Midwife, an Anglo-Saxon term meaning "with woman," aptly describes the role that women have long assumed as birth attendants. Throughout history and across cultures, women have traditionally provided direct assistance and support during childbirth; men were generally excluded. Attendance at birth has been suggested to be essential in facilitating mother-child survival as the physiology of birth changed during human evolutionary history. The upright stance necessary for bipedal locomotion made human birth more complicated than the births of other higher primates, whose quadrupedal locomotion allows a pelvis aligned for the direct descent of the fetal head, whereas the human infant must rotate as it descends through the pelvis, causing pain to the laboring woman. Immediately after birth primate babies can climb onto their mothers’ backs and cling; human infants, born earlier in their developmental cycle because of their larger brains, are relatively helpless at birth and require immediate nurturance. These factors encouraged the evolution of birth as a highly social process; in few societies do women give birth alone and unaided. Indeed it is reasonable to assume that midwifery must have evolved right along with Homo sapien birth. The presence of other females would have enhanced the success of the birth process as they acquired such skills as turning the baby in utero, providing emotional support to the mother through the pain of labor, assisting rotation of the head and shoulders at birth, massaging the mother’s uterus, and administering herbs to stop postpartum bleeding. Such skills typify the traditional midwifery of thousands of cultures throughout human history.
The birth attendant is not always a specialist, and some cultures do not have specifically delineated roles for midwives; in Nepal and Bangladesh, for example, family members are often the ones to care for the birthing mother. But thousands of traditional societies, and the vast majority of industrialized societies, do have a specific category of career that translates into English as midwife. Broadly speaking, a midwife is defined as a skilled practitioner who cares for the mother during pregnancy, birth, and the postpartum period and is recognized by her government or her community as such. In traditional societies midwives often serve additional roles as community healers, and in industrialized societies as specialists in primary health care, gynecological well-woman care, and sometimes also in complementary therapies such as homeopathy, herbalism, and nutrition.
According to the International Definition of a Midwife endorsed by the International Confederation of Midwives (ICM) and various development agencies, the midwife’s sphere of practice generally includes supervision, care, and advice to the pregnant woman; attending births on her own responsibility; caring for the newborn and mother after birth; identifying risks or abnormalities; taking preventive measures; procuring medical assistance when necessary; and dealing with emergencies in the absence of medical help. She also takes an active role in counseling and education not only for women but also for families and communities. She may practice in hospitals, clinics, health units, freestanding birth centers, homes, or any place her services are needed. Her government, her community, insurance companies, or individuals may pay for her services; traditional midwives often barter for their care, accepting whatever the family might offer.
OBSTETRICS AND MIDWIFERY
Throughout the world, during the nineteenth and twentieth centuries, biomedical obstetrics took over much of the care and "management" of pregnancy and birth. Biomedical personnel tend to attribute the dramatic decline in maternal and infant mortality of the twentieth century, especially in developed countries, to medical and technological advances. Yet public health experts insist that much of this decline is due to public health measures such as improvements in sanitation and hygiene, better nutrition, higher education, and better working conditions for women. They note that in the developing world, clean water would do far more to promote maternal health than the expensive high-tech hospital. Nevertheless, biomedicalization equates to modernization, so such hospitals continue to be built in modernizing countries, and governments continue to encourage or insist that women give birth in them.
One direct result is that the rates of obstetrical intervention in birth are rising worldwide. For example, national cesarean rates in Taiwan, China, Brazil, Argentina, Chile, Mexico, and Puerto Rico are between 40 and 50 percent. In the United States, the cesarean rate has risen since the early 2000s from 23 percent to 29.1 percent; most European countries, Canada, and Australia have cesarean rates in the mid-20 percent range. Although professional midwives attend the majority of births in some of these countries, they are biomedically socialized and often overworked, and have been unable to stem the rising cesarean tide, which is largely obstetrician-driven. The exceptions include the Scandinavian/Nordic countries and Japan, where cesarean rates range from 12 to 17 percent; in those countries, both midwives and obstetricians have worked hard to preserve normal vaginal delivery.
