We have looked at the accepted definition of a midwife, and we have looked at the philosophy that rejects that definition.  I want to finish this series by introducing you to the way I will be using the term midwife on this blog.  The concept has been born in me through conversations with many women I respect who have challenged my preconceived notions and helped me find my own voice. It is an idea that is still evolving in my mind, but formed enough to share.

The root of the word midwife, According to Judith Pence Rooks in Midwifery & Childbirth in America, dates to 1303 and means literally “with wife.”  The term simply meant “a woman who assists other women while they are giving birth” (Rooks, 1997).  She goes on to explain that women supported each other and educated each other as a normal course of events.  The women who became midwives were just really good at attending birth and often sought for assistance.

But what if, in our modern culture, defining the midwife as the baby catcher is too narrow?  Even the international accepted definition recognizes the role of the midwife in educating the woman and assisting her in maintaining a normal healthy state during pregnancy. To what extent this was or was not done by the “midwives” in various parts of the world throughout history I’m afraid I cannot say.  But as to the need in the place and time I occupy, I know it is real.

So what if instead of thinking of the midwife as the one who catches the baby, what if we think of the midwife as one who comes alongside an expectant mother and assists her during this time of transition. Rather than being defined by one instant in time, midwifery is defined as a continuum of services provided to help the family transition successfully.  On this continuum would be the fertility educators, the nurses, the childbirth educators, the doulas, the lactation consultants, the prenatal exercise and nutrition specialists, and the baby-catchers.

I know there are many problems with this definition, most of them legal. But I think it is important to understand and accept how all these interactions work together to bring the woman through the transition to motherhood. Perhaps you are a midwife because you are with the woman as she travels through this transition, this year long transition to being a mother, whether you are at the birth or not. Perhaps “midwife” is as much a verb as it is a noun.  Or, perhaps I need to reconsider this philosophy completely.

You are not a nurse because you give shots.

I like the continuum idea, and I like the “midwife” as a verb idea. But do I really think anyone who works with an expectant family is a midwife?  I don’t know yet.  I’m still trying to sort the fine details out in my head.  I do think words are used because they have meaning, and the words are only useful when everyone understands the word to mean the same thing.  So I can accept the insistence that the term “midwife” only be used by those who fit a specific definition. I can also accept that even though they are related, there is a big difference between a doula and a midwife.  Doulas are great, I happen to be a doula. I have fulfilled the roll of doula at many labors.  But I have not yet fulfilled the role of the “midwife.”  At no time did I accept responsibility for the care of the family. That acceptance of responsibility is a big step. And while I may happen to have much knowledge about birth and could probably perform the function of “catching” the baby, I know developing the acceptance of responsibility takes time. In nursing school, I could perform the function of giving a shot long before I understood all the reasons why I was giving a particular shot.  Being a midwife, and being a nurse, is not really about giving the shots or catching the baby. I remember my very first nursing class the instructor told us, “You are not becoming a nurse so you can give a shot.  I could train a monkey to give a shot. Giving a shot is just something you may do while you do the real work of nursing.”  So I can understand any disagreement with the idea of midwifery as any act of working with expectant families.

But at the same time I accept that a woman is more than a uterus.  There are more changes that happen during this transition than simply the opening of a cervix, and there are more needs than simply massaging the perineum. When you follow the midwifery model of care you ensure all the mother’s needs are met.  She receives education and counseling and support and referrals to others who can help fulfill these needs.  Are these needs any less important to the mother preparing for birth than the catching of the baby?  Is fulfilling these needs not fulfilling part of the midwifery role?

And so this is where I stand today. I did tell you the idea was still evolving right?  Today I see midwifery as a continuum, and within that continuum are many care providers offering many services to help ensure safe birth for all mothers. And though their title may not be midwife, they are all fulfilling the midwifery role.

What This Means to You

You do not have to accept my philosophy or my definition, I promise it will not hurt my feelings.  But please consider it honestly.  Maybe this is the way you have always thought about maternal health and I have simply given voice to your own intuitive knowledge.  Maybe I have challenged you to place more value on the work of others and yourself.  It’s possible you disagree completely.

But maybe, just maybe, I have given you permission to follow your calling to midwifery without your ever having to become a baby-catcher, and that freedom makes pursuing your calling possible.

If you did your homework yesterday, you now know what laws regulate midwifery where you live or where you hope to practice as a midwife. You may have discovered it is not as difficult as you anticipated, or you may have discovered becoming a midwife will take you more years than you wish to devote to the schooling.  So today I want to look at another definition of a midwife from another perspective, a perspective shared in this article from Midwifery Today.

