Midwifery

Midwifery is a health care profession in which providers offer care to childbearing women during pregnancy, labor and birth, during the postpartum period, and between pregnancies. Practitioners also help care for the newborn and assist the mother with breastfeeding. They provide birth control, education and prescriptions for well-woman health care as well.

A practitioner of midwifery is known as a midwife, a term used in reference to both women and men, although most midwives are female.^[1] In addition to providing care to women during pregnancy and birth, many midwives also provide primary care to women, well-woman care related to reproductive health, annual gynecological exams, family planning, and menopausal care.

Midwives are specialists in childbirth, postpartum, and well-woman health care. They are educated and trained to recognize the variations of normal progress of labor and deal with deviations from normal to discern and intervene in high risk situations. Midwifery is its own profession and in many developed nations is the entry point for maternity care having demonstrated safety, satisfying and cost-effectiveness for decades. In the US, more women utilize obstetricians, in contrast, who are specialists in illness related to childbearing and in surgery.^[2] While obstetricians are medical doctors and provide surgery and instrumental deliveries in complex situations and provide care for women with health challenges and complicated pregnancies, midwives generally trust the developmental and physiologic process that is normal for most women, and utilize interventions as needed.^[3]

Midwives refer women to specialists such as obstetricians or perinatologists in complications related to pregnancy and birth when a pregnant woman requires care beyond the midwives' scope of practice. In many parts of the world, these professions work in tandem to provide care to childbearing women. In others, only the midwife is available to provide care. Midwives are trained to handle certain more difficult deliveries, including breech births, twin births and births where the baby is in a posterior position, using non-invasive techniques.

For normal births, midwives offer care at a lower cost, use lower intervention rates, have lower mortality and morbidity as a result of fewer interventions, and fewer recovery complications.^[4]

Definition

According to the definition of the International Confederation of Midwives, which 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 midwife is recognized as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labor 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 counseling 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, and to gain the knowledge to counteract the lack of pain relievers and antiseptics.^{[citation needed]}

95% of midwives in the US are Certified Nurse Midwives and practice in hospitals. A midwife who is credentialed appropriately is qualified to practice in any setting including in the home, the community, hospitals, clinics or health units.^[5][6]

Etymology

The term midwife is derived from Middle English: midwyf literally "with-woman", i.e. "the woman with (the mother at birth), the woman assisting"^[7] (in Middle English and Old English, mid = "with", wīf = "woman").

In this context, the word wife means woman rather than married woman.^[8] This usage stems from Old English wif (woman) and is akin to the German weib, also meaning "woman". This sense of the word is still used in Modern English in constructions such as fishwife and old wives' tale.

In the term midwife, the morpheme -wife is pronounced as expected /waɪf/, but midwifery is normally pronounced /mɪdˈwɪf(ə)ri/ (mid-WIF-(ə)ree).^[9]

Early historical perspective

Midwives are mentioned in the Old Testament: Exodus, Chapter 1. The Bible describes how the children of Israel (Hebrews) were enslaved in Egypt and they multiplied greatly. The Egyptians became fearful of the potential power of so many Hebrews. Pharaoh, therefore, commanded the Hebrew midwives (named Shiphrah and Puah) to kill all male babies delivered to the Hebrew women. The midwives, however, "feared God" and disobeyed Pharaoh by allowing the male babies to live. When Pharaoh asked the midwives why they had disobeyed his orders, the midwives told him the Hebrew women had easier labors than Egyptian women and delivered their babies before the midwife arrived. "And God dealt well with the midwives" (Exodus, Chap. 1, verse 20).

