Definitions

birthing chair

Midwifery

[mid-wif-uh-ree, -wif-ree, mid-wahy-fuh-ree, -wahyf-ree]
Midwifery is a health care profession where providers give prenatal care to expecting mothers, attend the birth of the infant, and provide postpartum care to the mother and her infant. Practitioners of midwifery are known as midwives, a term used in reference to both women and men (the etymology of midwife is mid = with and wif = woman). Midwives are autonomous practitioners who are specialists in a low-risk pregnancy, childbirth, and the postpartum stage. They generally strive to help women have a healthy pregnancy and natural birth experience. Midwives are also primary care givers providing general health care for women. Midwives are trained to recognize and deal with deviations from the norm. Obstetricians, in contrast, are specialists in illness related to childbearing and in surgery. The two professions can be complementary, but often are at odds because obstetricians are taught to "actively manage" labor, while midwives are taught not to intervene unless necessary.

Midwives refer to obstetricians when a woman requires care beyond their area of expertise. In many jurisdictions, these professions work together to provide care to childbearing women. In others, only the midwife is available to provide care. Midwives are trained to handle certain situations that are considered abnormal, including breech births and posterior position, using non-invasive techniques. In many areas of the world, traditional midwives, renamed "traditional birth attendants" by the World Health Organization (WHO) and other groups, are the only available providers for childbearing women.

In the 1700s obstetricians were referred to as male midwives and once treated patients for female hysteria.

Defining midwifery

According to the International Confederation of Midwives (a definition that has also been adopted by the World Health Organization and the International Federation of Gynecology and Obstetrics):

A midwife is a person who, having been regularly admitted to a midwifery educational program that is duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. The educational program may be an apprenticeship, a formal university program, or a combination.

The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife's own responsibility and to provide care for the infant. This care includes preventive measures, the promotion of normal birth, the detection of complications in mother and child, accessing of medical or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and community. This work should involve antenatal education and preparation for parenthood and may extend to women's health, sexual or reproductive health and childcare.

A midwife may practice in any setting including in the home, the community, hospitals, clinics or health units.

This definition is controversial and not everyone agrees with the exclusion of traditional midwives who in developing countries often are the only people available to assist women in birth.'

Early historical perspective

Due to its importance it is assumed that midwifery has existed as long as human civilization.

In ancient Egypt, midwifery was a recognized female occupation, as attested by the Ebers papyrus which dates from 1900 to 1550 BCE. Five columns of this papyrus deal with obstetrics and gynecology, especially concerning the acceleration of parturition and the birth prognosis of the newborn. The Westcar papyrus, dated to 1700 BCE, includes instructions for calculating the expected date of confinement and describes different styles of birth chairs. Bas reliefs in the royal birth rooms at Luxor and other temples also attest to the heavy presence of midwifery in this culture.

Midwifery in Greco-Roman antiquity covered a wide range of women, including old women who continued folk medical traditions in the villages of the Roman Empire, trained midwives who garnered their knowledge from a variety of sources, and highly trained women who were considered female physicians. However, there were certain characteristics desired in a “good” midwife, as described by the physician Soranus in the second century. He states in his work, Gynecology, that “a suitable person will be literate, with her wits about her, possessed of a good memory, loving work, respectable and generally not unduly handicapped as regards her senses [i.e., sight, smell, hearing], sound of limb, robust, and, according to some people, endowed with long slim fingers and short nails at her fingertips.” Soranus also recommends that the midwife be of sympathetic disposition (although she need not have borne a child herself) and that she keep her hands soft for the comfort of both mother and child. Pliny, another physician from this time, valued nobility and a quiet and inconspicuous disposition in a midwife. A woman who possessed this combination of physique, virtue, skill, and education must have been difficult to find in antiquity. Consequently, there appears to have been three “grades” of midwives present in ancient times. The first was technically proficient; the second may have read some of the texts on obstetrics and gynecology; but the third was highly trained and reasonably considered a medical specialist with a concentration in midwifery.

