Introduction
Introduction to the Problem of Childbirth in the US
The state of pregnancy and childbirth in the US raises significant concerns, as highlighted by the 2009 CDC "National Vital Statistic Report," which notes a decline in first-trimester prenatal care, alongside rising rates of induced labors, Caesarean sections, preterm births, low birth weights, and teenage pregnancies These alarming statistics reflect systemic healthcare issues and underscore the malpractice crisis faced by obstetricians, who are burdened by escalating insurance costs and diminishing reimbursements Consequently, many obstetricians are exiting the field or prioritizing quantity over quality in patient care, leading to a decline in the standard of childbirth services To address these challenges, it is essential to reevaluate the approach to childbirth in the US by exploring non-obstetrical care models from both domestic and international contexts.
Midwifery is a holistic approach to care that prioritizes the health of women during pregnancy, childbirth, and breastfeeding, viewing these processes as natural rather than pathological Unlike obstetrics, which often focuses on complications, midwifery emphasizes preparation and support for expectant mothers This field is crucial for addressing maternal and child health, technology use, female empowerment, spirituality, and cultural practices The article will explore the history of midwifery in the US, England, and Ontario, Canada, as well as the government support for traditional birthing practices in Aboriginal and Cambodian communities This examination aims to highlight the diverse cultural and governmental approaches to midwifery and to shed light on the challenges present in the US healthcare system.
Birth, Technology and Safety in Research
Midwifery, while the standard birthing model in most developed countries, is less commonly used in the US, where only 11.3 percent of vaginal births were attended by midwives in 2006 Despite higher spending on maternity care and advanced technology in the US compared to other developed nations, the infant mortality rate remains alarmingly high This discrepancy highlights a significant gap between scientific evidence and clinical practice in the US, as evidenced by various maternal and infant health indicators.
A 1991 study examined vaginal births in the US at 35 to 40 weeks gestation, comparing outcomes between midwives and obstetricians After adjusting for risk factors, the research revealed that midwives achieved significantly lower rates of infant and neonatal mortality, as well as improved birth weight outcomes (DeVries et al., 2001) Additional studies have consistently shown that midwife-attended births also result in reduced rates of Caesarean sections, episiotomies, and severe lacerations compared to those attended by obstetricians (Marland).
Women, caregivers, and scholars have identified key differences between obstetrical and midwifery practices that influence maternal confidence and empowerment Feminist theorists like Jean Donnison and Ann Oakley argue that the transition from home births to hospital deliveries reflects an effort to subordinate women within a male-dominated medical system This shift results in women and female caregivers relinquishing their autonomy and control over their bodies Additionally, scholars such as Margaret MacDonald emphasize the significance of "space" in understanding these differences in childbirth practices.
Research has explored the differences in female control and power during obstetrical and midwifery births, highlighting significant variations in language used within these practices Analyses of gendered knowledge indicate that obstetrics tends to focus on terms like "goals," contrasting with the more collaborative language often found in midwifery.
“intervention” and “examination,” midwifery focused on “acceptance,” “process” and
Obstetricians often use language that emphasizes managing pregnancy, while midwives focus on portraying it as a natural process (Pitt, 1997) The midwifery model prioritizes educating women, empowering them to make informed decisions about pregnancy, birth, and motherhood In contrast, obstetricians face time constraints that limit their ability to provide extensive education during visits Active participation and informed decision-making are essential for women to feel empowered during pregnancy and birth (Rook, 1997), leading to increased positivity, confidence, and a sense of control (MacDonald, 2007; Mander, 2001).
In many cultures, such as the Mohawk Native Americans and Native Cambodians, spirituality plays a vital role in pregnancy and childbirth, yet it is often overlooked in mainstream American healthcare discussions Ina May Gaskin, a prominent midwife, highlighted the significance of spirituality in these experiences with her influential book, "Spiritual Midwifery," published in 1975, which has sold over half a million copies Now in its fourth edition, Gaskin emphasizes the interconnectedness of mental, emotional, and physical health for mothers and their babies, stating, “Since mind and body are One, sometimes you can fix the mind by working on the body and the body by working on the mind” (Gaskin, 2002, p.340) She also underscores the importance of physical connections between mothers and their partners, noting that intimacy during labor can facilitate the birthing process Furthermore, Gaskin advocates for a strong bond between mothers and midwives, as it cultivates trust, relaxation, and a sense of support during childbirth.
