nursing Council is pushing to create a nursing and midwifery council to steer these efforts.
By 2032, the government seeks to train 90,000 midwives, out of which Fernandez Hospitals, a national midwifery training institute led by Evita, is the only charitable and private player identified to support central and state government targets.
In the last two decades, 1.3 million Indian women have died from maternity-related causes. Every year, 2.7 million babies (of 25 million) are stillborn. The poorer states, especially the rural and tribal regions, account for over 60% of these deaths. The WHO notes that most of these deaths occurring during childbirth are preventable.
Government incentives draw 80% of pregnant women, mostly those who live below the poverty line, into government hospitals for antenatal care and delivery. This has increased the volume of women giving birth in public hospitals by 40% in some states. There is an acute shortage of skilled staff to meet this volume, and the infrastructure does not support it either. In some regions, hospitals report less than a doctor (0.3-0.5) per 10,000 people.
These intense pressures on the health system have pushed India’s maternity practices towards a strongly medicalized approach, leading to multiple unnecessary interventions, including an unacceptably high cesarean birth rate 21.5% of total institutional births both in private (47.4%) and public facilities (14.3%). Obstetricians confer that “clearing the labor room” is the ultimate barometer of good performance, which is what they work towards.
The excessive patient load also often results in either doctor absenteeism or poor quality of care manifesting in negligence or rampant obstetric violence. Physical and verbal abuse and shaming of pregnant mothers while birthing by medical staff is common. This trauma often drives pregnant women to unscrupulous private healthcare providers, where they end up with unnecessary C-sections and excessive debt burdens, further pushing them into poverty.
This overburdened and desensitized healthcare system is doctor-centric rather than woman-centric. An example of this is asking women to lie uncomfortably flat on their backs (against scientific evidence) while birthing because it is easier for obstetricians. No consent is sought before any physical examination, which is often done in a tearing hurry. Women, especially from resource-poor communities, are not lent the mental and physical care, compassion, and dignity that is due to them during the birthing process.
These factors make India one of the top five countries with the highest maternal deaths and a maternal mortality ratio (MMR) of 103 per 100,000 live births, much higher compared to the globally mandated SDG of 70.
In 2011, Evita’s quest to make the healthcare system woman-centric led her to design and establish a comprehensive model of midwifery practice in two of the six charitable hospitals she leads.
As the first step, she designed rigorous 18-month training programs for midwives and midwife educators based on the guidelines of the International Confederation of Midwives (ICM). Despite resource constraints, she worked with top-end international experts and invited midwife educators from across the globe to design and lead the program with her. Starting with eight inspired nurses in 2011, who raised their hands to make a career shift in midwifery, Evita grew the team to 28 midwives. Together, they demonstrated compelling impact, which attracted the attention of global medical experts and leaders of government health programs.
In 2016, Evita partnered with the Government of Telangana and UNICEF to replicate the midwifery experience in the public hospitals of Telangana. The first batch of 30 midwives was trained. Special midwife-led units (MLUs) were then created in public hospitals across the state. Today, these MLUs are supporting obstetricians by independently addressing healthy pregnancies and reducing the case load on them. They are also driving a sea-change in the ante natal care provided by 16 public hospitals across 12 districts in Telangana, which is visible in the healthcare statistics.
Public hospitals have been the main site of Evita’s work. They account for 80% of deliveries across India and are accessed by women from resource-poor communities with high nutritional and informational poverty. By listening to women and paying attention to detail, they are able to better categorize low and high-risk pregnancies, reduce waiting time for women, optimize obstetricians’ time, and improve the case history-taking process for women. The midwives have fought for more chairs for pregnant women who often have to stand in long queues in government hospitals and instituted childbirth classes on the hospital premise. ASHA workers, too, have started to sit in the ante natal classes run by midwives. They have become the PR vehicles for the initiative, taking the message of midwife-led care into local and rural communities. All obstetricians, other nurses, and the cleaning personnel have noticed the transformation across hospitals. Obstetricians report how women are more confident about natural birth, happier and also report lesser pain during birthing. In several public hospitals, midwives were actively sought out by women coming in for the first time.
For Evita, the field of midwifery creates a new and empowered career pathway for nurses. Because when nurses turn into midwives, they experience a change in the profession and are introduced to collaborative care, normal birthing, evidence-based practices, and respectful maternity care. Compared to a few weeks of training in maternal health and birthing experience that they receive in a standard nurse training program, a rigorous 18-month experience in midwifery makes them confident experts in the field. Over time, the midwives experience financial and professional growth (earning 50-60% higher salaries), move into senior roles in the hospital system and build recognition for themselves.