Midwives were known by many different titles in antiquity, ranging from iatrinē, maia, obstetrix, and medica. It appears as though midwifery was treated different in the Eastern end of the Mediterranean basin as opposed to the West. In the East, some women advanced beyond the profession of midwife (maia) to that of obstetrician (iatros gynaikeios), for which formal training was required. Also, there were some gynecological tracts circulating in the medical and educated circles of the East that were written by women with Greek names, although these women were few in number. Based on these facts, it would appear that midwifery in the East was a respectable profession in which respectable women could earn their livelihoods and enough esteem to publish works read and cited by male physicians. In fact, a number of Roman legal provisions strongly suggest that midwives enjoyed status and remuneration comparable to that of male doctors. One example of such a cited midwife is Salpe of Lemnos, who wrote on women’s diseases and was mentioned several times in the works of Pliny.

However, in the Roman West, our knowledge of practicing midwives comes mainly from funerary epitaphs. Two hypotheses are suggested by looking at a small sample of these epitaphs. The first is the midwifery was not a profession to which freeborn women of families that had enjoyed free status of several generations were attracted; therefore it seems that most midwives were of servile origin. Second, since most of these funeral epitaphs describe the women as freed, it can be proposed that midwives were generally valued enough, and earned enough income, to be able to gain their freedom. It is not known from these epitaphs how certain slave women were selected for training as midwives. Slave girls may have been apprenticed, and it is most likely that mothers taught their daughters.

The actual duties of the midwife in antiquity consisted mainly of assisting in the birthing process, although they could also help in other medical problems relating to women if needed. Often, the midwife would also call in a physician to be on-call with her in case a more difficult procedure was needed during an abnormal delivery; and in most cases she brought along two or three assistants. In antiquity, it was believed by both midwives and physicians that a normal delivery was made easier when a woman sat upright. Therefore, during parturition, midwives brought a stool to the home where the delivery was to take place. In the seat of the chair was a crescent-shaped hole through which the baby would be delivered. The chair also had armrests for the mother to grasp during the delivery. Most chairs had backs which the patient could press against, but Soranus suggests that in some cases the chairs were backless and an assistant had to stand behind the patient and support her. The midwife then faced the patient, gently dilating and pulling the fetus forward, all the while instructing the mother on proper breathing and how to push downwards during a contraction. The assistants helped by pushing downwards on the patient’s abdomen. Finally, the midwife received the infant, placed it in pieces of cloth, cut the umbilical cord, and cleansed the baby. The child was sprinkled with “fine and powdery salt, or natron or aphronitre” to soak up the birth residue, rinsed, and then powdered and rinsed again. Next, the midwives cleared away any and all mucus present from the nose, mouth, ears, or anus. Midwives were encouraged by Soranus to put olive oil in the baby’s eyes to cleanse away any birth residue, and to place a piece of wool soaked in olive oil over the umbilical cord. After the delivery, the midwife made the initial call on whether or not an infant was healthy and fit to rear. She inspected the newborn for congenital deformities and testing its cry to hear whether or not it was robust and hearty. Ultimately, midwives made a determination about the chances for an infant’s survival and likely recommended that a newborn with any severe deformities be exposed.

A second-century terracotta relief from the Ostian tomb of Scribonia Attice, wife of physician-surgeon M. Ulpius Amerimnus, details a childbirth scene. Scribonia was a midwife and the relief shows her in the midst of a delivery. A patient sits in the birthing chair, gripping the handles and the midwife’s assistant stands behind her providing support. Scribonia sits on a low stool in front of the woman, modestly looking away while also assisting the delivery by dilating and massaging the cervix, as encouraged by Soranus.

A more elegantly carved ivory relief from Pompeii depicts a similar scene. There are four women present: the parturient in the birthing chair; an attendant standing behind the chair providing support; the midwife seated in a low stool in front of the mother; and a fourth woman standing behind the midwife, waiting to take the infant or possibly offer a blessing. This minimal visual evidence confirms the verbal descriptions of childbirth present in the works of Pliny and Soranus.