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.^[10]

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.^[11] However, there were certain characteristics desired in a “good” midwife, as described by the physician Soranus of Ephesus in the 2nd 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.^[12] Pliny, another physician from this time, valued nobility and a quiet and inconspicuous disposition in a midwife.^[13] 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.^[13]

Agnodice or Agnodike (Gr. Ἀγνοδίκη) was the earliest historical, and likely apocryphal,^[14] midwife mentioned among the ancient Greeks.^[15]

Midwives were known by many different titles in antiquity, ranging from iatrinē (Gr. nurse), maia (Gr., midwife), obstetrix (Lat., obstetrician), and medica (Lat., doctor).^[16] It appears as though midwifery was treated differently 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 gynaecologist (iatros gynaikeios, translated as women's doctor), 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.^[12] One example of such a midwife is Salpe of Lemnos, who wrote on women’s diseases and was mentioned several times in the works of Pliny.^[13]

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.^[12]

The actual duties of the midwife in antiquity consisted mainly of assisting in the birthing process, although they may also have helped with other medical problems relating to women when needed. Often, the midwife would call for the assistance of a physician when a more difficult birth was anticipated. In many cases the midwife brought along two or three assistants.^[17] 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 birthstool was a crescent-shaped hole through which the baby would be delivered. The birthstool or chair often had armrests for the mother to grasp during the delivery. Most birthstools or chairs had backs which the patient could press against, but Soranus suggests that in some cases the chairs were backless and an assistant would stand behind the mother to support her.^[12] The midwife sat facing the mother, encouraging and supporting her through the birth, perhaps offering instruction on breathing and pushing, sometimes massaging her vaginal opening, and supporting her perineum during the delivery of the baby. The assistants may have helped by pushing downwards on the top of the mother's abdomen.

Finally, the midwife received the infant, placed it in pieces of cloth, cut the umbilical cord, and cleansed the baby.^[13] 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.^[12]

A 2nd-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 birth 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 vagina, as encouraged by Soranus.^[13]

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. They may have been highly trained or possessed only 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.^[12] Like a lot of other factors in antiquity, quality gynecological care often depended heavily on the socioeconomic status of the patient.

Later historical perspective

In the early 20th century, a conflict between surgeons and midwives arose, as medical men began to assert that their modern scientific techniques were better for mothers and infants than the folk medicine practiced by midwives.^[18] As doctors and medical associations pushed for a legal monopoly on obstetrical care, midwifery became outlawed or heavily regulated throughout the United States and Canada.^[18][19] Despite accusations that midwives were "incompetent and ignorant",^[20] some argued that poorly trained surgeons were far more of a danger to pregnant women.^[21] The argument that surgeons were more dangerous than midwives lasted until the study of bacteriology became popular in the early nineteen hundreds. Women began to feel safer in the setting of the hospitals with the amount of aid and the ease of birth that they experienced with doctors. “Physicians trained in the new century found a great contrast between their hospital and obstetrics practice in women’s homes where they could not maintain sterile conditions or have trained help.” (Leavitt) The denied access of midwives began because they were behind in their roles in bacteriology.^[22] German social scientists Gunnar Heinsohn and Otto Steiger theorize 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.^[23] According to Heinsohn and Steiger's theory, the 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 which had swept over the continent in waves, starting in 1348.

By country or region

United States

The paths to becoming a midwife in the United States are varied. One path begins with a degree in nursing, advanced education and a certificate in nurse-midwifery. Recently the American College of Nurse Midwives approved a path to membership, and certification which does not require nursing as a prerequisite. In its educational path, midwives are trained in the appropriate and necessary skills to providing care, and sit for the same certification exam and those trained in nursing. Their credential is Certified Nurse Midwife or Certified Midwife.

Nurse-midwives

Nurse-midwives were introduced in the United States in 1925 by Mary Breckinridge for use in the Frontier Nursing Service (FNS). 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 service 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 America, thousands of lives would be saved, and suggested nurse-midwife training should be made available in the United States. The Maternity Center Association and the Lobenstine Clinic opened the first nurse-midwifery school in the United States, which later closed.^[24] Breckinridge founded the Frontier Nursing University in 1939, the second nurse-midwifery education program in the United States, which is still open today.^[24]

