"Is there anything that you want done during your delivery?"
"Yes, I want to be talked out of an epidural."
"Why?"
"I don’t like them and I don’t want one. If it gets really bad I want some stadol or something."
"I won’t do that."
"You won’t do what?"
"I won’t talk you out of an epidural. I happen to think they are helpful."
"But right now, I can think clearly and I don’t want one. I had one last time and I can still pinpoint the exact location that the needle entered my spine! They screwed up and I don’t want another one!"
"Well, I’ll get the nurse-anesthetist and he can talk to you about it, but I refuse to talk you out of one."

Tonya* exits leaving me frustrated and tense over this encounter. I thought the labor and delivery nurses were supposed to be supportive of the laboring mother, this was awful!
However frustrating and unreal this sounds, this is a familiar scene in labor and delivery rooms across the country. Mother’s are frustrated because they can’t have things the way that they want them. Because of this, an old custom is popping up again and becoming more and more popular among middle to upper-class educated adults in the United States. That is midwifery.

The History

Midwives are a very old tradition. There are even references to midwives in the Bible. Women helping women through a terrifying and momentous occasion in their lives. But our modern-day ideas have turned it into so much more.
It was back in the 18th Century when Dr. Smellie opened up a school for doctors and midwives, in England, to learn about proper care of a pregnant and laboring mother. He began the practice of an Obstetrician attended birth because he performed the service for free if his students could attend as well ("Midwifery" 8:114). He began to set the standards for labor and delivery care.

In the early 1920’s midwives were all but instinct in the United States, except for in some rural areas of the country. All-in-all, however, women were electing to have their babies born in hospitals with a doctor in attendance ("Midwifery" 8:114). This was the norm (as was a sterile delivery room that looked like an operating room, the mom being strapped down to the table, and lots of medications for the mom) until the women’s movement in the 1960’s. During the 1960’s women were wanting to be more in control of their bodies. They cried that they wanted to give birth naturally without being strapped down to a table and without being put under general anesthesia. Methods of natural childbirth became popular, and the midwives were the women’s advocates. (?)

There are 3 different types of midwives that practice in the United States today. The "lay or empirical midwife", the "professional midwife", and the "certified nurse-midwife".

The Lay Midwife

The lay or empirical midwife, often times referred as the "direct entry midwife", are midwives who have obtained their training through various different routes. These women (and sometimes men) often learn their tasks from reading books, and from witnessing and assisting births (Rothman 62). These people have decided not to be licensed or certified for reasons varying from "lack of experience necessary for licensure to not wanting to work under any type of mandated protocols or guidelines" (Sonnenstuhl). People often confuse the lay midwife with the professional midwife. The lay midwife has become more popular in recent years with the "home-birth movement". Many women are choosing to give birth at home in the comfort of their own beds (Rothman 62). In many areas, such as Washington State, these lay midwives are not allowed to charge for their services and they can be prosecuted if they are caught doing so.
Lay midwives are unregulated by governments in many states. They attend home-births and unless they decide to go on to become a professional midwife, they are unable to practice anywhere else. These men and women, unfortunately are what the public commonly think of when they hear the word "midwife". Basically stated, if a women gives birth (and most women do) then she can proclaim herself an authority and go on to assist other women giving birth as a midwife. There are no set guidelines that she must follow and no authority to which she must answer. This is not legal in all states, however. Many states require the certification from the North American Registry of Midwives and that makes them a Certified Professional Midwife.

The Certified Professional Midwife

The certified professional midwife, or CPM, is now becoming much more popular than the lay midwife. The CPM receives their training through several different forms, including "formal schooling, correspondence course, self study, and apprenticeship" (Sonnenstuhl). The CPM then goes on to become licensed through the NARM (North American Registry of Midwives). This contains an extensive verification of experience, knowledge, and skills. This includes attendance of over 40 births and with a minimum of 3 of these births, s/he must provide primary care for at least 4 of the prenatal visits, birth, newborn exam, and 1 postpartum exam. In addition to this, s/he must perform at least 75 prenatal exams, 20 newborn exams, and 40 postpartum exams. S/he then must pass the NARM Written Examination. In Idaho, the NARM Written Examination is used by the State Midwifery Association for state certification (Midwives).
These men and women come from all backgrounds, including housewives, nurses, Physicians Assistants, General Practitioners, and even Obstetricians. There are no pre-requirements, just a passion for pregnancy and childbirth. In most cases, the CPM has medical back-up if needed and can practice in many birthing centers, at home, and occasionally in hospitals.