The services of a midwife were not inexpensive; this fact that suggests poorer women who could not afford the services of a professional midwife often had to make do with female relatives. Many wealthier families had their own midwives. However, the vast majority of women in the Greco-Roman world very likely received their maternity care from hired midwives, either highly trained or possessing a rudimentary knowledge of obstetrics. Also, many families had a choice of whether or not they wanted to employ a midwife who practiced the traditional folk medicine or the newer methods of professional parturition. Like a lot of other factors in antiquity, quality gynecological care often depended heavily on the socioeconomic status of the patient.

During the Christian era in Europe Midwives became important to the church due to their role in emergency baptisms, and found themselves regulated by Roman Catholic canon law. In Medieval times, childbirth was considered so deadly that the Christian Church told pregnant women to prepare their shrouds and confess their sins in case of death. The Church had a biblical explanation for the dangers of childbirth. They put the blame firmly on Eve and her misdemeanours in the Garden of Eden. The church decreed that women were the sisters of Eve, and the rigours of labour were God's punishment for Eve's sins. Any effort to relieve women's pain in childbirth was looked at suspiciously. "The better the witch; the better the midwife" was a popular Medieval saying. To guard against witchcraft the church decided who could give maternity care. Midwives had to be licensed by a bishop and swear an oath not to use magic when assisting women through labour.

Later historical perspective

In the 18th century, a division between surgeons and midwives arose, as medical men began to assert that their modern scientific processes were better for mothers and infants than the folk-medical midwives. Whether this was a valid claim or not can be seen in the entry for Justine Siegemund, a renowned seventeenth century German midwife, whose Court Midwife (1690) was the first female-authored German medical text.

At the outset of the 18th century in England, most babies were caught by a midwife, but by the onset of the 19th century, the majority of those babies born to persons of means had a surgeon involved. A number of excellent full length studies of this historical shift have been written.

German social scientists Gunnar Heinsohn and Otto Steiger have put forward the theory that midwifery became a target of persecution and repression by public authorities because midwives not only possessed highly specialized knowledge and skills regarding assisting birth, but also regarding contraception and abortion. According to Heinsohn and Steiger's theory, the modern state persecuted the midwives as witches in an effort to repopulate the European continent which had suffered severe loss of manpower as a result of the bubonic plague (also known as the black death) which had swept over the continent in waves, starting in 1348.

They thus interpret the witch hunts as attacking midwifery and knowledge about birth control with a demographic goal in mind. Indeed, after the witch hunts, the number of children per mother rose sharply, giving rise to what has been called the "European population explosion" of modern times, producing an enormous youth bulge that enabled Europe to colonize large parts of the rest of the world.

While historians specializing in the history of the witch hunts have generally remained critical of this macroeconomic approach and continue to favor micro level perspectives and explanations, prominent historian of birth control John M. Riddle has expressed agreement.

Midwifery in the United States

There are two main divisions of modern midwifery in the US: nurse-midwives and direct-entry midwives.