The Frontier School is still educating nurse-midwives and has added distance learning to its methodology. In 1989 the program became the first distance option for nurses to become nurse-midwives without leaving their home communities. The students do their academic work on-line with the Frontier Nursing University faculty members and they do their clinical practice with a nurse-midwife in their community who is credentialed by Frontier as a clinical faculty member. This community based model has graduated over 1500 nurse-midwives.^[25]

In the United States, nurse-midwives are variably licensed 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 licensing, 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.^{[citation needed]}

Direct-entry midwives

A direct-entry midwife is educated in the discipline of midwifery in a program or path that does not require any prior education or training as a nurse or doctor. Direct-entry midwives learn midwifery through self-study, apprenticeship, or a private midwifery school. A direct-entry midwife is trained to provide the Midwives Model of Care^[26] to healthy women and newborns throughout the childbearing cycle primarily in out-of-hospital settings. A CPM (Certified Professional Midwife) will often practice without the support of a hospital or an OBGYN. The use of medications is regulated by individual states; medications commonly authorized include pitocin, methergine, misoprostol, RhoGAM, oxygen, erythromycin eye ointment for the newborn, vitamin k for the newborn, intravenous fluids, ampicillin, penicillin, and epinephrine.^{[citation needed]}

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

A Certified Professional Midwife (CPM) is a professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives^[27] (NARM) and is qualified to provide the midwives model of care. As of November 2010, there are approximately 1800 CPMs practicing in the US.^[28] However, midwives practicing with a CPM certification are not required to carry insurance.^{[citation needed]} Peer review occurs locally at least quarterly.^{[citation needed]}

A Licensed Midwife is a midwife who is licensed to practice in a particular state. Currently, licensure for direct-entry midwives is available in 27 states as of 2011.^[29]

The term "Lay Midwife" has been used to designate an uncertified or unlicensed traditional 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 their type of education (as was the fact before the Certified Professional Midwife (CPM) credential was available).^[30]

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.

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). The CPM certification process 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, 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

Midwives work with women and their families in many different settings. While the vast majority of nurse-midwives work in hospitals, some work within the community or home. In many states, midwives form birthing centers where a group of midwives may work individually or together^[31] and provide additional clinical opportunities to student midwives. 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.

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, whether at home or in a hospital (although most births in the UK occur in a hospital). There are two 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 a degree in midwifery (diploma courses in midwifery have been discontinued) 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 additional while training. Funding varies depending on which country within the UK the student is located, students are eligible for NHS bursaries in addition to a £1000 grant per year, neither are repaid.^[32] Shortened course students, those who are already registered adult nurses, have different funding arrangements, and are employed by the local NHS Trust, via the Strategic Health Authority (SHA), and are paid a salary. This varies between universities and SHAs, with some students being paid their pre-training salary, others employed as a Band 5, and others paid a proportion of a Band 5 salary. Although most practising midwives within the United Kingdom are female, men are able to train but represent less than 0.5% of the NMC workforce register.^[33]

All practising 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.^[34]

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.

Professional association/college:

• The Royal College of Midwives^[35]

The Nursing and Midwifery Council ^[36] is the regulatory body for nurses, midwives and health visitors in the UK.

Midwifery training

Most midwives undergo a 36 month direct entry degree program, or an 18 month nurse conversion course (following 36 months of nurse training. Midwifery training consists of classroom based learning provided by select universities^[37] in conjunction with hospital and community based training placements at NHS Trusts.

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

Community midwives

Many midwives also work in the community. The role of community midwives include the initial appointments with pregnant women, managing clinics, postnatal care in the home, and attending home births.^[38] A community midwife would typically have a pager and be responsible for a particular area, contacted by ambulance control when needed. Sometimes they are paged to help out in the hospital when there are insufficient midwives available.