The Certified Nurse-Midwife

Of the choices, the most educated regarding modern-day standards is the Certified Nurse-Midwife, or CNM. As the name implies, the CNM is first trained as a nurse, "an occupation created to assist physicians…nurse-midwives inherited a history of control by the medial profession", and later as a midwife (DeVries 39). There are several programs for training, depending on where a person decides to go to school. In some areas, a person must first obtain a Bachelors of Science and Nursing and then apply to either a 1 year certificate program in Midwifery, or a 2 year Masters of Science and Nursing with a specialty in midwifery. In other areas, a person can obtain an Associates of Science and Nursing degree (ASN) and attend a university that has a program designed to go from an ASN to a (MSN) in 3 years with a specialty in midwifery, without obtaining a Bachelors Degree first. And in other areas, like Yale University, the only requirement is a Bachelors Degree in anything and the student completes a 3 year MSN program, specializing in midwifery, and takes the licensure exams for both nursing and midwifery (Sonnenstuhl). These programs generally consist of ½ of it book work and ½ hands-on experience. All of these programs’ curriculum must contain proper certification from the ACNM. (American)
All students who have completed the advanced certification degree in midwifery then go on to take the certification test given by the American College of Nurse-Midwives (ACNM). CNM are allowed to practice in all 50 states, however there are different requirements in different states, the CNM must follow state laws. For example, in some states the CNM has prescriptive privileges, while in other states they have partial prescriptive privileges or no privileges. Also, a CNM is considered an Advanced Registered Nurse Practitioner (ARNP). In some states, like Washington, this becomes part of the title. The CNM is registered through the Board of Nursing as a Nurse Practitioner because of the CNM. The feeling about this varies, some CNM’s prefer the distinction between themselves and a NP, but the benefit is that the NP’s across the country are uniting to form a strong coalition and this may be the official title in years to come (Sonnenstuhl).

What Do They Do?

