Midwives have had a long and varied history. For much of history, they were the only health care providers in many areas. Physicians were concentrated around cities or isolated in universities, while the health concerns of the majority of the population were seen to by skilled women in the community who learned through apprenticeship and self study. These days, the term midwife is used almost exclusively in conjunction with pregnancy and women’s health.
Over the course of the last hundred years, as birth changed from happening mostly at home to mostly at the hospital, the role of midwives has continued to shrink. The increasing availability of doctors due to expansion in medical schools and improvements in transportation has reduced consumer demand. Medical organizations have sought to undermine the legitimacy of midwives through negative publicity campaigns and legislative action. The result is that in many states, midwives are severely restricted in their ability to practice or have been barred from practicing altogether.
Recently, midwifery supporters have made progress by increasing the notoriety of midwives and the research that supports their safety. The largest study of planned homebirth with trained midwives ever compiled for the US was released recently and it confirms the safety of homebirth and midwives. While public opinion seems to be shifting in the favor of midwives, some obstacles still remain. The American College of Obstetricians and Gynecologists is against births that occur outside of the hospital. Their position even extends to suggesting that rural hospitals that do not have extensive surgical abilities should also refuse to host women in labor. Though their concerns over safety are commendable, these recommendations are unrealistic.
In states like Alaska, the nearest fully outfitted hospital can be temporarily inaccessible for months at a time. And, of course, there will always be situations out of anyone’s control such as, the increasingly severe weather events related to climate change that can result in displacement of pregnant women and disruption of medical services. Also, there is plenty of evidence that out of hospital births attended by midwives are safer for healthy women than being in the hospital.
To meet the demand for skilled care providers that attend to all pregnant women, midwives must be part of the equation. Their skills and experience in and out of hospital births are important parts of safe maternity care everywhere in the world. Even midwives who practice in the hospital setting, tend to have lower rates of intervention and higher patient satisfaction. Unfortunately, certain restrictions can prevent necessary midwives from getting the training they need.
In states unfriendly to midwives, women who are not either registered nurses or certified through NARM (North American Registry of Midwives) cannot legally practice. Many women who are officially trained and certified may not be able to meet licensing requirements due to the high fee. This not only prevents safe, helpful midwives from being available, it prevents the next generation of midwives from being prepared to attend births in the future.
As midwives continue to be under intense scrutiny from medical groups, large organizations like NARM and MANA (Midwives Alliance of North America) face difficult decisions about how to move forward. Recently, NARM has changed its requirements for midwives who have learned through the apprenticeship model, making it more difficult for women trained by direct entry midwives or at international birth centers to be certified. At a recent conference, MANA members discussed the possibility of moving away from apprenticeship altogether, favoring an approach similar to that of physicians attending regulated universities.
Preparation is a key part of becoming a competent midwife. Apprenticeship within a local community has been the primary method of educating midwives for generations. Many women who enter this field do not have the ability to attend formal school either because of financial restraints, family commitments, or the lack of available schools to attend. In addition, midwifery as a field benefits from the varied experience of its practitioners which keeps innovation and diversity commonplace. Remaining within a community for training ensures that the women who attend births are familiar to the families they work with and tuned in to the needs of the population.
Midwives are not doctors. Most don’t have encyclopedic knowledge of pharmaceutical drugs or an index of the symptoms and frequency of rare complications and obscure diseases. They don’t see dozens of patients in a day, and they do have the luxury of referring high risk women to high risk care providers. Midwives are experts in healthy birth, and they get that expertise through an endless array of educational pathways. Reducing the variety of avenues these women can approach from will narrow the field of candidates and reduce the number of care providers available to an increasing population. The places in the world where midwives are most effective are also the places where they are respected, integrated members of the health care team. They are allowed to balance cooperation with autonomy for the benefit of women and babies. In a country that pays the most in the world for its maternity care, uses more doctors and hospitals for birth than anywhere else, and still ranks 47th in maternal health outcomes, more midwives, in every setting, is the answer.