India

History & Development of Maternal & Child Health Services in India These were started with the help of voluntary organizations. Modern Maternal & Child health work was begin in India by the foreign missionaries with effort to train dais. The historical facts are as follows 1885  : An association for medical aid by the women t the women of India was established by the Countess of Dufferin 1918 : Lady reading Health School was started in Delhi offering helath visitors course. This was another stepping stone in MCH Services 1921 : Lady Chelmsford League was formed in India for developing Maternity & Child welfare services 1931 : The Indian Redcross society established MCH Bureau in association with the Lady Chelmsford League & Victories memorial Scholarship Fund & Co-ordinated the MCH work throughout the country.

• Madras was the first state then to set up a separate section for maternal & child welfare in the public health department under the charge of an Asst. Director of Public Health. It was again Madras state which first attempted to replace by the better qualified personnel such as midwives & nurse midwives

1938 : Indian Research Fund Association was established which formed a committee that undertook the investigation into the incidence & cause of Maternal & infant morbidity & mortslity. Sir A. Mudaliar was the key person of this committee.

Investigation thus carried out in certain cities of the country revealed that • Institutional Midwifery services were limited • Maternal & Child welfare centre were poorly equipped & staffed • Untrained dais mostly handled deliveries

This situation continued for some more time. In 1946 the 5th health survey & development committee (Bhore committee) stated in its report that India was facing the problem of high maternal & infant death. It recommended empathetically that the measures for the reduction of sickness & mortality of mothers & children should have the highest priority in the health development programme of India. It was also mentioned that these deaths were preventable with the help of organized health services.

1951 : BCG Vaccination programme was launched
1952 : Primary Health centre set up
1953 : Nationwide family planning programme was initiated
1965 : Direct BCG Vaccination without prior tuberculosis test on a house to house Basis initiated
1970 : All India Hospital (Post partum) Family Planning Programme was started
1976 : National Programme for Prevention of Blindness was formulated
1977 : Multipurpose health worker scheme was launched
1978 : EPI was launched
1983 : National Health Policy – MCH & Family welfare services were integrated during this policy
1985 : Universal Immunization Programme was launched. A separate Department of women & child Development was set up under the newly created Ministry of Human Resource Development
1987 : A world wide “Safe Motherhood Campaign” was launched by World Bank
1990 : Control of Acute respiratory infection (ARI) programme initiated as a pilot Project in 14 districts
1992 : Child Survival & Safe Motherhood Programme (CSSM) was launched on 20 August • SMI (Safe Motherhood Initiative) Programme was started • The Infant Milk substitute, feeding bottles & Infant food (regulation of Production, Supply & Distribution) act 1992 came into force
1995 : ICDS renamed as Integrated Mother & Child Development Services (IMCD)
1996 : Pulse Polio Immunization, the largest single day public health event took place on 9th & 20th Jan 1996. 2nd phase PPI was conducted on 7th Dec 1996 & 8th Jan 1997
Family Planning Programme made target free from 1 April 1996
Prenatal Diagnostic Technique (Regulation & Prevention of Misuse) act 1994 came into force from Jan 1996^[39]

Canada

Midwifery was reintroduced as a regulated profession in most of Canada's ten provinces in the 1990s.^[40] After several decades of intensive political lobbying by midwives and consumers, fully integrated, regulated and publicly funded midwifery is now part of the health system in the provinces of British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, and Nova Scotia, and in the Northwest Territories and Nunavut. Midwifery legislation has recently been proclaimed in New Brunswick where the government is in the process of integrating midwifery services there. Only Prince Edward Island, Yukon 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 by the French-language equivalent, 'sage femme', regardless of their route of training. From the original 'alternative' style of midwifery in the 1960s and 1970s, midwifery practice is offered in a variety of ways within 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 or their newborns experience complications, midwives will work in consultation with an appropriate specialist. Registered midwives have access to appropriate diagnostics like blood tests and ultrasounds and can prescribe some medications. Founding principles of the Canadian model of midwifery include informed choice, choice of birthplace, continuity of care from a small group of midwives and respect for the woman as the primary decision maker. Midwives typically have hospital privileges and support women's right to choose where she will have her baby.^{[citation needed]}

Five provinces offer four-year university baccalaureate degrees in midwifery. In British Columbia, the program is offered at the University of British Columbia.^[41] Mount Royal University in Calgary, Alberta offers a Bachelor of Midwifery program. In Ontario, the Midwifery Education Program (MEP) 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. In Quebec, the program 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 federally funded pilot project called the Multi-jurisdictional Midwifery Bridging Program^[42] has been offered in Western Canada.

