The midwife is a professional in obstetrics. The term is used in reference to both women and men, although most midwives are female. In addition to providing care to women during pregnancy and birth, some midwives may also provide primary care related to reproductive health, including annual gynecological exams, family planning, and menopausal care. Many developing countries are investing money and training for midwives and other community health workers so that they can provide well-woman primary care services that are currently lacking.
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. In many developing countries, where it is available midwifery is the front-line of maternal health services and provides necessary care in a safe and cost effective manner. In the United States, more women utilize obstetricians rather than midwives, Obstetricians are medical doctors who can provide care not only in healthy pregnancies, but surgical and instrumental deliveries in situations which require them as well.
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.
A 2013 Cochrane review concluded that "most women should be offered midwife-led continuity models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications." The review found that midwife-led care was associated with a reduction in the use of epidurals, with fewer episiotomies or instrumental births, and a decreased risk of losing the baby before 24 weeks' gestation. However, midwife-led care was also associated with a longer mean length of labor as measured in hours.
- 1 Definition
- 2 Etymology
- 3 By country or region
- 3.1 United States
- 3.2 United Kingdom
- 3.3 Canada
- 3.4 New Zealand
- 3.5 Ireland
- 3.6 Netherlands
- 3.7 Japan
- 3.8 India
- 3.9 Balochistan (Tribal Pakistan)
- 3.10 Mozambique
- 3.11 Maya of Guatemala
- 4 Midwife-led continuity of care
- 5 History
- 6 See also
- 7 References
- 8 External links
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. A midwife who is credentialed appropriately is qualified to practice in any setting including in the home, the community, hospitals, clinics or health units.
The midwife also has an important task in health counseling and education, not only for the woman, but also within the family and community. This work may involve antenatal education and preparation for parenthood and may extend to women's health, sexual or reproductive health, and childcare.
The term midwife is derived from Middle English: midwyf literally "with-woman", i.e. "the woman with (the mother at birth), the woman assisting" (in Middle English and Old English, mid = "with", wīf = "woman").
In this context, the word wife means woman rather than married woman. 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.
By country or region
The North American Registry of Midwives (NARM) is the certifying 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. The American Midwifery Certification Board (ACMB) is the certifying body for certified midwives (CMs) and certified nurse-midwives (CNMs).
Midwives work with women and their families in many settings. They 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. Many states have birthing centers where a midwive may work individually or as a group, which provides additional clinical opportunities for student midwives.
Certified professional midwives
A CPM is an independent professional certified by the North American Registry of Midwives (NARM) and adheres to the Midwives Model of Care. The CPM is the only US credential that requires knowledge and experience for out-of-hospital settings. CPM certification process consists of two steps:
- The validation of midwifery education, through one of the following categories:
- Graduation of a midwifery education program accredited by the Midwifery Education Accreditation Council (MEAC).
- NARM's Portfolio Evaluation Process (PEP) pathway.
- Midwifery licensure of a state approved by NARM.
- Midwifery international education.
- AMCB-certification CNM or CM.
- The NARM Written Examination
CPMs have to apply for recertification every three years.
A certified midwife (CM) is certified by the American Midwifery Certification Board (AMCB). The CM route was created in 1997 to provide an alternative entry to midwifery. The CM program is at the post-baccalaureate level. Candidates can apply for admissions to a midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME) with a bachelor’s degree and completion of relevant courses in the sciences. After completion of the education component, CM candidates earn a master’s degree and are eligible to take the national exam toward certification. All CMs must pass the same national certification exam administered by the AMCB. CMs also have to go through a recertification process every five years.
Certified nurse midwives
A certified nurse midwife (CNM) is a registered nurse who has advanced training in women's health care certified by the American Midwifery Certification Board (AMCB). CNMs focus on care of women and their families during pregnancy, delivery, and the postpartum period. They are licensed and practice in every state. CNMs provide physical and emotional support during normal birth, which can reduce the rate of complications and interventions. They practice in hospital, birth center, and home settings, with the majority associated with a hospital or birth centers. CNMs practice with OB/GYN backup. They are taught to identify conditions which are beyond their scope of practice and consult with, or refer to, physician care as appropriate. They also provide well-woman care, including annual exams, birth control, infection checks, and pre-pregnancy counseling.
Currently, licensure for direct-entry midwives is available in 27 states as of 2011.
The US Midwifery Education, Regulation, and Association (US MERA) is made up of individuals from seven national organizations: North American Registry of Midwives (NARM), Midwifery Education Accreditation Council (MEAC), Midwives Alliance of North America (MANA), National Association of Certified Professional Midwives (NACPM), American Midwifery Certification Board (AMCB), Accreditation Commission for Midwifery Education (ACME) and American College of Nurse Midwives (ACNM). These organizations have worked together since 2011 to “envision and work toward a more cohesive midwifery presence inspired and informed by global midwifery standards and competencies adopted by the International Confederation of Midwives in 2011” 
Midwives are practitioners in their own right in the United Kingdom. They 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, in a midwife-led unit or in a hospital (although most births in the UK occur in a hospital). There are two routes to qualify as a midwife. Most midwives qualify via a direct entry course, which refers to a three- or four-year course undertaken at a 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 additional financial support 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. 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.
In December 2014, the National Institute for Health and Care Excellence updated its guidance regarding where women should give birth. The new guidance states: the evidence now shows midwife-led units to be safer than hospital for women having a straightforward (low risk) pregnancy. Its updated guidance also confirms that home birth is equally as safe as a midwife-led unit and traditional labour ward for the babies of low risk pregnant women who have already had at least 1 child previously.