Gaskin blends Christian, Jewish, and Buddhist teachings in her exploration of spirituality, viewing birth as a sacred event She provides practical guidelines for sustaining positive energy during labor, ensuring a successful birth experience where the baby enters the world feeling cherished.
Gaskin uses detailed explanations and diagrams of anatomy and physiology to support her understandings of spirituality during childbirth
Midwifery is a comprehensive approach to maternity care that includes various practices In the United States, contemporary midwifery features certified nurse-midwives (CNMs), lay midwives, direct-entry midwives (DEMs), and certified professional midwives While midwifery has historical significance, particularly in the southeastern US, its presence diminished significantly by the late twentieth century (Rooks, 1997).
Certified Nurse-Midwives (CNMs) are registered nurses who have completed a midwifery education program and passed a national certification exam regulated by the American College of Nurse-Midwives (ACNM) Typically holding a master’s degree or higher, CNMs are legally authorized to practice across all US jurisdictions Their scope of practice encompasses the independent management of women's and infants' health during normal pregnancy, labor, delivery, and the postpartum period, as well as providing gynecologic examinations and family planning services CNMs operate within the healthcare system, offering consultations, collaborative management, and referrals, and are often employed by hospitals or free-standing birth centers.
(“About the midwifery profession,” 2005; Ventura, 1996) The CDC reports that in
2006, 94.3 percent of midwifery births were attended by CNMs, most of which were in hospitals (Martin et al., 2009)
The Midwives Alliance of North America (MANA) distinguishes between lay midwifery and direct-entry midwifery, clarifying that lay midwives are uncertified or unlicensed practitioners who have acquired their skills through informal training, such as self-study or apprenticeship.
Direct-entry midwives are independent practitioners trained in midwifery through various means, including self-study, apprenticeships, or formal education programs distinct from nursing Both lay and direct-entry midwives provide essential care to women during pregnancy, childbirth, and the postpartum period, offering health counseling and guidance on natural and barrier contraception methods They often collaborate informally with physicians to ensure comprehensive care for their clients.
Certified Professional Midwives (CPMs) are recognized by the North American Registry of Midwives (NARM), which established a certification examination process in 1994 to ensure the competency of direct-entry midwives ACC Certified Midwives (CMs) complete comprehensive midwifery education programs and undergo evaluation by the American College of Nurse-Midwives (ACNM), which accredits them based on standards of nurse-midwifery care without the nursing component Additionally, Licensed Midwives (LMs) are direct-entry midwives legally recognized by their respective states, with licensing laws varying across different states.
A Brief History of Midwifery in the US: Eighteenth through Twentieth Centuries
Historically, childbirth has predominantly been a woman's responsibility, with knowledge about the process being passed down through generations (Robinson, 1984; Rook, 1997, p 18) In colonial times, women maintained traditional English birthing rituals, often surrounded by female friends and family who offered comfort and support during labor (Wertz & Wertz, 1989).
1989) Midwives also contributed significantly to social childbirth because they offered reassurance for having witnessed births before
Some midwives were licensed in some colonial cities, however most practiced without regulation (Rothman, 1983) Even so, they were granted community recognitions and benefits (Wertz & Wertz, 1989)
Methods
This study aimed to investigate the interplay between midwifery training, personal philosophy, and practice location, seeking to understand how these factors influence the care provided by midwives Specifically, it focused on the integration of medical technologies, spirituality, and empowerment in midwifery care, while addressing the challenges associated with childbirth in the United States.
The study aimed to explore the experiences and beliefs of midwives, utilizing qualitative methods to capture the depth of their insights An unstructured interview approach was employed, allowing for a flexible dialogue that encouraged midwives to express their thoughts freely without the constraints of predetermined questions This method facilitated a deeper understanding of the issues relevant to the midwives' experiences, as their responses were shaped by the broad topics introduced by the interviewer (Guba & Lincoln).
The unstructured interview method highlights the interviewee's comprehension of their circumstances, allowing them to present their narrative based on what they find significant (Dexter, 1970) Grounded in constructivist principles, this approach acknowledges that individuals form their own realities and truths, shaped by their unique life experiences, even while sharing cultural and value-related commonalities (Guba & Lincoln, 1998) Rather than using participant insights to validate pre-existing hypotheses, the emphasis is on the richness of these perspectives and the researcher's skill in synthesizing and organizing this information (Glaser & Strauss, 1967; Strauss & Corbin).