The legal recognition of midwifery has brought midwives into the mainstream of health care with universal funding for services, 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, 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. Legalizing midwifery has made midwifery services available to a wide and diverse population of women and in many communities the number of available midwives does not meet the growing demand for services. Midwifery services are free to women living in provinces with regulated midwifery.

British Columbia

The BC government announced on March 16, 1995 the approval of regulations governing midwifery and establishing the College of Midwives of BC. In 1996, the Health Professional Council released a draft of Bylaws for the College of Midwives of BC which received Cabinet approval on April 13, 1997. In 1998, midwives were officially registered with the College of Midwives of BC.^[43]

In BC Midwives are primary care providers for women in all stages of pregnancy, from prenatal to six weeks postpartum. Midwives also care for newborns. To see the approximate proportion of women whose primary birth attendant was a midwife in British Columbia see, "What Mothers Say: The Canadian Maternity Experiences Survey. Public Health Agency of Canada. Ottawa, 2009, p. 115.^[44]

In BC midwives deliver natural births in hospitals or homes and if a complication arises in a pregnancy, labour, birth or postpartum, a midwife will consult with a specialist such as an obstetrician or paediatrician.

Core competencies and restricted activities are included in the BC Health Professions Act Midwives Regulation.

As of April 2009, the scope of practice for midwives allows them to prescribe certain prescription drugs, use acupuncture for pain relief, assist a surgeon in a Caesarean section delivery and to perform a vacuum extraction delivery. These specialized practices require additional education and certification.

Current supply: As of August, 2011, the College of Midwives of BC^[45] reported 182 General, 3 Temporary, 1 Conditional, 32 Non-practicing Registrant midwives.

There were 2 midwives per 100,000 people in BC in 2006.^[46]

A midwife must be registered with the College of Midwives of BC in order to practice.

To continue licensure midwives must maintain regular recertification in neonatal resuscitation and management of maternal emergencies, maintain the minimum volume of clinical care (40 women), participate in peer case reviews and continuing education activities.^[43]

Midwives education in BC: The University of British Columbia (UBC) has a four-year Bachelors of Midwifery program.^[47] The UBC midwifery program is poised to double in size thanks to an increase in government funding. Graduation of students will increase to 20 per year.

Professional association/college:

• College of Midwives of BC^[43]
• Midwives Association of BC^[48]

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. Midwives are required to undertake a 4 year equivalent undergraduate degree to become registered. That is followed by a year of one on one mentored practice and professional development support.^[49]

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).^[50] 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 a normal pregnancy. Antenatal care is normally provided in clinics, and postnatal care is initially 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. Private obstetric care will incur a fee in addition to the government funding.)

Professional association/college:

• The New Zealand College of Midwives,^[51] a professional organisation for midwives, representing nearly 90% of practising midwives. Membership is voluntary.

Ireland

Midwives are trained either as nurses obtaining a higher diploma in midwifery which lasts 18 months, or the direct entry who study and practice for 4 years, internship is done on the last year. In 2009 the first male midwife joined the midwifery programme.

Netherlands

Midwives are called vroedvrouw (knowledge woman, female midwives), vroedmeester (knowledge master, male midwives), or verloskundige (deliverance experts, general) in Dutch. Midwives are independent specialists in physiologic birth. In the Netherlands, home birth is still a common practice, although rates have been declining during the past decades. Between 2005-2008, 29% of babies were delivered at home.^[52] This figure fell to 23% delivered at home between 2007-2010 according to Midwifery in the Netherlands, a 2012 pamphlet by The Royal Dutch Organization for Midwives.^[53] Midwives are generally organized as private practices, some of those are hospital-based. In-hospital outpatient childbirth is available in most hospitals. In this case, a woman's own midwife delivers the baby at the delivery room of a hospital, without intervention of an obstetrician.In all settings, midwives will transfer care to an obstetrician in case of a complicated childbirth or need for emergency intervention.