In 2019, the visible wins led the government of India to partner with Evita’s organization. This led to the launch of the national midwifery educators training program, training 30 nurses who hold a Master’s degree from five states. The program is now in its 2nd round. With the growing cadre across states, the senior midwife educators are now conducting weekly handholding meetings with trainee-midwives to troubleshoot, resolve problems and clear the bottlenecks in the implementation of their plans.
To build a supportive ecosystem for midwives, Evita has been mindful of on-boarding obstetricians as critical allies from the start, advocating with them despite their doubts and resistance to a midwife-led system. The evidence created through the pilots, such as reduced time in labor, reduced number of episiotomies and drop in epidurals, has led to buy-in from the community of obstetricians. As a result, the Government of India guidelines on Midwifery Services were co-created in partnership with leading obstetricians of the country.
Evita’s efforts have borne fruit at the highest policy advocacy levels. In 2018, the Government of India recognized midwifery as a vital profession and released a set of Guidelines on Midwifery Services in India. India has set a goal to have 86,000 midwives by 2023. 14 National Midwifery Training Institutes (NMTIs) have been set up to fulfill this mandate. Fernandez Hospitals, led by Evita are a critical resource in this exercise, providing handholding support to upcoming NMTIs, and creating a research hub to aggregate the experiences and needs of NMTIs across India and its neighboring countries.
Evita recalls that her time as a senior house officer at National Health Service in the UK from 1982-83 was a truly formative period for her as a young doctor. She saw midwives in complete charge of labor wards, working as equals with obstetricians. Evita was brought up in a very different ethos. Seeing doctors consulting midwives, respecting their opinion, and working collaboratively to provide a dignified, respectful birthing experience to mothers was liberating for her. She was inspired to bring home a democratic healthcare system where mothers were listened to, and their needs considered supreme.
When Evita returned home, her older brother suddenly passed away due to a brain hemorrhage and the responsibility of leading the hospital came on her unwilling shoulders. In 1985, Fernandez Hospitals was a 35-bed facility, quite reputed for its service but bursting on its seams. She took the call of razing the old hospital in 1992 to create a new infrastructure, taking a massive loan of INR 30 million. At one point, when they were building the second floor, she didn’t have money for cement and sold her share of ancestral jewelry to keep construction going.
In her early years as an obstetrician, she saw how HIV-positive mothers were abandoned and there was pervasive fear within the medical community. Evita worked hard to sensitize and prepare her team and offered these mothers a safe and respectful environment at the hospital. Fernandez became the first hospital in India to treat HIV-positive mothers, all for free and their babies were provided free vaccinations for up to a year and a half.
Evita traces her strong sense of giving back to the community to an interaction with a Jesuit Priest on a train when she was returning from the UK. He advised her to travel to find her purpose and spirit of service. In the years that followed, she constantly checked with herself, “Whether we are in this for business or service” and later institutionalized this talisman into a guiding principle for the whole organization. In 2018, she decided to register Fernandez Foundation as a not-for-profit Section 8 company. It was a request that was unheard of in the history of Indian Revenue Services¾for a highly profitable hospital to be converted into a not-for-profit entity.
In her mission to champion midwifery for maternal and new-born care, Evita traces her inspiration to two sources. One was reading a book by Nutan Pandit called Pregnancy: The Complete Childbirth Book, which introduced her to a new philosophy of treating pregnancy as a normal, physiological process that needed to be awarded that dignity. This made Evita re-analyse her own practices at the hospital and reformed them drastically. Secondly, in the mid-2000s, when Fernandez Hospitals became a referral center for complicated pregnancies, she came across several cases of young mothers arriving at the last minute with multiple organ failures. Seeing so many maternal deaths shook Evita deeply.
Given her research on how countries with midwifery saw much lower MMR, she was convinced that it was the solution to India’s maternal healthcare crises. Stirred by these deaths, she relentlessly followed up with international experts. Despite opposition from the Indian medical fraternity, she persisted and eventually brought on board a range of international midwives, obstetricians, and bureaucrats¾all of whom, convinced by the vision, lent it national institutional backing.
In the face of the rapid global privatization of healthcare, Evita’s vision is a radical rethinking of the potential of public healthcare. Through her decades of work, she has demonstrated that high-quality services can be provided at low costs, reaching people across the socio-economic spectrum. Fernandez runs six non-profit health facilities with 320 beds, including a Child Development Center and is known for several nation-level pioneering initiatives¾like the Kangaroo mother care to improve breastfeeding and reduce neo-natal care costs, human milk banks to reduce infections among infants, newborn screening and more. Her attempt to integrate midwifery into public health systems and the success it has seen so far is a telling example that equitable access to healthcare is possible for all, with utmost dignity and compassion.