Traditional Birth Attendant or Midwife?

From this perspective, the midwife is the woman who takes care of pregnant mothers.  The type of education she has is not as important as the work she does.  Do you remember from yesterday’s post that the tasks of the midwife were vaguely defined but the process by which to become a midwife was strongly defined?  In the ICM definition, you are midwife because you have completed a government recognized program (and work with expectant mothers in some capacity). But this definition is different.  This definition doesn’t care how you were trained, where you were trained or who approved of your training.  In this definition, you are a midwife because you assume the role of the midwife.

And here is where it gets a little soggy. Is a woman any less of a midwife because technically, for research and statistical purposes, she is a traditional birth attendant?  Is the work she does any less important than the work of a skilled birth attendant (government approved midwife, nurse or doctor)?

And here is where it gets downright muddy.  Should a traditional midwife be required to stop practicing when there are no workable options for care in her community?  If her community is more than a day’s walk to the  closest hospital and families have no access to motorized transportation?  If the women in her community will not accept government approved care because it does not fit within their culture?

Wait, do you think I am only talking about developing countries?  I definitely agree these are problems facing some of the poorest countries in the world, but I also know these are problems families face right here in my own country.

The United States is an immigrant nation.  Families who live within its borders come from all cultures, some who value western medicine and some who do not. How do you provide adequate prenatal care to a woman who sees no value in visiting the doctor when pregnant? What about the family who do not trust western medicine, and so avoid participating in the system? Similarly, much of the United States is rural.  The rural poor are always worse off than the urban poor whether they are in a developed nation or a developing nation.  So what do you do with the rural poor family who cannot use public transportation to visit a clinic?

These may not be the kind of problems you normally think about, but they are very real problems that face every government. Ensuring access to health care means so much more than how much money is available.  It means providing acceptable services to all members of society in a way that meets their needs.

Enter the push for traditional midwifery in the United States.  Seen by some as a move backwards, and see by others as the ultimate in family-centered care. With a wide range of educational experiences, these women define themselves as midwives by the job they do. Every state has them, though not every state recognizes them as midwives.

What Does this Mean to You?

Some women choose not to accept the international definition of the midwife, and instead simply serve the women in their community. These women feel it is more important to serve families than to worry about what the government wants them to do.  Many work as activists to help change government policies. But operating without benefit of  law can be difficult. Spend some time exploring the different ways midwives operate outside the system, and try to change the system.  Check out the Association of Radical Midwives, this article from Midwifery Today and  this brief from Midwives Alliance of North America.

The first topic to explore is the meaning of the word “midwife.”  What does it mean to be called to midwifery?

We could take the internationally accepted definition from the International Confederation of Midwives:

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 practise 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 preventative measures,

the promotion of normal birth, the detection of complications in mother and child, the

accessing of medical care 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 the community. This work should involve antenatal

education and preparation for parenthood and may extend to women’s health, sexual or

reproductive health and child care.

A midwife may practise in any setting including the home, community, hospitals, clinics or

health units.

This is a very thorough definition that includes all the things a midwife may do, but I am not sure any midwife actually does all the tasks listed.

Logistically speaking, creating a universal definition is a tricky thing. What if midwives in one country are given more responsibility than midwives in another? Or what if the roles are simply different?  Did you pick out the requirement that the midwife complete a program that is recognized in the country in which it is located? I am sure this was an important factor because the definition could not negate any laws that require specific training for midwives. But this does leave us with some issues.  For example, what if the program of study completed by a midwife is not recognized by another country when she crosses borders?

This gets even tricker here in the United States where I live because each state has it’s own Midwifery Practice Act.  This means a person who is legally able to practice as a midwife in one state may not be considered qualified to practice in another.  Sometimes it is not a question of training, but instead a difference in scope of practice. What does that mean?  Well, all states allow Certified Nurse Midwives (CNMs) to practice.  But not all states allow the CNM to practice independently for example, in some places she must have a written practice agreement with a physician.

What this means to you

So here you are, hoping to someday become a midwife and not really knowing where to start.  One place to start is to determine what laws regulate midwifery where you live.  This will help you understand what type of training you will need, and in what capacity you will be able to serve families when you officially offer services as a  midwife. Citizens for Midwifery keeps a great listing of the current laws for the United States.  For other countries check with your midwifery council to learn about laws.  Some links are available within their respective countries in the Natural Childbirth Directory.

Once you know about the laws where you live you need to consider how your ability to practice will be affected if you move to another state or want to do midwifery in another country. Every circumstance is different, only you know what your future is likely to hold for you and the probability that international midwifery is your calling.