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Midwifery is a health care profession in which providers give prenatal care to expecting mothers, attend the birth of the infant, and provide postpartum care to the mother and her infant including breastfeeding.
A practitioner of midwifery is known as a midwife, a term used in reference to both women and men. (The etymology of midwife is Middle English mid = with and Old English wif = woman). In the United States, nurse-midwives (see below) are advance practice nurses (nurse practitioners]). In addition to giving care to women in connection with pregnancy and birth, they also provide primary care to women, well-woman care (gynecological annual exams), family planning, and menopause care.
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 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 women to obstetricians when a pregnant woman requires care beyond the midwives' 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.
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 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 womens health, sexual or reproductive health and childcare.
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.
Midwifery in the United States
There are two main divisions of modern midwifery in the US: nurse-midwives and direct-entry 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. The Frontier School is still educating nurse-midwives today but in a new way. 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 School of Midwifery and Family Nursing 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 1200 nurse-midwives. http://www.frontierschool.edu/. 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.
A direct-entry midwife is educated in the discipline of midwifery in a program or path that does not also require her/him 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).
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). 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[attribution needed], some nurse-midwives and many non-nurse-midwives[attribution needed] work within the community or home. In many statesTemplate:Which?, 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[attribution needed] 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 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. http://www.nhscareers.nhs.uk/details/Default.aspx?Id=1946
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.
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.
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. Midwifery training consists of classroom based learning provided by select Universities in conjunction with hospital and community based training placements at NHS Trusts.
Midwives may train to be community Health Visitors (as may Nurses).
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, 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 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 federally funded ["Multi-jurisdictional Midwifery Bridging Program"] is offered in Western Canada. Regulated provinces and territories admit internationally 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, 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 birthplace (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. 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.)
Midwifery in Japan
Midwifery in 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.
- Epstein, Abby The Business of Being Born (film). URL accessed on 2009-10-30.
- Wagner, Marsden. Welcoming Baby, or Not: Are men, machines, and hospitals really necessary for a healthy childbirth? American Sexuality Magazine. Accessed 3-27-07.
- Threat to Independent Midwifery (BBC News)
- Radical Midwives
- Midwifery Universities in the UK
- Schroff, F (1997) The New Midwifery.
- New Zealand Health Information Service: "Report on Maternity - Maternal and Newborn Information 2003."
- , PBS documentary Birth of a Surgeon
- 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
- Labor (childbirth)
- Natural childbirth
- Nurse midwife
- Pre- and perinatal psychology
- Traditional birth attendant
Articles / Presentations
- MIDIRS (Midwives Information and Resource Service) is an educational charity. Our mission is: 'To be the leading international information resource relating to childbirth and infancy, disseminating this information as widely as possible to assist in the improvement of maternity care'.
- StudentMidwife.NET - (SMNET) The online support network for student midwives and persons thinking of pursuing midwifery as a career. Education based networking and resources.
- 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' Many articles and news stories related to birth and midwifery
- MyMidwife.org - '...everything you need to know about midwifery, pregnancy, and women's health', American College of Nurse-Midwives
- Rogue Midwifery: Birthing On The Sly An article on Modern Day Rogue Midwifery/Underground Birthing and Barter for Birth
- 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 Professional: A New Kind of Midwife in Mexico," and "Mutual Accommodation or Biomedical Hegemony? Anthropological Perspectives on Global Issues in Midwifery."
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