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

Background: 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 of participants on midwifery and nursing regulatory systems, education and development in India. Thirty-four in-depth interviews were conducted with senior midwifery and nursing leaders representing administration, advocacy, education, regulation, research and service provision. Results: There’s a lack of importance accorded to midwifery roles within the nursing system. The councils and statutes do not adequately reect midwifery practice, and are a barrier to good quality care provision. The lack of amendment of Acts, lack of representation of midwives and nurses in key governance positions in councils and committees have restrained and undermined leadership positions, which has also impaired the growth of the profession. The standards for 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 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 decision-making powers within health care and workforce governance. on the midwives current role in direct entry education practiced on rotation with other nursing roles. Direct entry midwifery is a 3 years degree course recommended by ICM provides Registered Midwife (RM). Participants responded with mixed opinions on the requirement and future of midwifery in India as an independent profession. 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 harder, the best phase of


Plain English Summary
Midwifery and nursing education, professionals and practice, are key areas of regulation for a well functioning workforce and health care service provision that is crucial to understand and yet understudied in India. Our qualitative study addresses this gap in literature from the experience and perspectives of midwifery and nursing leaders at the central level and in ve states in India along with a secondary review of the respective acts in these states and at the centre. Nursing in India faces many challenges such as corruption in education and regulation; poor education in private sector; poor resources in public sector; lack of regulation of nursing professional and absence of proper standardization of care. A reform in regulation is expected to establish an independent professional midwifery with direct entry courses in India which is currently provided to some extent in each of the three entry level courses but none at par with the international standards of midwifery education or practice. The challenges these professions and the discrimination the professionals face are gender based and a result of medical domination that has also led to denoting these professions a secondary stature in the structure of health care delivery systems. There is tremendous scope for improvement for the central and state level regulatory bodies and their respective acts, some of which were formulated before independence. This will enable good quality education and service provision through regulated nursing and midwifery workforce in India.

Background
Midwives and nurses are integral to reproductive and maternal health care provision in India. A comprehensive and strong regulatory mechanism is therefore needed to regulate education, practice and to ensure competent nurses and midwives in the Indian health workforce. The International Confederation of Midwives (ICM) recommends six functions that regulatory bodies should maintain; setting the scope of practice, pre-registration of education, registration, relicensing and continuing competence, complaints and discipline, code of conduct and ethics [1] . The Indian Nursing Council (INC) and State Nursing Councils (SNC) play key roles in the regulation of nursing and midwifery education in India. They oversee registration, licensing, inspection and examination. However, there is duplication of these roles both at the national and the state levels [2] .
In India, nurse-midwives become part of the health care workforce after completing 2-4 years of mandatory Pre Service Education (PSE) which aims to provide skill sets of both professions. Currently, India does not have a cadre of competent independent midwives. Midwifery education is provided both as a part of a diploma course called General Nursing and Midwifery (GNM) for three years and also as a part of a four year BSc nursing degree. The midwifery component in BSc nursing degree lasts approximately six months when compared to 18 months midwifery education after completing three years of a nursing degree in other countries [3] .
There are elements of midwifery skills education in the Auxiliary Nursing and Midwifery (ANM) certi cate course as well. The curriculum of these three entry level courses of midwifery education are not comparable with the ICM recommended skill-set which [1] . Hence, India people graduating from the diploma and degree course can be addressed as nurses or nurse-midwives, but there is a lack of midwives in India as per ICM guidelines. The National Health Mission (NHM) of the Government of India (GOI) recently initiated efforts to formulate clear operational guidelines to implement midwifery training in India [4] . An existing diploma course for Nurse Practitioners in Midwifery (NPM) has been updated for this though it is not in line with the ICM recommendation for developing competent midwives. It is essential to understand India's midwifery education, regulation and practice capacities as there is evidence suggesting that 87% of maternal health care during childbirth can be managed effectively by professional midwives [5] .
Midwives and nurses are recognized are often neglected and subjected to discrimination right from their PSE to all through their professional careers [6,7] . Indian nursing and midwifery education is faced with several challenges including resource constraints such as lack of teachers; a mismatch between theory and practice in learning; a lack of opportunities for practice; discrimination and stigma [2,[8][9][10] . Around 88% of nursing education in India is provided by the private sector where the quality of education is reportedly poorer than in public institutions, especially in the resource-poor states in northern India [6] . The private share in nursing education has continued to grow in terms of the number of training institutions and recruitment quota, in response to the global demand of nurse-midwives making India rank second in terms of nurses outmigration [11] . The uneven distribution of nursing institutes is yet another challenge. The privatization of education has led to a skewed production of human resources for health (HRH) with six high HRH producing states of Andhra Pradesh, Karnataka, Kerala, Maharashtra, Pondicherry and Tamil Nadu, which represent 31% of the Indian population but have 63% of nursing and 58% of medical colleges compared to the eight low HRH producing states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Uttar Pradesh, Uttaranchal, Odisha and Rajasthan, which has 46% of the population but only 20% of nursing and 21% of medical colleges [6,12] . The training institutes are further skewed toward the urban areas within these states [6] . Regulatory mechanisms are reportedly relaxed to allow training in certain private institutes, despite capacity challenges [7] .
The current midwifery and nursing regulatory structure of India also faces many challenges. It is dominated by medical representatives and provides little authority to nursing and midwifery regulators. The regulation of nurses and midwives' migration is cumbersome; the regulation of practice is weak, and there is a failure to improve the quality of education in private sectors [6,[13][14][15][16][17][18] .
Over the last few years, non government and international development organizations have coordinated efforts to improve preservice and in-service education in India [18][19] . However, these efforts have not been extended to establishing and sustaining a strong regulatory structure. There have been some initiatives to understand the quality of nursing and midwifery education and services in India though the challenges in regulation remain unaddressed [6,10,16] .

