Midwifery

Midwifery is the term traditionally used to describe the art of assisting a woman through childbirth. In the modern context, this term is used to describe the activities of these health care providers who are experts in women's health care including giving prenatal care to expecting mothers. They 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 term means "with woman").

Midwives are autonomous practitioners who are specialists in normal pregnancy, childbirth and the postpartum. Midwives are also primary care givers: providing general women's health care. 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 are complementary. Midwives refer to obstetricians when a woman requires care beyond her areas 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 using non-invasive techniques, including breech birth on occasion. In many areas of the world, traditional birth attendants, also known as traditional midwives care for childbearing women. This is different from the U.S. definition.

In the U.S. there three types of national midwifery certification: Certified Nurse-Midwife (CNM), Certified Midwife (CM), and Certified Professional Midwife (CPM) (see below for more information).

International definition
A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised 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 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 newborn and the infant. This care includes preventive measures, the promotion of normal birth, the detection of complications in mother and child, the 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.

Adopted by the International Confederation of Midwives, 19 July 2005

Historical perspective
Historically, midwifery has been one of the few medical practices dominated by female practitioners. From Agnodice in ancient Greece to the 18th century in Europe, the care of mothers and delivery of infants has been regarded, both by patients and by the medical profession, as appropriately carried out by women. 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 reknowned 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.

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

Nurse midwives
In the United States, nurse-midwives are advanced practice nurses who have specialized in the practice of obstetrical and gynecological care of relatively healthy women. In addition to a registered nursing license, most nurse-midwives have a master's degree in nursing. Nurse-midwives practice in hospitals and medical clinics, and may also deliver in birth centers and at home. They are able to prescribe medications in 48 out of the 50 states. Nurse-midwives provide care to women from puberty through menopause. Nurse-midwives may work closely with an obstetrician, who provides 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 education programs and serves as the national specialty society for the nation's certified nurse-midwives. At present there are approximately 5500 Certified Nurse-Midwives 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 international 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 which 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.

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. Laws regarding who can practice midwifery and in what circumstances vary from state to state, and some midwives are forced to practice outside of the law.

Midwifery in the United Kingdom
Midwives are practitioners in their own right in the United Kingdom, and take responsibility for the antenatal, intrapartum and immediate postnatal care of women. Nearly all births are supervised by midwives, mostly in a hospital setting. Following completion of nurse training, a nurse may become a registered midwife by completing an eighteen month course (leading to a degree qualification), or by undertaking a three year degree or university diploma in midwifery.

All practicing midwives must be registered with the Nursing and Midwifery Council, and are subject to the 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.

To be a midwife is to be responsible, at all times, for the woman for whom you are caring, to know when to refer complications to medical staff, to act as the woman's advocate, and to ensure the mother retains some 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.

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

Community midwives
There are also numerous midwives working in the community, in addition to the midwives working in hospitals. The roles of community midwives include the initial appointments of pregnant women, the running of clinics, postnatal checks in the home, and attending home births.

Midwifery in Canada
Midwifery was reborn as a profession in Canada in the 1960s, along with other aspects of heath care reform that trace their roots to that decade of societal ferment and change. After several decades of intensive political lobbying by midwives and consumers, regulated midwifery has become part of the health system in the provinces of British Columbia, Alberta, Manitoba, Ontario, and Quebec, and in the Northwest Territories and Nunavut. Alberta does not publically fund midwifery. Saskatchewan has legislation but has not integrated midwifery yet. Midwifery is not yet legally recognised in the Atlantic provinces of New Brunswick, Nova Scotia, Prince Edward Island or Newfoundland and Labrador.

Midwives in Canada have come from a variety of backgrounds, including nurse-midwifery, lay midwifery and direct-entry midwifery. However, they are all simply known as 'midwives', regardless of their original 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 practises, 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. Woman as primary decision maker, informed choice, and choice of birth place are primary tenets of midwifery care in Canada.

There are three provinces that now offer midwifery education, which consists of 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 Quebec, the programme is offered at the Université du Québec à Trois-Rivières. In northern Quebec, Inuit women are being educated to be midwives in their own communities. A program for First Nations midwifery students will open soon in Manitoba.

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 and birth, and rights to order blood work and ultrasounds for their own clients. To protect the tenets of midwifery and keep midwives providing woman-centerd 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 about care, and continuity of care. Midwives in Ontario have had malpractice insurance since prior to legislation and all other legislated midwives also have malpractice insurance.

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.

Midwifery Organisations

 * Midwife.org - American College of Nurse-Midwives
 * Australian College of Midwives
 * Midwives Alliance of North America (MANA)
 * Midwifery Education Accreditation Council
 * National Association of Certified Professional Midwives
 * NMC-UK.org - 'Nursing & Midwifery Council: Protecting the Public through Professional Standards' (overseers of UK midwifery, by mandate of Parliament)
 * [[The North American Registry of Midwives]- Certification agency for direct-entry midwives.]

Articles

 * MidwifeInfo is an independent US site with articles about midwifery, becoming a midwife, pain relief, evidence-based midwifery practice, drugs, herbs and other information relevant to midwives and consumers.
 * EFN.org - 'The role of social support in midwifery practice and research', Melinda Cook, BHS, Hunter Valley Midwives Association Journal, vol 2, no 6 (November, 1994)
 * MidwiferyToday.com - 'Midwifery Today, the Heart and Science of Birth'
 * MyMidwife.org - '...everything you need to know about midwifery, pregnancy, and women's health', American College of Nurse-Midwives
 * Home Birth Video & Story Home Birth by Midwife
 * http://www.davis-floyd.com contains a number of articles by anthropologist Robbie Davis-Floyd about American and international midwifery, including "Intuition as Authoritative Knowledege in Midwifery and Home Birth," "The Ups, Downs, and Interlinkages of Nurse- and Direct-Entry Midwifery in the US," "Types of Midwifery Training: An Anthropological Interview," "Home Birth Emergencies in the US and Mexico: The Trouble with Transport," "La Partera Profesional: A New Kind of Midwife in Mexico," and "Mutual Accommodation or Biomedical Hegemony? Anthropological Perspectives on Global Issues in Midwifery."