Each type of midwife has limitations in their practices. The most limited is, of course, the lay midwife. S/he is allowed to practice within the home setting and occasionally in birthing centers. And as stated before, in some states, like Washington, it is illegal for them to charge for their services. There are currently about "two to three thousand independent midwives in the US alone" (Sonnenstuhl).
CPM’s have a little more leniency with where they practice, in most states. They practice in home-births and birthing centers, as well, but because of their certification process they have more credibility.
They, like the lay midwife, provide prenatal care, management of the birth, initial newborn care, and postpartum care. Some CPM’s do wish to obtain hospital privileges, but are rarely able to. Hospitals are unwilling to allow non-medical practitioners into their setting. Because of this, midwives need to have doctor back-up in case they need to order lab work or ultrasounds. However, in such cases, the CPM’s do not receive the results, they results go back to the doctor who ordered them initially (Sonnenstuhl). However, to stay involved, many lay midwives and CPM’s are members of committees that encourage changes in obstetrical care.
The CNM is allowed to do much more than the latter two. In many areas, they are allowed to practice in home-births, birthing centers, and in some hospitals. It is still difficult for them to obtain hospital privileges, but it is the other doctors that work in the hospitals that push them out. According to Phoebe Gray, PNP, it is really difficult to gain hospital privileges in one of the major hospitals in Boise, St. Luke’s. Phoebe was able to obtain hospital privileges on the Pediatrics and the Newborn nursery after nearly a year of meetings, paperwork, and red tape. It is felt that the reason Boise’s only CNM, Liz Brittain, is not allowed to deliver babies at St. Luke’s is because it is primarily set-up for high-risk pregnancies and deliveries. Liz does, however, continue to manage her patients care at times other than the labor and delivery and before St. Alphonsus opened up it’s doors to the new Birthing Center. Liz now manages the full-spectrum of her patients care, now that she is also allowed to "run the show" when it comes to her patients deliveries. She has a been a CNM for the last 10 years. Not only does she take care of her pregnant patients, she also advises women about family planning and yearly women’s health examination. Liz also informed me that many CNM’s obtain specialties in a variety of areas such as ultrasound and the identification and treatments for cervical cancer. In the training of a CNM, Liz also says that because of the nursing aspect, CNM’s are more likely to be an advocate for their patient.
In a telephone interview with Liz Brittain, CNM, I asked her several questions about her views on modern-day midwifery. Here is a brief synopsis of our conversation:
"Liz, many people associate the term ‘midwife’ with home-birth, what does it really mean?"
"I’m glad you asked, I would really like to dispel that theory. Choosing a midwife doesn’t by any means equal a home-birth. What it means is that you are choosing someone to care for you during your pregnancy who will be work for you as an advocate. Home-births are fine in their place. I believe that they can be done safely as long as they are cared for by a true professional who has taken the risk factors into account and explained those to the parents."
"So, does that mean that all types of midwives are okay?"
"No, definitely not. You have to look at each one individually. I know from being here is Boise, that there are a few lay-midwives who think of any type of medical intervention as the enemy. This isn’t right. The midwife needs to be doing a risk assessment on each individual patient before deciding that a doctor is the enemy. The primary goal should be the mother-baby safety issue, not making it through without medications.
You also have to look at each midwife’s history. Some are well-trained and others are not. The theory that ‘I’ve seen one birth then I’ve seen them all’ is absolutely not the case. Each pregnancy and each delivery are different. Because of this, a midwife who has delivered 100 babies is more likely to have this mind-set to a midwife who has only delivered 10. Some of the lay-midwives who have the attitude that medical intervention is the enemy and eliminate science and technology are dangerous! We can’t ignore the years of research to go back to the middle ages!"
"So, what exactly are your feelings on medical intervention? When is it all right?"
"I feel that medical intervention has its place. If a woman is suffering from pre-eclampsia, then by all means, she should be admitted to the hospital and given some magnesium-sulfate it could save her life as well as her baby’s. If a woman is pregnant with twins and the they aren’t positioned right, then she should probably be sectioned. Or if a woman has been pushing for over 2 hours and is exhausted and I can help her get that baby out, then use a vacuum extractor. And, if a woman is just plain having a really tough time dealing with the pain and there is nothing else that we can do for her, then by all means, let her have some medication. You really have to look at the big picture which is a safe delivery for mom and baby."
Everything that Liz said made sense to me. I have looking into Nurse-midwifery (or as my husband calls it, Nurse-witch-doctory) for over a year now, and have tried to look at the different views to everything around us. I guess the most difficult aspect is dealing with people’s individual opinions about midwifery. Like my husband, many people look at it as a form of witch -doctor, something that deals with voodoo and shrunken heads. I think that he is probably right. The majority of people, here is Boise, that I’ve asked have said that they wouldn’t choose a midwife to deliver their baby. Unfortunately, even though I want to become a CNM, I’m one of the people who wouldn’t/couldn’t use one.
The reason that I wouldn’t see someone like Liz to deliver my babies is because I’m what is considered "high-risk". That is becoming quite a term now-a-days. Once doctors became involved in the delivery of babies, pregnancy was no longer considered a "natural occurrence", it became a "medical condition". Almost every pregnancy, at some point, can be considered high-risk. For me, it was my border-line high-blood pressure and pre-term contractions. My doctor even admits that my pre-term contractions probably wouldn’t have resulted in a pre-term delivery, but you never know for sure and doctors would rather be safe than sorry. Heck, I would too! But, pregnancies become high-risk for other reasons too, like gestational diabetes and obesity. If a woman has previous pregnancy complications, she is advised to meet with an Obstetrician to discuss her medical care, rather than a CNM. In cases where the situation becomes apparent later or the woman still decides to go with a CNM/midwife, the CNM doesn’t act on her own (and the midwife shouldn’t), she consults with a physician and in some cases, the physician may even take over the case.

Views

Here in Boise, Idaho, the majority of families elect to have their children born in a hospital, like St. Luke’s, with an Obstetrician present. That is the "safe" way to do things. But, there is an advocacy across the country to change the views of people regarding midwives. I remember when I first began looking up information on midwives on the Internet over a year ago. I had a hard time finding anything worth-while. Now, however, I can find hundreds of well informed sites with hundreds of resources. What people are trying to do is "get the word out"! There is a fear that midwifery is becoming extinct because of uninformed people. As I said before, my husband associates the word "midwife" with witch-doctor. I must say that I tend to agree with that statement. The majority of Americans have a mind-set of midwives as being uneducated women who cast spells and give herbs to laboring women. Of course, when we think about this, we know that it is untrue, but the word-association is still present and can cloud our thinking. One of the goals of midwives is to change people’s attitudes through education and encouraging women to take control of their own health care (Sonnenstuhl).
In Idaho, there are very few CNM’s and a limited number of midwives. I have spoken with only one person who would consider using a midwife for her pregnancy. Yvonne discovered that she was pregnant with her fifth child this last February and after many hours of research decided that she would like this baby delivered by Liz Brittain, CNM. She came to this decision because she wanted her baby born in a hospital-like setting, but she wanted things to go the way she wants them, not based on a doctor’s convenience. As a new advocate for midwifery, I encouraged my friend to actively pursue this choice for her pregnancy. Unlike Yvonne’s past experiences with doctors, Liz does not push ultrasounds unless she feels there is a reason, she does not push pain medications, and she does not push labor induction unless necessary. Like a growing number of educated women across the country, Yvonne is finding that she does have choices with her labor and delivery and she is anxious that she is going to be allowed to make them with the guidance and assistance of Liz.