Methods
Our study investigates the regulatory system to understand its potential impact on nursing and midwifery education and development in India. The objectives of this research are threefold: (i) to document the regulatory system for nursing and midwifery in India and highlight its weaknesses; (ii) to understand the underlying gender and power based issues adding to the regulatory challenges of midwifery and nursing and (iii) to recommend reform measures for strengthening nursing and midwifery regulation and workforce governance in India.
We use qualitative methods to examine the perceptions and experiences of nurse-midwives in senior leadership roles regarding the regulatory systems of midwifery and nursing in India. The study participants were selected through purposive and snowball sampling in ve states in India: Rajasthan, Odisha, Bihar, Madhya Pradesh and West Bengal and at the national level. The ve states selected represent different cultural, social, economic and health contexts. All selected states, except West Bengal, are amongst the low HRH producing states, known for poor quality of midwifery and nursing education and face similar challenges. West Bengal is known for good nursing and midwifery governance and quality of education, especially in the public sector. The selection of leaders at the centre allows us to understand the larger context of health policy making and governance in India. The inclusion criteria for in depth interviews followed a strategy to select nursing and midwifery leaders who represent various domains of administration, advocacy, education, regulation and service provision in the selected states and at the centre. Some of the participants represented multiple domains. The paper presents a global perspective from nursing and midwifery leaders based in the United Kingdom and Switzerland. Switzerland is the hub of all the international development organizations including the World Health Organisation (WHO), that plays a key role in global nursing and midwifery governance. United Kingdom (UK) was selected so that the participants can re ect and share based on the successful model of midwifery education and regulation in the UK. The interviews with participants from UK and Switzerland were mainly focussed on the regulation of midwifery given the absence of a midwifery cadre independent of nursing in India. Additionally, the study includes a review of the nursing acts from all the selected states and the INC act to understand the guiding documents for regulation in India.

Data collection and analysis
In-depth interviews were conducted between July 2018 and January 2019. The participants were informed about the purpose of the study over email or phone before seeking appointment for interviews. Forty three leaders were approached for data collection. Nine of them could not provide time for the interview or dropped out. All the interviews were conducted in person, except three which were done as a video call. The study instrument is a semi-structured guide with three sections: 1) background information; 2) participant's role and responsibilities and 3) nursing and midwifery regulation.
The interviews were conducted by the lead author, an experienced qualitative researcher with educational background in nursing, midwifery and with research experience on issues pertaining to nursing and midwifery in India. All participants were aware of the researcher's background, professional quali cations and the rationale of the study prior to the interviews. The interviews were carried out in English in most cases, or in Hindi and Bengali in a few states. The female lead researcher is uent in these languages. Data were processed and analysed thematically using NVivo 12 software. Coding was applied simultaneously with data collection which helped to clarify emerging themes in subsequent interviews. The codebook consisted of apriori codes which were supplemented by deductive codes, as the analyses progressed.

Participant pro le
The age of respondents varied from 46 to 83 years. All respondents were midwives and nurses except one who did not receive formal education in midwifery. Twenty-six participants completed their education in nursing and midwifery in India. Their quali cation was the degree that combined nursing and midwifery curricula. Four out of the 34 participants were men, who were all interviewed in Rajasthan, where men are allowed to opt for midwifery and nursing education. All respondents held senior level positions. Two of them have retired from service. The total experience of the participants ranged between 24 to 60 years. Table 1 presents relevant demographic, quali cations and work pro le related information of the participants.