1990) This approach supported the goals of the study because of the flexibility and creativity required of the researcher
Due to the small sample size of participants, quantitative methods would have been unreliable and could have led to the loss of valuable descriptive information Additionally, quantifying characteristics like philosophy and spirituality would have posed significant challenges.
Midwives in Ithaca were primarily located through community sources, including personal recommendations and interactions at a local birth-education fair Their familiarity with one another and shared connection to the Ithaca community fostered a common ground among them This word-of-mouth recruitment method is typical for families in Ithaca seeking midwifery services, enhancing the sense of authenticity in their connections.
Midwives were invited to participate in the study through letters and emails, resulting in four midwives agreeing to interviews conducted in accordance with the approval of the Cornell University Human Subjects Committee.
Interviews were conducted in October and November 2008, lasting between one to two hours and recorded with participant consent The discussions encompassed various topics, including personal background, lifestyle, caregiving, professional challenges, comparisons with obstetrics and hospital births, as well as cultural and community aspects While all subjects were addressed, midwives had the flexibility to focus on the issues they considered most significant and were encouraged to share any additional insights they felt were important.
After the interviews were completed, clarifications and follow-up questions and responses were obtained through email
The interviews were paraphrased and partially transcribed, with time markers added for easy reference to the tapes The analysis revealed themes through flexible coding, focusing on the midwives' experiences without statistical analysis Utilizing the constant comparative method, emergent ideas were categorized and compared, facilitating creative insights into the nuanced relationships identified in the interviews Additionally, various schematics were created to visually represent the connections between different aspects of the midwives' experiences and their training, enhancing the overall understanding of their practices.
The unstructured interview format effectively addressed the research questions by allowing midwives to speak freely, minimizing researcher bias This approach enabled midwives to express themselves in their own language, rather than conforming to the researcher’s terminology Consequently, the study was enriched as the midwives' language revealed their values, philosophies, and unique perspectives.
Interviews conducted in the midwives' offices and homes fostered a sense of comfort and openness, as they felt "in their own territory." This informal setting likely encouraged the midwives to share personal insights and experiences during the discussions.
The study's small sample size enabled detailed interviews; however, including more participants could have enhanced the findings The limited number of interviews prevents broad conclusions about midwifery as a whole Additionally, varying comfort levels among participants in discussing topics like finances pose a significant limitation to the research.
Results
This section delves into the backgrounds of each midwife, highlighting their educational qualifications, work experience, and current practice details To ensure privacy, names and identifying information have been altered The midwives are presented in order of their hospital involvement, beginning with those most engaged in medical institutions.
Lily's office, located across from a medical center, occupies the second floor of a renovated barn, featuring a spacious waiting room adorned with images of families and equipped with comfortable couches The area is complemented by a receptionist who manages appointments and greets clients, while a small playroom for children and several clinical offices are also present After a tour of the facility, the interview took place in a well-furnished office, showcasing a bookshelf, desk, and walls decorated with framed diplomas and medical certifications.
Lily received a Bachelor of Arts in Psychology at Cornell University in the 1970s. She studied nursing at Hudson Valley Community College where she earned an
Associate in Applied Science degree in the 1980s She then attended the Regents
External Program She culminated her formal education in Midwifery at University of Pennsylvania where she received a master’s in nursing
Lily transitioned from a career in television to nursing after experiencing a "career crisis," realizing she had more knowledge about cars than her own body despite growing up with the book *Our Bodies, Our Selves* She opted for a two-year nursing program for its short-term commitment and flexibility During her time on the obstetrics floor, she discovered her passion for labor and delivery, leading her to pursue a master's degree in childbirth.
Lily has a degree as a certified nurse midwife She is a registered nurse with special training that allows her to care for pregnant women.
Lily bridges the gap between the medical community and traditional midwifery through her hospital-based practice, where she feels secure with the available technology, even when opting for natural birth methods She believes the hospital setting is ideal for many women, allowing her to facilitate natural births while also providing pain relief when necessary With her group performing forty percent of the hospital's vaginal births, she collaborates with six physicians and four midwives, working four days a week that include two office days and two twenty-four-hour call days, followed by a day off This group practice offers her flexibility and support, enabling her to pass on labor to colleagues when needed Despite the demanding hours, Lily has learned to manage her sleep effectively, a skill honed in the operating room, and finds the rewarding connections she builds with her patients, often encountering them in her local grocery store.