Obstetrical dominance over birthing represents not a neutral substitution of one care provider by another, but rather a fundamentally different and opposing philosophical approach to birthing care—one that takes a mechanistic approach to birth, treating the laboring body as a dysfunctional machine unable to work properly without technological intervention. The high rates of unnecessary intervention in birth and the resultant iatrogenic damage to mother and child have spurred professional midwives around the world to develop, articulate, and practice a "midwifery model of care"—a woman-centered, humanistic, and physiological approach to birth based on respect and compassion for the woman, and on the large body of scientific evidence that demonstrates the much better outcomes that result when the woman is encouraged to birth in the place of her choice, to move about freely, eat and drink at will during labor, and give birth in upright positions. Application of this model has been shown in multiple studies to result in far less technological intervention in birth, greater maternal satisfaction, higher rates of breast-feeding after birth, and low rates of cesarean section and perinatal mortality.
In Europe and Australia, midwives have always been and continue to be the primary attendants at the majority of births, yet during the 1900s their education became heavily medicalized and their practices moved almost entirely into the hospital. In Canada and the United States, the obstetrical takeover of birth in the early 1900s resulted in the near-elimination of midwifery. In all these countries, home birth has become rare (around 1% of all births) in spite of much evidence demonstrating planned, midwife-attended home birth to be as safe as, or safer than, hospital birth for women without serious complications. Many professional midwives are engaged in a process of self-examination, attempting to reclaim the autonomy they lost with the obstetrical takeover of birth in the nineteenth and twentieth centuries, to return to attending out-of-hospital births at homes and in birth centers, and to work in nonhierarchical collaborative relationships with obstetricians.
NURSE- AND DIRECT-ENTRY MIDWIFERY
The early British combination of nursing and midwifery has long been the model for the profession of nurse-midwifery in many developed and developing nations, but many have come to critique this model because education in nursing first tends to heavily socialize midwives into the hierarchical, interventionist biomedical model of birth. Such critics have worked to generate or regenerate direct-entry midwifery, in which midwives are not first educated in nursing, but instead are educationally grounded in the midwifery model of care. The best-known example of this kind of midwifery comes from the Netherlands, where for centuries midwives have been trained in their own midwifery schools and have enjoyed full integration into the health care system as autonomous practitioners, maintaining in the 2000s a 30 percent home birth rate in their country. Since the 1970s midwives in Canada, the United States, Australia, New Zealand, Mexico, and other countries, inspired in part by the Dutch model, have developed new models of direct-entry education and autonomous practice for midwives based on the midwifery model of care. This reclaiming and revitalization of midwifery has resulted from alliances between activist consumers, mid-wives, public health officials, and many others working to humanize birth.
TRADITIONAL AND PROFESSIONAL MIDWIVES
There is a sharp distinction made in international literature and discourse between professional midwives and traditional birth attendants (TBAs). The definition created by the professional midwives of the ICM stresses the completion of prescribed course(s) of studies in midwifery and registration and/or legal licensing to practice midwifery.
Professional midwives who meet these criteria, including both nurse- and direct-entry midwives, are usually fully incorporated into health care systems. Traditional midwives, who still attend the majority of births in many developing countries, have no such formal education; they suffer multiple forms of discrimination within biomedical systems. The World Health Organization (WHO) does not recognize the traditional midwife as a midwife, but rather as a TBA—"the term TBA refers only to traditional, independent (of the health system), non-formally trained and community-based providers of care during pregnancy, childbirth, and the postnatal period" (WHO 2004, p. 8). WHO suggests that TBAs are stopgap measures until more "qualified" personnel are available (and indeed, traditional midwives have been largely eliminated or greatly reduced in number and scope of practice in, for example, Thailand, Costa Rica, Venezuela, Argentina, Chile, and Brazil, with the exception of the Amazon region). Health authorities tend to accept this distinction, while social scientists reject or contest it, examining the social roles of definitions as tools of power to determine insiders and outsiders, and studying and documenting the vital roles traditional midwives still play in many societies.