Apart from childbirth and immediate postpartum care, midwives are the first line of care in pregnancy control and education of mothers-to-be. Typical information that is given to mothers includes information about food, alcohol, life style, travel, hobbies, sex, etc.^[54] Some midwifery practices give additional care in the form of preconceptional care and help with fertility problems.^[55]

Education in midwifery is direct entry, i.e. no previous education as a nurse is needed. A 4-year education program can be followed at four colleges, in Groningen, Amsterdam, Rotterdam and Maastricht.^[56]

All care by midwives is legal and it is totally reimbursed by all insurance companies. This includes prenatal care, childbirth (by midwives or obstetricians, at home or in the hospital), as well as postpartum/postnatal care for mother and baby at home.^[57][58]

Professional association/college:

• The Royal Dutch Organisation of Midwives^[59] is the primary midwifery organisation in the Netherlands.

Japan

In Japan, midwifery was first regulated in 1868. Today midwives in Japan are regulated under the Act on Public Health Nurse, Midwife and Nurse (No. 203) established in 1948.

Japanese midwives must pass a national certification exam. Up until March 1, 2003 only women could be midwives.^[60]

To understand the Japanese model see, Midwifery in Japan by the Japanese Nursing Association.^[61]

Professional association/college:

• Japan Academy of Midwifery^[62]
• Japanese Midwives Association^[63]

Balochistan (Tribal Pakistan)

In Balochistan, midwives are the third most powerful leaders in the community, and the most powerful among women. People say that they give life to a child as the majority of tribal areas have no doctors. Midwives also solve problems between women. If there is a conflict between a man and a woman, the man has more power, and he will go to the tribal chief instead.^[64]

Mozambique

When a 16-year-long civil war ended in 1992, Mozambique's health care system was devastated and one in ten women were dying in childbirth. There were only 18 obstetricians for a population of 19 million. In 2004, Mozambique introduced a new health care initiative to train midwives in emergency obstetric care in an attempt to guarantee access to quality medical care during pregnancy and childbirth. These midwives now perform major surgeries including Cesareans and hysterectomies. As the figures now stand, Mozambique is one of the few countries on track to achieve the United Nations Millennium Development Goal (MDG) of reducing the maternal death rate by 75 percent by 2015.^[65]

Karbis of Goria Ghuli

The village of Goria Ghuli is an example of a rural and traditional village. The village has no electricity, and they have no access to a telephone. The primary health facility is in Sonapur, which is about 7 km from the village. This health facility has 3 doctors, 2 lady health visitors, 6 auxiliary nurse midwives, 3 microscopists, and 2 pharmacists. The Karbis believe that good health “is the outcome of a pious life and illness is the punishment meted out by spirits”^[66] The Karbis have specialists or healers who are not alike; midwives, or ethnogynacologists are one of these specialists. The village has two different categories of midwives. The first is known as the ‘traditional’ midwife, who is also an herbalist. The second is the ‘nurse’ midwife; these are the ‘government’ midwives.^[66] Traditional midwives are favored in the village. They receive some informal training that is used to help with before, during, and after pregnancy care of villagers. This information is transferred from generation to generation. In the village there are 3 ethnogynacologist, which can be approached at any time for assistance at the time of delivery. She, and usually another elderly woman in the village help during and after the delivery. If for any reason there are complications, the village midwife will forward the ‘patient’ to the ‘nurse’, and if she is unable to help then they are forwarded to the Primary Health Center. These midwives do not take on the traditional role of a midwife that we may see in the United States, for example. Rather, a huge role of the midwife is as an herbalist for the village.