Lily appreciates the advantages and disadvantages of working in a ten-person midwifery practice She values the reassurance that her patients will never be alone during delivery, as there is always a midwife available The practice ensures effective communication among midwives, allowing most pregnant women to meet all the midwives before their delivery In some cases, a midwife can "special" a patient to increase the likelihood of being present at the birth Lily particularly enjoys delivering babies for patients she has previously worked with However, she acknowledges the downside of having multiple healthcare providers, as some women may be attended by a midwife they have only met a few times, which could be unsettling for some Despite this, Lily remains unconcerned about the situation.
Lily, who works in an office and makes hospital deliveries, enjoys a steady salary but faces soaring malpractice insurance costs, which have skyrocketed from $1,500 to $30,000 annually Although this amount is still lower than what obstetricians pay, her reimbursement rates do not match those of physicians She notes that midwives struggle to advocate against increasing malpractice insurance rates due to their lack of organization and political influence compared to doctors.
Role as a Midwife/ Types of Care
Lily, a midwife, primarily begins her role at the onset of pregnancy, providing comprehensive care throughout the entire pregnancy and continuing until the final office visit four to six weeks post-birth However, due to insurance restrictions, she is unable to maintain contact with her clients in a home setting.
Lily believes that home visits can effectively address breastfeeding challenges, postpartum depression, and other overwhelming issues new mothers may face after childbirth She encourages her clients to reach out to her for support whenever they encounter difficulties.
Lily, a nurse midwife, provides comprehensive gynecological services, including yearly exams, pap smears, birth control prescriptions, and STI diagnoses and treatments, along with referrals for mammograms She offers primary care services, such as cholesterol tests, and often serves as the sole healthcare provider for her patients Advocating for holistic approaches, she supports acupuncture and herbal medicine, connecting patients with community resources Specializing in normal births, Lily refers patients with abnormal pregnancies, such as those requiring surgery or experiencing miscarriage, to obstetricians For high-risk pregnancies, including twins, hypertension, or diabetes, she collaborates with obstetricians, leveraging her expertise in non-surgical deliveries Lily emphasizes the importance of patient relationships, stating that her attentive care allows her to identify potential issues, and she enjoys a strong, respectful partnership with obstetricians who value her insights.
Lily fosters a strong connection with her colleagues and actively involves her clients’ families in the pregnancy and birth process She encourages children to participate by measuring their mother’s belly, emphasizing the significance of this bonding experience Advocating for flexibility during pregnancy and labor, Lily acknowledges the variability of normal occurrences and the unpredictability of outcomes While she invites her patients to express their birth preferences, whether medicated or unmedicated, she stresses the importance of being realistic and responsive to their bodies' needs As an expert guide in childbirth, Lily provides her clients with a comprehensive understanding of their options.
Nora’s home was situated about thirty minutes from the downtown area of the city The inside décor combined traditional Mohawk design with contemporary
In an inviting American-style kitchen, Nora welcomed guests and prepared tea while conducting an interview at her cluttered kitchen table filled with books and papers As friends and family came and went, she paused the recording for proper introductions Nora provided lengthy, descriptive answers, honoring Mohawk tradition by sharing her experiences through storytelling She recounted her family history, her own birth story, and the experiences of former clients, detailing her patients' dreams and how these insights helped address their deepest fears surrounding pregnancy and birth Additionally, she discussed her approach to tackling clinical issues using her knowledge of chemistry and natural herbal remedies.
Nora's journey into midwifery began at birth, as she was delivered at home by her grandmother, a skilled midwife from a lineage of midwives and obstetricians Growing up in her grandmother's home, Nora was deeply influenced by her grandmother's work and the respect she garnered from the community, often being called "mother" by those she helped deliver Nora admires the practicality, resourcefulness, and self-sufficiency that both her grandmother and her backup obstetrician exhibited, shaping her own values in the field of midwifery.
In the 1970s, Nora pursued her studies in Biology at Skidmore College, later enhancing her knowledge through the University of New Mexico Women’s Health Training Program Additionally, she participated in the Plenty International Midwives Training Program Throughout the 1980s, Nora furthered her education by studying Biology and Society at Cornell University.
