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The Midwife Midwifery is one of the oldest professions in
history. In English, the word midwife means "with woman", in French, "sage
femme" (wise woman) and in Latin "cum mater" (with mother) (Sweet, 1997).
Whatever the language the role of the midwife relates to being with the
woman at the time of her childbearing. Midwifery is a unique profession
and midwives have a unique role to play when caring for the mother, and
her baby.
A midwife is a person who, having been regularly admitted to a midwifery educational program, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery.The midwife is able to work in the community and hospital and can provide the necessary care, support, education and advice to women during pregnancy, labour and the postpartum period, and care for the newborn. Primary care is an important function of the role since the physical and psychosocial aspects of the woman and her family are catered for. This care incorporates information on family planning, care of the newborn and infant and integration of the newborn into the family. The midwife must be able to detect deviations from the norm and deal with an emergency situation until medical help arrives. Thus, according to Page (1993) the "midwife must be a confident and competent practitioner, able to work in and through relationships with the woman, and her family, and sensitive to their individual needs" (p. 21). Midwifery Practice Through Time Midwifery is an ancient art traditionally conducted by women with no medical training and quite often with little education. Many civilizations, including the Romans, Greeks, Asian and old European, have data relating to the midwife, her role and place in society. The Aboriginal community also had their midwives to conduct "women's business" and still have today. Mediaeval times were a dangerous period for midwives as they were thought to be witches and burned at the stake. Modern times have also proven to be a hazardous time for some individuals. This campaign against the practice normal midwifery remains as the struggle to control pregnancy and birthing continues. This is illustrated so potently by Wagner (1994) in the following passage for his book, Pursuing the Birth Machine: ... an unmarked police car pulled up infront of a midwife's house in the United States. A plain-clothes police officer and government officials searched the house, jailed the midwife on charges that she was practicing independent midwifery, and separated her from her breast feeding infant.The above incidents and quote occurred in the same year that The Netherlands could boast that one-third of all births were home births. Significantly, The Netherlands has a lower rate of perinatal mortality than the United Sates. How then did the medical men take over an area of care that for centuries was conducted by women, when generally midwives were revered and allowed in practice in peace. Not until 1886 were medical practitioners required to be qualified in midwifery. Midwifery was not a part of medical science because pregnancy was not considered a disease state. Doctors, however, began to realise that midwifery was an area that they could dominate - but they had to get rid of the midwife who at that time conducted the majority of births. The specific aim of their strategy was to dismantle the credibility of midwives. Firstly, they proclaimed that they were the experts and secondly, they accused midwives of being uneducated, dirty and had a liking for gin. Indeed, Charles Dickens description of Sairey Gamp remains the stereotypical portrait of midwives at that time. Thirdly, "lying-in" hospitals were introduced so that women would deliver there out of reach of the midwives and of course, midwives were not granted access. The medical men were successful in their campaign and it became fashionable to have a male-midwife in attendance. Doctors directed their practice toward the middle and upper classes, were a fee was charged. The midwife continued caring for the poor in the community. (Willis, 1989: Cochrane, 1995). The two-tiered health care system had begun. Once their dominance in midwifery was established the medical fraternity began another campaign, this one was to achieve that all women would give birth in hospital. They lobbied relentlessly for their target of 100%. Home birth would soon become outdated, when once they were the norm, conducted by the local midwife who was well known and respected in the community. In the United States in 1940, 44% of all births were outside of the hospital - by 1970 this figure was 1%. In the United Kingdom in 1940 50% by 1970 10%. Remarkably in 1990 the Netherlands home delivery rate was 35% (Wagner, 1994). As stated earlier, The Netherlands has the lowest rate of perinatal mortality, yet obstetricians continue to proclaim that hospitals are the safest place to have a baby. This misguided obeisance to the demands of obstetricians brought about further demise of the midwife. The historical account of midwifery is very interesting and it is recommended that you review the literature to understand how the shift of power began and how it effected midwifery practice. It was unfortunate that midwives neglected to write down accounts of their work or make journals to hand on the knowledge of midwifery. This transfer of information was by word of mouth, being with the midwife and watching and learning. Significantly, the potency of knowledge and literacy gave the medical men their powerful platform. The medicos produced scientific literature and began to catalogue their take-over and ultimate dominance of midwives, women and childbirth (Willis, 1989). Midwifery Practice in Western Australia It is assumed that hospital is the safest place to give birth (Alexander, Levy & Roch, 1990). Obstetricians proclaim that the decrease in the perinatal mortality rate is because nearly all women give birth in hospital. Indeed, increase in technology is acclaimed as having a positive impact on outcomes. You may want to flip the coin and question if this is so. Technology is big business and childbirth is a lucrative part of the health industry. Elaborate beds and birthing stools are marketed to provide comfort in labour - yet an inexpensive beanbag can do the same at minimum cost (Wagner, 1994). Cardiotocograph monitors (CTG) were introduced with no scientific evidence yet, it was proclaimed, they would improve outcomes. On this premise, these machines appeared in every delivery room in most towns and cities throughout Europe, America and here. Everyone wanted the machine that went "ping" and the delivery room became the "fetus frightening room" (Monty Python, The Meaning Life). It was not hospital births or the obstetrician expertise that improved maternity and perinatal outcomes it was the improvement in housing, sanitation and nutrition - thus the population became healthier (Wagner, 1994). Perpetuation that childbirth is unpredictable is reflected in how women are catagorised into groups. To remove the idea of normality of birth semantics are used to the advantage of the obstetricians. Within midwifery practice, women were described as normal or abnormal (according to factors related to their pregnancy), now they are termed low and high-risk, these categories reflect an element of risk in ALL pregnancies. It would seem that normal is not an option. In Western Australia during 1995, there were 128 stillbirths and 59 neonatal deaths (Gee, 1996). The perinatal mortality rate being 7.4/1000 of total births (Gee, 1996, p.49). In the last 10 years, there has been an overall decline in stillbirth, neonatal and perinatal mortality rates. However, Aboriginal rates continue to be double that of Non-Aboriginals (Gee, 1996). If this degree of loss within the non-Aboriginal population would it be tolerated? These figures indicate a disparity to provision of care and this reflects on the outcomes. The table below displays the figures for 1995 in Western Australia (Gee, 1996, p.49). The majority of stillbirths occurred in metropolitan
teaching hospitals (80.5%), however, most high risk pregnancies are referred
to metropolitan teaching hospitals, hence the higher percentage of perinatal
mortality rates compared to other areas. Gee (1996) also points out that
62.5% of stillbirths were of low birth weight. The neonatal mortality rate
for multiple births was four times the rate for singleton births. Multiple
births rate being 8.8/1000 and singleton birth rate 2.2/1000 (Gee, 1996).