Results
The interviews focused on the quality of nursing and midwifery education, regulation, challenges of regulation in education and practice, and recommendations to improve regulation of nursing and midwifery education and service provision. The ndings are presented in four sections: 1) regulatory system for midwifery and nursing; 2) weaknesses in the current regulatory system; 3) gender and power as factors in uencing regulation; and 4) midwifery under nursing as a regulatory challenge, in India.

Regulatory system of midwifery and nursing
This section presents a review of the regulatory acts implemented in the selected states and centre ( Table 2). All the acts are extracted from the respective council's websites. Table 2 Nursing and midwifery Acts reviewed, by year of enactment Name of the Act Year of enactment The Indian Nursing Council Act [20] 1947 The Bengal Nurses Act [21] 1934 The Bihar and Orissa Nurses Registration Act [22] 1935 The Central provinces Nurses Registration Act (Madhya Pradesh) [23] 1936 The Orissa Nurses and Midwives Registration Act [24] 1938 Rajasthan Nurses, Midwives, Health visitors and Auxiliary Nurse Midwives Registration Act [25] 1964 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 pro le of members, key de nitions, process of becoming a member, information for professional registration, reregistration and clauses under which a practitioner can lose registration. The pro le of the governing body is not uniform, ranging from seven members in Odisha to fteen in Bihar. Every council has a set number of members who are doctors and some members are non-nursing/ midwifery administrators. The ex-o cio 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 ve 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 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.

Weaknesses in the regulatory and governing bodies
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 certi cate, 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.
"These days in nursing council a person can be President for life! The council seems to be happy with it… elections are conducted in every term but the leadership does not change. They can change that if they want to." (Centre) "INC president has been in position for 15 years… One term of leadership at INC is 4 years." (Centre) 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  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 a liations to medicine and nursing education institutes, from public and private. It is di cult 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 rst (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 lled 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 certi cates by untrained persons. To address this, the councils take precautions before registering candidates from other states. However, the Registrars do not have su cient 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 con dence in their own students because of their lack of skills. A participant from Rajasthan re ected 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 nds 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 a liated 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.

Gender and power in uencing 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 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 1 st 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 con dence and attitude that only if men are there will we succeed. There is a dependence… we surrender too easily." (West Bengal)

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." 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 identi ed 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)