Nora has dedicated her career to promoting women's health and environmental awareness through her extensive work with both native and non-native organizations She has served on various traditional aboriginal councils and contributed to numerous health research development programs, maintaining affiliations with several American and Canadian universities Initially reluctant to associate with her community's health service clinic, she has since formed a close partnership, attending conferences and establishing agreements for knowledge sharing At a traditional aboriginal birthing center, she inspired other women to pursue midwifery, leading to federal government support for the program's baccalaureate initiative.
Nora identified herself as a member of a pioneering generation of midwives dedicated to the professionalization of the field She played a crucial role in training emerging midwives and fostering a connection between traditional midwifery practices, as exemplified by her grandmother, and contemporary professional midwifery standards.
Discussion and Analysis
This chapter includes a discussion and analysis of the results of the study
This article explores the key similarities and differences in the training, ideologies, and practices of midwives By comparing their educational backgrounds, work environments, and personal philosophies, it highlights how these factors influence their approaches to technology, spirituality, and the promotion of female empowerment in midwifery.
Importance of Training and Education
The analysis of midwives' practices starts with an exploration of their education and training, which lays the foundation for their understanding of the field While all four midwives attended Cornell University, their individual journeys to studying midwifery varied significantly Their personal values likely played a role in selecting their training programs, and the nature of this training has undoubtedly shaped their perspectives on midwifery and overall health care.
Lily received her midwifery training at The University of Pennsylvania, where she integrated certified nurse-midwifery into a comprehensive hospital system This education equipped her to effectively utilize hospital resources and collaborate with physicians, while also exposing her to the medical community's often pathological view of childbirth Despite being trained to recognize birth as a natural process, she gained insights into situations where medical interventions could enhance patient care Earning her certified nurse-midwife degree has made Lily confident in her ability to operate within a hospital setting.
Emma trained as a midwife in the US through a direct-entry program not affiliated with a hospital, focusing primarily on homebirth care At the Seattle Midwifery School, she learned that midwifery is an autonomous health profession aimed at minimizing unnecessary interventions during pregnancy and childbirth Emma's education emphasized the importance of understanding normal births in non-institutionalized settings Additionally, she studied in South East Asia, where she experienced low-tech midwifery rooted in indigenous practices and engaged with Western European midwives This diverse training reinforced her belief in midwifery as a natural process, contrasting with allopathic healthcare principles that view pregnancy and birth as pathological.
Abigail's international training profoundly influenced her midwifery beliefs, particularly during her time in England, where a growing dissatisfaction with conventional birth practices fueled the demand for diverse childbirth options Influenced by movements like the Association of Radical Midwives advocating for reduced intervention and increased homebirths, Abigail's perspective was further shaped by her experiences in rural Africa, where limited medical resources reinforced her commitment to more holistic and accessible birthing practices.
Nora's journey in midwifery began early, influenced by her grandmother's traditional practices as a midwife, supported by a local doctor She received training in both traditional Aboriginal techniques and modern healthcare, blending these methodologies Her education at the Michener Institute equipped her to work in both home and hospital settings, ensuring she understood the diverse ideologies surrounding childbirth.
Abigail, Emma, and Nora gained valuable international experience that enhanced their ability to critique American birth policies, contrasting with Lily, who was trained solely in technology-driven childbirth environments While hospital births often present medical interventions as the norm, Abigail, Emma, and Nora also worked in settings devoid of such technology This diverse experience compelled them to rely on their personal knowledge and resources to effectively support women during delivery.
The diverse training experiences of midwives have significantly influenced their chosen practices, shaping their perspectives on the institutionalization and medicalization of childbirth.
Importance of Location of Practice
The training received by midwives significantly impacts their learning and choice of practice location, with a strong correlation between educational background and professional autonomy, as noted by Benoit et al (2001) The type of institution influences their practice style; for instance, Lily, trained in a hospital, continues to work there, while Abigail and Emma, who studied in direct-entry programs abroad, have opted for independent home-based practices In contrast, Nora's diverse training across home and hospital settings allows her to attend births wherever needed These varied training environments shape the midwives' perspectives on the scope and limitations of their practice.
Lily operates within the legal and institutional guidelines of her hospital, recognizing her professional boundaries as a healthcare provider She understands when to refer patients to other specialists and is committed to adhering to the hospital's restrictions The hospital network supports her by promoting collaboration with midwives, physicians, and utilizing pharmaceuticals and technologies, all aimed at enhancing the birthing experience for women.