Maya of Guatemala

This study was specifically in San Pedro. The midwives of San Pedro have many roles in the society, and are respected highly for them. The shamans of San Pedro are rapidly declining which has caused an increase in the number of midwives, in order to care for the people. They call the midwife, "iyom". The Maya believe that being pregnant is to be "yawa", meaning ill.^[67] The midwife is an obstetrical and religious specialist all at once. She provides prenatal care, massage, attends delivery, and takes care "takes charge of" mother and child after birth. Midwives in this society are similar to shamans, in that her calling is divine. She is the connection between the spiritual and real world, and in order to protect her 'patients' she performs rituals to keep them safe. The load of work for these midwives is huge. There are not many, and they serve most women in the village.^[67] (This case study was done in 1975, and the community has changed since. A recent book documents cultural change and continuity in San Pedro and in local midwifery practices as related to the life and work of a renowned local iyom).^[68]

Midwife-led continuity of care

Midwife-led continuity of care is where one or more midwives have the primary responsibility for the continuity of care for childbearing women, with a multidisciplinary network of consultation and referral with other health care providers. This is different from "medical-led care" where an obstetrician or family physician is primarily responsible. In "shared-care" models, responsibility may be shared between a midwife, an obstetrician and/or a family physician.^[69]

According to a Cochrane review of public health systems in Australia, Canada, Ireland, New Zealand and the United Kingdom, midwife-led continuity of care, in contrast to "medical-led care", has effects including the following:^[69]

• a reduction in the use of epidurals, with fewer episiotomies or instrumental births.
• increased chances of being cared for in labour by a midwife known by the childbearing woman
• increased chances of having a spontaneous vaginal birth
• decreased risk of preterm birth
• decreased risk of losing the baby before 24 weeks' gestation, although there appears to be no differences in the risk of losing the baby after 24 weeks or overall

There was no difference in the number of Caesarean sections. All trials in the Cochrane review included licensed midwives, and none included lay or traditional midwives. Also, no trial included out of hospital birth.^[69]

According to a study published in The Lancet in 2013, it is safe and cost effective to have pregnancy women receiving antenatal, intrapartum, and postnatal care from a named "caseload" midwife.^[70]

See also

Afghanistan Midwifery Project Marie-Rosalie Cadron-Jetté Childbirth and obstetrics in antiquity Kristopher Crawford Yvonne Cryns Doula Global Library of Women's Medicine International Confederation of Midwives

Midwives Alliance of North America Monthly nurse Natural childbirth Nurse midwife Obstetrics Justine Siegemund Traditional birth attendant

References

Notes

Bibliography

• Craven, Christa. 2007 A “Consumer’s Right” to Choose a Midwife: Shifting Meanings for Reproductive Rights under Neoliberalism. American Anthropologist, Vol. 109, Issue 4, pp. 701–712. In I.L. Montreal and Kingston: McGill-Queens University Press.
• Ford, Anne R., & Wagner, Vicki. In Bourgeautt, Ivy L., Benoit, Cecilia, and Davis-Floyd, Robbie, ed. 2004 Reconceiving Midwifery. McGill-Quenn’s University Press: Montreal & Kingston
• MacDonald, Margaret. 2007 At Work in the Field of Birth: Midwifery Narratives of Nature, Tradition, and Home. Vanderbilt University Press: Nashville
• Martin, Emily. 1991 The Egg and the Sperm: How Science Has Constructed a Romance Based on Stereotypical Male-Female Roles. Journal of Women in Culture and Society, Vol.16, No.3, pp. 485–501.
• (Dutch) Obstetricians in the city of Groningen.

Further reading

• 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 of West Africa detailed within the Ifa traditional philosophy. Asefin Media Publication
• Greene, M. F. (2012). "Two Hundred Years of Progress in the Practice of Midwifery". New England Journal of Medicine 367 (18): 1732–1740. doi:10.1056/NEJMra1209764. PMID 23113484. 

External links

Wikimedia Commons has media related to Midwives.

Look up midwifery in Wiktionary, the free dictionary.

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