Since the mid-twentieth century nongovernmental organizations, multilaterals, and bilaterals have invested heavily in professional midwife and TBA training in their efforts to reduce maternal and perinatal mortality in the third world. The social science of midwifery grew out of this trend, and reflects social scientists’ roles in analyzing training programs for development organizations and the impact of new models on both quality of care and health outcomes. Social scientists find that women trained as professional midwives are usually young and have borne no children themselves. In developing countries, they are educated in an urban environment, usually in two-year programs, then sent out to serve in a rural village, where they wear the white coat and expect respect from the townspeople for their professional, educated status. They usually work in underfunded and understaffed government-built clinics, but for an extra sum of money will sometimes attend a home birth if they are called. Workloads and stress levels in such clinics are high, often resulting in maltreatment of women and early burnout on the part of the professional midwife.
Thus even though the governments of almost all developing countries have embarked on massive programs to bring birth into the clinics and hospitals under the care of professional midwives and obstetricians, many rural women resist because of inadequate and impersonal care. For example, women are forced to birth flat on their backs in very exposed positions, usually receiving an episiotomy to widen the vaginal outlet and speed the birth. To the apparent bewilderment of governments and biomedical personnel, many women in developing countries prefer the more nurturing and culturally appropriate care provided by the local traditional midwife/TBA, usually an older woman who has given birth several times and has earned the respect and trust of her community through years of midwifery practice.
Training courses intended to educate TBAs in how to identify risks and to improve their prenatal and maternity care have been strongly criticized. Designed by biomedical personnel, course content is often inappropriate to local circumstances and realities. Courses often assume access to material resources that are lacking locally, are taught in a style inappropriate to the literacy skills and learning styles of midwives, and fail to provide TBAs a respected and effective place within an integrated system of medicine. Additionally, TBA trainings emphasize transporting the woman to a hospital for a large number of risk factors, in places where transport is often unavailable and hospital care is inadequate. Traditional midwives take such courses to seek additional skills to cope with emergencies; in many countries, traditional midwives are very aware that their community-based care is the only viable alternative to an unnecessary cesarean and an unpleasant hospital experience.
In some places, professional midwives and physicians scorn and denigrate TBAs, treating them and their clients disrespectfully when they transport to a hospital or clinic. But sometimes professional midwives make a sincere effort to learn about and honor local customs and traditions, approach local people with an attitude of respect, and cooperate with traditional midwives; in such situations of mutual accommodation between the biomedical and traditional systems, TBAs and their clients are more willing to transport to the hospital in case of need, and birth outcomes improve.
It is important not to romanticize or demonize professional or traditional midwives. Both work under discriminatory biomedical systems and both usually try to give skilled and considerate care and remain, in many parts of the world, the only viable option for millions of women. Social scientists question the wisdom of dividing professional midwives and TBAs in a hierarchical manner that allows government agencies and development planners to support one group while trying to exterminate the other, suggesting that a "real midwife" may be recognized either by her government or her community as such, and that all midwives should have access to adequate, scientifically based, and culturally appropriate training.
Changes in midwifery in the developing world are intimately linked to debates over midwifery in the developed world, where professional midwives provide care for the majority of pregnant women. Their education is generally university-based and often postgraduate, giving them skills in research and publication unavailable to midwives in the developing world. They practice in hospitals that are usually well staffed, well funded, and replete with medical technologies. Their major dilemmas are ideological: they struggle both in thought and in practice with the tension between what they themselves call the "medical" and the "midwifery" models of care. Many professional midwives are working to support and sustain traditional midwifery and its future development. Many weave elements of traditional midwifery knowledge, such as the use of herbs for aiding labor or stopping a postpartum hemorrhage, manual techniques for turning breech babies and facilitating the delivery of "stuck" babies, and upright positions for birth, into their practices.
In general, midwives spend more time than physicians with women during pregnancy, answering their questions and providing emotional reassurance, and know more about how to facilitate normal labor and birth without drugs or surgery than obstetricians. The vast body of epidemiological evidence demonstrating the benefits of midwifery care in many countries will prove key to mid-wives’ maintenance of their roles and their identities as being "with women" in the new millennium.