Abigail and Emma, homebirth midwives operating in the private sector, have been pivotal in advocating for the rights of direct-entry midwives in New York State and their community Although government regulations restrict their participation in hospital births, they maintain autonomy in providing care within their homes and those of their patients They collaborate with other healthcare providers for tests and homeopathic remedies, yet they manage labor and delivery independently Their confidence in their abilities and their patients reinforces the safety and healthiness of home birth as a viable option.
Nora, a traditional aboriginal midwife, operated without stringent legal constraints, allowing her to prioritize the needs of her community over government regulations While she adhered to certain health care standards, her practice was deeply rooted in cultural understanding and client-specific requirements This holistic approach to midwifery encompassed various responsibilities, including finding suitable housing, interpreting dreams, and facilitating lab orders and hospital visits Ultimately, Nora's midwifery was shaped by her patients' unique needs rather than legal limitations.
Training and location significantly influence midwives' practice choices, intertwining their education with personal philosophies about midwifery While it remains unclear whether these ideologies shape training and workplace selection or the reverse, they are essential for understanding midwives' perspectives on women's bodily capabilities during labor and delivery Additionally, these philosophies impact their views on technology use, spirituality, and the importance of female empowerment throughout pregnancy and childbirth.
Faith in Labor and Delivery
All four midwives share a strong belief in the innate ability of a woman's body to successfully labor and deliver, viewing pregnancy and birth as timeless processes that have proven effective They emphasize the importance of trusting a woman's body while acknowledging the complexities and unknowns of labor and delivery Emma and Nora illustrate the intricacies of the female body through concepts like biological feedback loops and "locks and keys," reinforcing that birth should be understood as a holistic process rather than disassembled into parts They recognize that while birth can be challenging and requires preparation, the female body is capable of delivering when the time is right Lily and Abigail further stress the importance of empowering patients to believe in their own strength during labor, promoting self-confidence despite the challenges faced Although their interpretations of "natural birth" may vary, MacDonald (2007) highlights that the essence of midwifery is rooted in the concept of natural birth itself.
Natural births symbolize midwifery and reflect specific gender expectations, emphasizing that women’s bodies are inherently capable With adequate support, women can manage labor pain and may even view it as an empowering experience Trusting their instincts is vital, and in an environment where choice is essential, interventions become negotiable, fostering a trusting relationship between midwives and their clients.
Conclusion
The study reveals intriguing connections between midwives' personal philosophies, educational backgrounds, workplace environments, and their practice styles These factors interact in a complex yet compelling manner, highlighting the interconnectedness of various elements that shape their midwifery experiences.
Figure 1 Illustrates how the workplace, practice, philosophy and training are linked through important and complex ties
Figure 1 Schematic representation of the relationship between training, workplace, philosophy and practice
Identifying midwives' personal philosophies proved challenging, yet each expressed strong views on midwifery care Their training and workplace experiences significantly shaped these opinions, although assessing the influence of their pre-training beliefs on their educational choices and practice styles remains complex Additionally, some midwives' philosophies were closely linked to their spiritual or religious beliefs.
Training significantly influenced midwives' perceptions of care delivery, as the techniques learned and their familiarity with technology shaped their chosen practices Additionally, all midwives, except for Nora, found that their training determined their professional qualifications, certifications, and the legal boundaries of their practice.
The workplace significantly impacts midwives' practices, shaping their approaches to female empowerment and spirituality Legal limitations and technological access in these environments influence how midwives engage with patients, ultimately affecting women's sense of control during childbirth Consequently, the nature of the workspace plays a crucial role in midwives' involvement and management of the birthing process.
The practice of midwives is shaped by various factors, including their philosophy, training, and work environment, which collectively influence the care they provide to women and families Their beliefs and experiences are further molded by hands-on practice, while interactions with other healthcare settings, such as hospitals, can impact their willingness to seek external support Additionally, midwives view each birth as a valuable educational opportunity, enriching their professional development.
Effects of the US Model for Midwifery and Suggestions for the Future of the Field
Midwifery models must integrate philosophy, training, workplace, and practice without restricting any single factor, as limitations in one area can bias the others For instance, if midwifery training is confined to a single approach, it restricts the midwives' abilities and the diversity of care they can offer In the U.S., such constraints, often rooted in historical and political contexts, hinder the growth of midwifery, despite its recognition as a safe and healthy option for many women The Ontario model, which requires midwives to be trained in both home and hospital settings, provides a comprehensive approach that prepares them for various birth scenarios, rather than adhering to a singular ideal By adopting this model, the U.S could empower midwives to collaborate with women and families to determine the best individualized birth experiences, allowing for flexibility in prenatal and childbirth care while respecting personal values and ensuring continuity of care.