In 25.8% of stillborn babies, the cause of death was unknown. Other identifiable causes were birthweight less than 1000grams (18.8%) and birth defects incompatible with life (12.5%). Intervention and caesarean section rates have increased significantly over the last 20 years. In 1995 the caesarean rate was 20.3%, with assisted deliveries, including; forceps, vacuum extractions and breech, at 15,2% (Gee, 1996). These figures are quite extraordinary in a population that is, in the majority, well nourished and healthy. It is formidable to contemplate that these figures can rise even further and if so will there be any resistance to facilitate a return to normality. Mr Foss, the West Australian Minister of Health
in 1993 and 1994 lobbied the Federal Government for a Medicare rebate for
families who elected a home birth. Mr. Foss had experience of home birth
as his three children were delivered with the independent women in attendance.
This petition, however, incensed the Conservative Medical Association and
Mr. Foss has had a difficult time since then (Lecky-Thompson, 1995).
Midwifery Practice It is unfortunate that the medicalisation of childbirth meant that most midwives have lost the knowledge and skills, particularly in actual care and delivery of mothers. Furthermore, it is lamentable that many Australian women are not aware of the role of the midwife (Murphy-Black, 1995). However, many Australian midwives are working hard to reestablish midwifery as a recognised, unique and independent profession that provides high quality midwifery care. The fight back started when we, as midwives, began to look at our own practice and the medical driven demands we inflicted on mothers and babies. Midwives used the power of knowledge - our practices were audited - and research projects were implemented. From this research many changes have been made, from ceasing to shave women (for the doctors convenience so the perineum could be visualized to suture) and the awful enema. Areas of practice investigated included; use of birthing stools, bean bags, water births, management of the first, second and third stages of labour and cord care, to name a few. Today practice is becoming more evidence-based rather than old routines and habits - but there is still more work to be done. Many skills that midwives once were recognised and acknowledged for are now dominated by the medical profession (Bogossian, 1998). One area that has been a "bone of contention" for sometime is to allow midwives to order tests and drugs for mothers. The National Health and Medical Research Council (NHMRC) recommend that midwives, as part of ongoing care for uncomplicated pregnancies, be approved to order drugs and tests. However, this recommendation only applies to midwives working within hospitals - independent midwives are still exempt (West Australian, 1998). Although a development, hospital based midwives are still bound by policy and medical orders of the obstetricians, therefore, to implement this recommendation could be problematic. The Way Forward Midwives view pregnancy and birth as normal life events and believe that women should be active participants in their care, that is, they work with women as opposed to on women. Holly Powell-Kennedy (1995) has published the results of a most interesting qualitative study that aimed to discover the experience of the woman cared for by midwives. The study is important for several reasons. Firstly, it demonstrates how qualitative research lends itself to investigating the complex knowledge that underpins midwifery. It is important that midwives do not blindly follow their medical colleagues who seem to believe that a positivistic paradigm is the only route to the acquisition of knowledge. Secondly as Powell-Kennedy points out '(t)o increase knowledge about women and birth one must explore from the woman's perspective what it is that aids and comforts her in not only her birth experience but in aspects of her health' (Powell-Kennedy, 1995, p.410). Powell-Kennedy found that women articulated how the midwives respected their time, families, fears and need for information. It was this respect from the midwife that empowered the women to determine and direct their care (1995, p.410). Review the following themes and make notes on thoughts of their meaning as they relate to you as a midwife and midwifery practice. Use your journal to reflect on these issues as they may change over time, as you become more familiar with midwifery practice and confidence as a midwife. The themes that emerged from the data were as follows:
The woman felt cared for within the domain of her family; the family's needs and potentials were always considered in relationship to her. Development of a caring relationship built on mutual respect, trust and allianceThe qualities and behaviours of the midwife laid the foundation for the richness of the woman's experiencA sense of safety encompassed the woman's trust in the midwife's knowledge and ability; Time that most valued commodity, was both given and respected by the midwife; The woman (and her family) felt guided in her decision-making and actions based on the information provided by the midwife; The health and normalcy of pregnancy were the presiding focus of care; A continuous link with the midwife was repeatedly demonstrated to the woman throughout her care experience Mayes' Midwifery (1997): Chapter 18: Choices and Patterns of Care (pp. 203-204 read under the heading Philosophy of Care). Bogossian, F. (1998). A review of midwifery legislation in Australia - history, current state and future directions. ACMI Journal, 24-31. |
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