Discussion
The ICM identi es Education, Regulation and Association (ERA) as the three pillars for development and practice of midwifery [26] . The nursing and midwifery workforce in India faces many challenges in each of these three areas. These three pillars often do not work together for the development of nursing and midwifery in India. The challenges include poor quality of education stemming from a weak regulatory structure that needs to adapt to changes over time. The lack of leadership role and decision-making power for nurse-midwives' further weakens the governance of these professions dominated by doctors [6,17,36] . This is recommended by the majority of participants.
India does not have an independent midwifery workforce or direct entry midwifery education yet. Hence, regulation is currently targeted at nurses who are playing a dual role of nurse and midwife. As more evidence is generated on the advantages of midwifery for maternal and neonatal health [26] , it becomes important for the Council to make legitimate efforts to start direct entry midwifery education that will create a cadre of midwives independent of their nursing role.  [27] . The Acts also need to include key de nitions such as nurse, nursing, midwife, midwifery, scope of practice and speci c scope of practice [27] . This was not an issue identi ed by the respondents. Interviewing leaders from different aspects of nursing and midwifery governance helped identify many other challenges. The increasing workload was frequently mentioned by the participants representing regulatory bodies which is a challenge reported in other countries as well [28] . The participants did not mention gender-based discrimination in education, partial treatment of medical students in comparison to nursing and midwifery students and the powerlessness in nursing, midwifery and health policy making. The doctor dominance and political nature of regulation was reported with caution. All these challenges and more, including lack of leadership qualities in the regulatory bodies, were raised by nursing and midwifery leaders representing education, service provision, association and administration. Respondents urged the need for more transparency and inclusivity in the processes of INC and SNCs. This is essential to ensure accountability [1,17] . The participants felt that a change in leadership at INC might improve regulation and that the key position should not be stagnant.
The regulation of private education is particularly concerning, given 88% of India's nursing education is being imparted in the private sector [6] . This creates more avenues for corruption [17] . Other issues including non-attendance of students, working in the nursing homes during pre-service education, lack of quali ed teachers, less opportunities to practice and illegally practicing with no formal quali cation have been reported, which should be addressed by regulatory bodies.
These interviews and evidence reported elsewhere reinforce the urgent need to improve midwifery and nursing education [26,29,[37][38] .
In the Indian context, shortcomings in regulation have persisted for decades [6,[13][14][15][16] . The participants of this study have clearly identi ed that key stakeholders have failed to take a gender sensitive approach. Nursing and midwifery needs a people centric approach to address the existing gender-related barriers. Gender-based discrimination begins with each nursing and midwifery student's education and extends to their clinical practice or teaching thereafter. When male candidates are given opportunities for graduation and post-graduation in midwifery (gynaecology and obstetrics) and all streams of nursing, the SNCs must ensure that they receive enough practical experience [13][14][15] . This could also enable practical experience for all students regardless of their gender. Men and women in the profession have speci c issues that need to be addressed in a way that ensures quality education, opportunities to practice and provide care in line with patients rights and choices. Nursing and midwifery being traditionally women dominated professions, adds to the gender based discrimination and stigma, which gets exacerbated because of facts such as that of nurse-midwives often coming from poor socio economic background and belonging to backward classes and castes, which has a relevant history behind it on how nursing began and progressed in India [8][9]30] .Though it is established that these characteristics has an impact on nurses and midwives education and practice but the extent of it alongside the practice of medicine, owing to this intersectionality based on their personal attributes, remains to be understood in the context of India [31] .
A key challenge is the discrimination between nursing-midwifery and medical students, as they practice in the same health care delivery system. This discrimination results in inadequate practical experience opportunities for nursing and midwifery students and establishes a hierarchy in the medical care system early on from pre-service education. This clearly implies the lack of attention given to nursing and midwifery education in comparison with medical education. This hierarchy is often gender-based and creates inequalities within the health care team by centralising decision-making power in the hands of the medical profession at every level of care provision [32] . The powerlessness of nursing and midwifery leaders in health systems policy making, due to the doctor-centric nature of health policy making and regulation, has been a persistent challenge [6,17] .
The nursing councils do not play a role in regulation of practice, which is mainly managed by the state and central government bodies. Increasing the SNC's role in practice regulation will ensure quality and evidence-based nursing and midwifery care provision, which could be supervised by the INC to ensure uniformity [1] . Regulation is divided between different bodies including INC, the SNCs, the directorates of medical education and universities. This segregated nature of regulation adds to the confusion and decreases the rigour when education and regulation is managed by so many different bodies, mostly without the involvement of nursing and midwifery representatives. It results in duplication of functions such as inspection; while other functions including the regulation of practice are completely ignored.
Literature suggests poor working condition and low remuneration as key drivers for nurses migration from India, which could be addressed by better regulation of practice. Nurse (midwife) migration is also an area that needs to be regulated, given India is a major supplier of nurses to the Middle-East and high-income countries, ranking second in outmigration after Philippines [6,11,33,34] .
Information about overseas migration and practice on return is provided in other country Acts [28,35] . An understanding of the magnitude and reasons for nurse-migration will help to improve the quality of working conditions in India and decrease the workforce shortages by retaining more nurse-midwives.
The respondents interviewed in Switzerland and United Kingdom presented a global perception mentioning some key challenges that were otherwise missed. The lack of evidence-based education was mentioned by a participant who felt the INC had a role to lead by showing best examples and guiding evidence-based education and practice in the country. The global leaders interviews also highlighted the issue of underfunding for nursing and midwifery, from education to practice, and the development of professions and professionals.
Similar challenges as shown in this study have been reported about regulation of medical education, professionals and practice as well [39] . Where a new National Medical Council (NMC) presents scope for improvement such as regulation of fees for medical education in private institutions [39] , which is an area of reform for nursing and midwifery education as well, along with regulation of salaries in the private sector. The regulation of midwifery, nursing and medical education, professional and practice are crucial for Universal Health Coverage (UHC). Figure 2 summarises areas and actions to reform midwifery and nursing, education and practice regulation in India along with the need for research in future. It presents overarching areas of reform such as governance, where the establishment of midwifery and nursing directorate will aid many of the reforms suggested in the gure. Four key reform measures are suggested for each of the areas. There are some aspects which need more research and understanding in India, which also have been shown in Figure 2, such as, gender-based challenges in nursing, midwifery and health policy making; challenges in private sector education, regulation and practice; scope for independent midwifery practice; development of a strong regulatory structure and implementation of innovative strategies in regulation to ensure good quality and respectful care provision.

Conclusion
Nurses-midwives are the primary health care providers in India. Regulatory failures leads to nurses and midwives graduating without su cient knowledge and skills thereby putting people's life at risk. This is a serious issue because practice is unregulated, care providers are unsupervised and not updated timely as the standards of care gradually deteriorate. The health regulatory structures of the country, that includes the regulatory bodies of all health care related professions, have a major role to play in maintaining standards of education and practice to ensure good quality of health care to its people. This requires a team approach similar to how a team of care providers with different expertise come together to provide quality health services. The INC, the SNCs, the Indian