Nurse-midwives

Nurse-midwives were introduced in the United States in 1925 by Mary Breckinridge for use in the Frontier Nursing Service (FNS). Mrs. Breckinridge chose the nurse-midwifery model used in England and Scotland because she expected these nurse-midwives on horseback to serve the health care needs of the families living in the remote hills of eastern Kentucky. This combination of nurse and midwife was very successful. The Metropolitan Life Insurance Company studied the first seven years of the FNS, and reported a substantially lower maternal and infant mortality rate than for the rest of the country. The report concluded that if this type of care was available to other women in the USA thousands of lives would be saved, and suggested nurse-midwife training should be done in the USA. Mrs. Breckinridge opened the Frontier Graduate School of Midwifery in 1939 the first nurse-midwifery education program in the USA that is still educating nurse-midwives today http://www.frontierschool.edu/. The Midwifery Program of Philadelphia University established the first Masters in Midwifery degree in the United States beginning the first class in May, 1997 http://www.philau.edu/midwifery. In the United States, nurse-midwives are variably licenced depending on the state as advanced practice nurses, midwives or nurse-midwives. Certified Nurse-Midwives are educated in both nursing and midwifery and provide gynecological and midwifery care of relatively healthy women. In addition to licensure, many nurse-midwives have a master's degree in nursing, public health, or midwifery. Nurse-midwives practice in hospitals, medical clinics and private offices and may deliver babies in hospitals, birth centers and at home. They are able to prescribe medications in all 50 states. Nurse-midwives provide care to women from puberty through menopause. Nurse-midwives may work closely with obstetricians, who provide consultation and assistance to patients who develop complications. Often, women with high risk pregnancies can receive the benefits of midwifery care from a nurse-midwife in collaboration with a physician. Currently, 2% of nurse-midwives are men. The American College of Nurse-Midwives accredits nurse-midwifery/midwifery education programs and serves as the national professional society for the nation's certified nurse-midwives and certified midwives. Upon graduation from these programs, graduates sit for a certification exam administered by the American Midwifery Certification Board. At present approximately 5500 Certified Nurse-Midwives are practicing in the U.S.

Direct-entry midwives

A direct-entry midwife is educated in the discipline of midwifery in a program or path that does not also require her to become educated as a nurse. Direct-entry midwives learn midwifery through self-study, apprenticeship, a midwifery school, or a college- or university-based program distinct from the discipline of nursing. A direct-entry midwife is trained to provide the Midwives Model of Care to healthy women and newborns throughout the childbearing cycle primarily in out-of-hospital settings.

Under the umbrella of "direct-entry midwife" are several types of midwives:

A Certified Professional Midwife (CPM) is a knowledgeable, skilled and professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives (NARM) and is qualified to provide the midwives model of care. The CPM is the only US credential that requires knowledge about and experience in out-of-hospital settings. At present, there are approximately 900 CPMs practicing in the US.

A Licensed Midwife is a midwife who is licensed to practice in a particular state. Currently, licensure for direct-entry midwives is available in 24 states.

The term "Lay Midwife" has been used to designate an uncertified or unlicensed midwife who was educated through informal routes such as self-study or apprenticeship rather than through a formal program. This term does not necessarily mean a low level of education, just that the midwife either chose not to become certified or licensed, or there was no certification available for her type of education (as was the fact before the Certified Professional Midwife credential was available). Other similar terms to describe uncertified or unlicensed midwives are traditional midwife, traditional birth attendant, granny midwife and independent midwife.

The American College of Nurse-Midwives (ACNM) also provides accreditation to non-nurse midwife programs, as well as colleges that graduate nurse-midwives. This credential, called the Certified Midwife, is currently recognized in only three states (New York, New Jersey, and Rhode Island). All CMs must pass the same certifying exam administered by the American Midwifery Certification Board for CNMs. At present, there are approximately 50 CMs practicing in the US.

The North American Registry of Midwives (NARM) is a certification agency whose mission is to establish and administer certification for the credential "Certified Professional Midwife" (CPM). CPM certification validates entry-level knowledge, skills, and experience vital to responsible midwifery practice. This certification process encompasses multiple educational routes of entry including apprenticeship, self-study, private midwifery schools, college- and university-based midwifery programs, and nurse-midwifery. Created in 1987 by the Midwives' Alliance of North America (MANA), NARM is committed to identifying standards and practices that reflect the excellence and diversity of the independent midwifery community in order to set the standard for North American midwifery.

Practice in the United States

Midwives work with women and their families in any number of settings. While the majority of nurse-midwives work in hospitals, some nurse-midwives and many non-nurse-midwives work within the community or home. In many states, midwives form birthing centers where a group of midwives work together. Midwives generally support and encourage natural childbirth in all practice settings. Laws regarding who can practice midwifery and in what circumstances vary from state to state, and some midwives practice outside of the law.