This research serves as a preliminary study aimed at identifying key issues, concerns, successes, and relationships related to midwifery in a Central New York city, acknowledging the limitations inherent in its methodology.
The midwifery field stands to gain significantly from extensive quantitative and qualitative research that assesses the physical and emotional health outcomes of various midwifery patients It is crucial for women to evaluate their childbirth experiences based on their personal priorities Collecting data on women's childbirth expectations with midwives and whether those expectations were fulfilled can provide valuable insights By examining both the positive and negative aspects of these experiences, researchers can stimulate a broader dialogue about midwifery births This conversation can help women become more acquainted with midwifery options and establish a supportive network for sharing birthing stories, as previously emphasized by midwives.
Research should compare the outcomes of midwives in the Ontario model with those trained in direct-entry and nurse-midwifery frameworks in the U.S This study must assess midwives' attitudes towards medical technologies, birthing environments, and their caregiving roles Additionally, it should identify the primary obstacles they face, such as legal limitations, resistance from the medical community, misconceptions about childbirth safety, and evolving technology trends Midwives should also provide insights on enhancing the quality of their care By collecting comprehensive data on various midwifery models and practices, we can make informed decisions that benefit pregnant women, their families, and the future of midwifery.
APPENDIX AA: Legal Status of Direct Entry Midwives by State (MANA, 2009)
B.1 History of Midwifery in England
Before the 1930s, midwives in England served as independent health care providers during childbirth However, following World War II, the introduction of the National Health Service transformed maternity care, making it universally accessible and free of charge This new model promoted both obstetrics and midwifery but placed a greater emphasis on hospital births, leading to the medicalization of childbirth and diminishing the influence of midwives within the system By the 1970s, the government recognized the need to address these changes.
In the 1970s, hospital births accounted for 100 percent of deliveries, which led to midwives functioning more as maternity nurses rather than independent care providers Despite midwives being the lead caregivers in three-quarters of births in England, their capacity to exercise clinical judgment and manage patient care was restricted due to the hospital-centric model of childbirth (Weitz, 1987) By the mid-1970s, only about four percent of births occurred at home (Chamberlain, 1988).
In the 1970s and 1980s, there was a rising demand for more choices in childbirth, with homebirths accounting for just one percent of all births amid growing dissatisfaction with traditional childbirth procedures This shift was driven by maternity consumer groups like the National Childbirth Trust and the Association for the Improvement in Maternity Services, alongside the formation of the Association of Radical Midwives This organization advocated for greater independence for midwives, training for homebirths, reduced medical interventions, increased natural births, and continuity of care.
B.2 History of Midwifery in Canada
The evolution of Canadian midwifery in the 1970s mirrored American trends, as movements advocating for natural and homebirth gained momentum Canadian midwives championed the empowerment of women in childbirth, emphasizing the detrimental impact of hospitals on the birthing experience Identifying as “community midwives,” they sought to maintain autonomy from a single authoritative body As the midwifery movement gained traction through the 1970s and 1980s, tensions with obstetricians escalated In response, Ontario midwives united to establish formal clinical standards, forming the Ontario Association of Midwives (OAM) and aligning with the Midwives Alliance of North America (MANA) This association later merged with the Ontario Nurse-Midwives Association to create the Association of Ontario Midwives (AOM) Additionally, organizations like the College of Midwives of Ontario (CMO) and the Ontario Midwifery Consumers Network (OMCN) were established to regulate and promote midwifery practices in Ontario.
B.3 Traditional Aboriginal Midwifery in Ontario, Canada
The Ontario government promotes traditional Aboriginal health care through funding organizations like The Six Nations Maternal and Child Centre, which was created to address the holistic needs—physical, spiritual, and traditional—of Aboriginal communities A key program at the Centre is midwifery training, which prioritizes service choices that align with the personal beliefs and customs of women and their families, ensuring culturally sensitive care.
B.4 Traditional Midwifery (IKPs) in Cambodia
IKPs believe that mothers know what is best for both themselves and their children While pregnancy is seen as a natural phase of life, pregnant women are regarded as vulnerable To protect the health of both mother and baby, traditional practices often involve physical restrictions, specific nutritional guidelines, and rituals centered around breast milk.