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.
- The Royal College of Midwives
- The Nursing and Midwifery Council is the regulatory body for nurses, midwives and health visitors in the UK.
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 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 role of community midwives include the initial appointments with pregnant women, managing clinics, postnatal care in the home, and attending home births. 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.
Midwifery was reintroduced as a regulated profession in most of Canada's ten provinces 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, 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.
Five provinces offer four-year university baccalaureate degrees in midwifery. In British Columbia, the program is offered at the University of British Columbia. 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 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.
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.
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.
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.
As of August, 2011, the College of Midwives of BC reported 182 General, 3 Temporary, 1 Conditional, 32 Non-practicing Registrant midwives.
There were 2 midwives per 100,000 people in BC in 2006.
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.
Midwives education in BC: The University of British Columbia (UBC) has a four-year Bachelors of Midwifery program. 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.
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.
Women may choose 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 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.)
- The New Zealand College of Midwives, a professional organisation for midwives, representing nearly 90% of practising midwives. Membership is voluntary.
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.
Midwives are called vroedvrouw (knowledge woman), vroedmeester (knowledge master, male), or verloskundige (deliverance experts) 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. 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. 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. Some midwifery practices give additional care in the form of preconceptional care and help with fertility problems.
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.
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.
- The Royal Dutch Organisation of Midwives is the primary midwifery organisation in the Netherlands.
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.
To understand the Japanese model see, Midwifery in Japan by the Japanese Nursing Association.
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History and development of maternal and child health services
Maternal and child health services in India were started with the help of voluntary organizations. Modern maternal and child health work was begun in India by foreign missionaries with an effort to train dais. The time line are as follows:
- 1885 – An association for medical aid by the women of India was established by the Countess of Dufferin.
- 1918 – Lady Reading Health School was started in Delhi, offering health visitors course, which was another stepping stone in MCH Services
- 1921 – Lady Chelmsford League was formed in India for developing maternity and child welfare services.
- 1931 – The Indian Red Cross society established MCH Bureau in association with the Lady Chelmsford League & Victories memorial Scholarship Fund and co-ordinated the MCH work throughout the country.
- Madras was the first state then to set up a separate section for maternal and child welfare in the public health department under the charge of an Assistant Director of Public Health. It was again Madras state which first attempted to replace by the better qualified personnel such as midwives and nurse midwives.
- 1938 – Indian Research Fund Association was established which formed a committee that undertook the investigation into the incidence and cause of Maternal and infant morbidity and mortality. Sir A. Mudaliar was the key person of the committee.
Investigation thus carried out in certain cities of the country revealed that
- Institutional midwifery services were limited
- Maternal and child welfare centre were poorly equipped and staffed
- Untrained dais mostly handled deliveries
This situation continued for some more time. In 1946, the fifth health survey and development committee (Bhore committee) stated in its report that India was facing the problem of high maternal and infant death. It recommended empathetically that the measures for the reduction of sickness and mortality of mothers and 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 – A 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 – The National Programme for Prevention of Blindness was formulated.
- 1977 – Multipurpose health worker scheme was launched
- 1978 – EPI was launched
- 1983 – National Health Policy – MCH and family welfare services were integrated during this policy
- 1985 – The Universal Immunization Programme was launched. A separate department of women and 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
- Child Survival and Safe Motherhood programme (CSSM) was launched on 20 August
- SMI (Safe Motherhood Initiative) programme was started
- The infant milk substitute, feeding bottles and infant food (regulation of production, supply and distribution) act 1992 came into force
- 1995 – ICDS renamed as Integrated Mother and Child Development Services (IMCD)
- 1996 – Pulse Polio Immunization (PPI), the largest single-day public health event, took place on 9 and 20 January 1996. The second phase of PPI was conducted on 7 December 1996 and 8 January 1997
- Family Planning Programme made target free from 1 April 1996
- Prenatal Diagnostic Technique (Regulation and Prevention of Misuse) act 1994 came into force from January 1996
Karbis of Goria Ghuli
The village of Goria Ghuli is an example of a rural and traditional village. It has no electricity or 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”
The Karbis have specialists or healers who are not alike; midwives or ethnogynacologists are one of these specialists. The village has two 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. Traditional midwives are favored in the village. They receive some informal training that is used to help with before, during, and after pregnancy care. This information is transferred from generation to generation. In the village there are 3 ethnogynacologists, which can be approached 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’. 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.
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.
When a 16-year 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.
Maya of Guatemala
Most of the documented evidence has been from San Pedro la Laguna, a Tz'utujil Maya community. 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, to care for the people. They call the midwife, "iyom". The Maya believe that being pregnant is to be "yawa", meaning ill. 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 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. (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.)
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.
According to a Cochrane review of public health systems in Australia, Canada, Ireland, New Zealand and the United Kingdom, "most women should be offered midwife-led continuity models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications." Midwife-led care has effects including the following:
- a reduction in the use of epidurals, with fewer episiotomies or instrumental births.
- a longer mean length of labour as measured in hours
- 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.
Early historical perspective
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.
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. 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. Pliny, another physician from this time, valued nobility and a quiet and inconspicuous disposition in a midwife. There appears to have been three “grades” of midwives present: 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.
Midwives were known by many different titles in antiquity, ranging from iatrinē (Gr. nurse), maia (Gr., midwife), obstetrix (Lat., obstetrician), and medica (Lat., doctor). 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. 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.
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.
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. 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. 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. 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.
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.
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. 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. 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. Despite accusations that midwives were "incompetent and ignorant", some argued that poorly trained surgeons were far more of a danger to pregnant women. 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. 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.
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