Missouri Controversy

Direct entry midwifery (those midwives who are not registered as a certified nurse midwife) is unlawful in Missouri and practicing without a CNM license is a felony. However, on 26 May 2007 the Missouri Legislature passed a bill which provides tax incentives for those who purchase their own insurance in order to increase private health coverage for the uninsured. Attached to this legislation was a one sentence provision added by Sen. John Loudon which effectively legalizes certain direct entry midwifery. Although such measures had been previously been rejected by the legislature, Loudon was able to attach the provision undetected by use of the word tocology (word of Greek origin that means the practice of obstetrics and childbirth) rather than any reference to midwifery. Despite protests from some members of the legislature, Gov. Matt Blunt signed the bill into law. A circuit judge issued a temporary restraining order on 3 July 2007 barring the implementation of the law, which was to take effect on 28 August 2007. Following a 2 August 2007 hearing, the judge ruled the midwifery law illegal. A Columbia, Missouri-based midwives association plans to appeal the decision to the Missouri Supreme Court.

Midwifery in the United Kingdom

Midwives are practitioners in their own right in the United Kingdom, and take responsibility for the antenatal, intrapartum and postnatal care of women, up until 28 days after the birth, or as required thereafter. Midwives are the lead health care professional attending the majority of births, mostly in a hospital setting, although home birth is a perfectly safe option for many births. There are a variety of routes to qualifying as a midwife. Most midwives now qualify via a direct entry course, which refers to a three- or four-year course undertaken at university that leads to either a degree or a diploma of higher education in midwifery and entitles them to apply for admission to the register. Following completion of nurse training, a nurse may become a registered midwife by completing an eighteen-month post-registration course (leading to a degree qualification), however this route is only available to adult branch nurses, and any child, mental health, or learning disability branch nurse must complete the full three-year course to qualify as a midwife. Midwifery students do not pay tuition fees and are eligible for financial support for living costs while training. Funding varies slightly depending on which country within the UK the student is in and whether the course they are on is a degree or diploma course. Midwifery degrees are paid for by the NHS and some students may also be eligible for NHS bursaries.

All practicing midwives must be registered with the Nursing and Midwifery Council and also must have a Supervisor of Midwives through their local supervising authority. Most midwives work within the National Health Service, providing both hospital and community care, but a significant proportion work independently, providing total care for their clients within a community setting. However, recent government proposals to require insurance for all health professionals is threatening independent midwifery in England.

Midwives are at all times responsible for the woman for whom they are caring, to know when to refer complications to medical staff, to act as the woman's advocate, and to ensure the mother retains choice and control over her childbirth experience. Many midwives are opposed to the so-called "medicalisation" of childbirth, preferring a more normal and natural option, to ensure a more satisfactory outcome for mother and baby.

Midwife training

Midwifery training is considered one of the most challenging and competitive courses amongst other healthcare subjects. Most midwives undergo a 32 month vocational training program, or an 18 month nurse conversion course (on top of the 32 month nurse training course). Thus midwives potentially could have had up to 5 years of total training.

Midwives may train to be community Health Visitors (as may Nurses).

Community midwives

Many midwives also work in the community. The roles of community midwives include the initial appointments of pregnant women, running clinics, postnatal checks in the home, and attending home births.

Midwifery in Canada

Midwifery was reintroduced as a regulated profession in Canada in the 1990s. After several decades of intensive political lobbying by midwives and consumers, fully integrated and regulated midwifery is now part of the health system in the provinces of British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, and Quebec, and in the Northwest Territories and Nunavut. Alberta does not publicly fund midwifery. Midwifery legislation has recently been proclaimed in New Brunswick and Nova Scotia and governments are in the process of integrating midwifery services there. Only Prince Edward Island and Newfoundland and Labrador do not have legislation in place for the practice of midwifery.

Midwives in Canada come from a variety of backgrounds including: aboriginal, post nursing certification, direct-entry and "lay" or traditional midwifery. However, after a process of assessment by the provincial regulatory bodies, registrants are all simply known as 'midwives', 'registered midwives' or 'sage femme' regardless of their route of training. From the original 'alternative' style of midwifery in the 1960s and 1970s, midwifery practice has become somewhat standardized in all of the regulated provinces: midwives offer continuity of care within small group practices, choice of birthplace, and a focus on the woman as the primary decision-maker in her maternity care. When women experience deviations from normal in their pregnancies, midwives consult with other health care professionals. The women's care may continue with the midwife, in collaboration with an obstetrician or other health care specialist; her care may be transferred to an obstetrician or other health care specialist, temporarily or for the remainder of her pregnancy and birth. Founding principles of the Canadian model of midwifery include informed choice, choice of birth setting, continuity of care from a small group of midwives and respect for the woman as the primary decision maker.

Four provinces offer a four year university baccalaureate degree in midwifery. In British Columbia, the program is offered at the University of British Columbia. In Ontario, the Midwifery Education Program is offered by a consortium of McMaster University, Ryerson University and Laurentian University. In Manitoba the program is offered by University College of the North, which offers the only degree program exclusively for aboriginal students; combining education in western and traditional aboriginal midwifery. In Quebec, the programme is offered at the Université du Québec à Trois-Rivières. In northern Quebec and Nunavut, Inuit women are being educated to be midwives in their own communities. A Bridging program for internationally educated midwives is in place in Ontario at Ryerson University. A national ["Multi-jurisdictional Midwifery Bridging Program"] is being developed for delivery in Western Canada. Regulated provinces and territories will admit foreign educated midwives to their regulatory body if they can demonstrate compentency through a Prior Learning and Experience Assessment (PLEA) process.

The legislation of midwifery has brought midwives into the mainstream of health care with universal funding for services (except in Alberta), hospital privileges, rights to prescribe medications commonly needed during pregnancy, birth and postpartum, and rights to order blood work and ultrasounds for their own clients and full consultation access to physicians. To protect the tenets of midwifery and support midwives to provide woman-centered care, the regulatory bodies and professional associations have legislation and standards in place to provide protection, particularly for choice of birth place (see home birth), informed choice and continuity of care. All regulated midwives have malpractice insurance. Any unregulated person who provides care with 'restricted acts' in regulated provinces or territories is practicing midwifery without a license and is subject to investigation and prosecution.

Prior to legislative changes, very few Canadian women had access to midwifery care (in part because it was not funded by the health care system). Legislating midwifery has made midwifery services available to a wide and diverse population of women and in many communities midwives cannot meet the growing demand. With the exception of residents of Alberta, midwifery services are free to women living in midwifery regulated provinces.

Midwifery in New Zealand

Midwifery regained its status as an autonomous profession in New Zealand in 1990. The Nurses Amendment Act restored the professional and legal separation of midwifery from nursing, and established midwifery and nursing as separate and distinct professions. Nearly all midwives gaining registration now are direct entry midwives who have not undertaken any nursing training. Registration requires a Bachelor of Midwifery degree. this is currently a three year full time programme but is in the process of being reviewed by the New Zealand midwifery regulatory authority..

Women must choose one of a midwife, a General Practitioner or an Obstetrician to provide their maternity care. About 78 percent choose a midwife (8 percent GP, 8 percent Obstetrician, 6 percent unknown.). Midwives provide maternity care from early pregnancy to 6 weeks postpartum. The midwifery scope of practise covers normal pregnancy and birth. The midwife will either consult or transfer care where there is a departure from normal. Antenatal and postnatal care is normally provided in the woman’s home. Birth can be in the home, a primary birthing unit, or a hospital. Midwifery care is fully funded by the Government. (GP care may be fully funded. Obstetric care will incur a fee in addition to the government funding.)

References

  • S. Solagbade Popoola, "Ikunle Abiyamo: It is on Bent Knees that I gave Birth" 2007 Research material, scientific and historical content based on traditional forms of African Midwifery from Yoruba people of West Africa detailed within the Ifa traditional philosophy. Asefin Media Publication

See also

External links

Midwifery Organizations

International:

Australia:

Canada:

New Zealand:

United Kingdom:

United States:

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