Benefits

I believe that there are many benefits to choosing a midwife for labor and delivery. The main reason being the intimidation factor. The majority of women are intimidated by male doctors. Heck, the majority of women are intimidated by female doctors! I know that I really like my doctor and trust her implicitly, but I still feel embarrassed and somewhat intimated everytime that I speak with her. However, most women feel more comfortable with a nurse. Liz states that this is because of the different styles of training. When first trained as nurses, nurses are taught to care for the patients and become an ally for them. CPM’s and lay midwives also show more concern for their patients and because they don’t hold that 8 year degree, people tend to feel like they are on a more even level with them. Even though the majority of doctors now are taught to have a nice "bed-side manner", they still tend to intimidate us. Mostly, I think that it has to do with that according my Sociology text, a doctor is the most prestigious career that there is in the United States (Macionis 172).
Another benefit, is that the midwife is more likely to try alternative methods for pain-control. For example, a midwife is more likely to try a massage or heat-packs during active labor to ease the pain while a doctor is more likely to prescribe stadol or an epidural. It is not that these methods of pain control are bad, they just aren’t preferable. My husband came home from work last summer after speaking with an anesthesiologist who performs lots of epidurals on laboring women. According to my husband, this doctor says that he doesn’t like epidurals and thinks that they are a poor choice for managing labor pain. There are too many factors that can go wrong and he wishes that they weren’t done nearly as often as they are. Also, in most cases, women decide to become midwives after having given birth to their own children and thus have "been there". It is easier to sympathize with someone when you understand the pain and frustration that they are going through.

The Down-side

I feel the biggest problem with choosing a midwife is the safety issue. In Boise, the CNM only delivers at St. Alphonsus and has doctor back-up, but what about the rest of the area midwives. The other area midwives perform home-births. When a problem arises during a delivery, sometimes seconds count and if you are at home, 15 minutes away from a hospital what do you do? These midwives, if they are smart, usually have some sort of back-up planned, like an ambulance or a doctor on-call. But, even then, the few minutes it takes for a doctor or an ambulance to arrive could mean life or death for mom and/or baby. This is where experience plays a crucial role. The midwife needs to be able to identify even the minute detail to see if a complication is arising. This is also a reason that a woman who has had a history of pregnancy or delivery complications should stick with an Obstetrician for their next baby.

What do I think?

Ultimately, I am still in favor of the midwife route when it comes to pregnancy, childbirth, and women’s health. I do, however, not fully support of the lay midwife. Mostly this is because it seems illegal to me with no regulation of her. The CPM, I feel is a good choice for women who have no history of medical problems, or pregnancy and delivery problems. However, according to Brenda Ball a mom who has had several home-births, the mom-to-be should take careful steps to ensure that the midwife is well-educated and well-prepared (through an interview) before choosing that route. I am in full support of the CNM. This is the route that I’ve ultimately chosen to take with my education. The Nurse-Midwife, seems better able to handle a multitude of situations and problems, as well as has a strong support system by doctors and hospitals. There is a movement by some doctors to get rid of these Nurse-Midwives, however, many others feel that CNM’s are a crucial part of the obstetrical team.
There are several organizations which are helping to support the existance of midwives. For the Certified Nurse-Midwife, there is the American College of Nurse-Midwives. Many CNM’s and CPM’s are associated with the Midwives Association National Alliance. The ACNM was created in 1971 and is approved by the American College of Obstetrics and Gynecology it’s function is to preserve the art of nurse-miwifery and to regulate those members of the ACNM (ACNM). MANA was created in 1988 when there was little support for the existing midwives. They strive to ensure the existance of the midwife and again, preserve the art of midwifery. MANA is very active in groups and legislation that is trying to regulate midwifery even more. MANA has also worked with the NARM to try to make sure that those practicing midwifery are properly educated and tested (MANA). It is because of these two groups that midwifery is still going today, and there is hope for it’s future.

Works Cited

• American College of Nurse Midwives. 1997. N. pag. Online. Internet. 20 April 1998. Available WWW: http://www.midwife.org
  
• Ball, Brenda. Personal interview. 15 March 1998.
  
• Brittain, Liz. Personal interview. 21 April 1998.
  
• DeVries, Raymond G. Regulating Birth Midwives, Medicine, & the Law. Philadelphia. Temple University Press, 1985.
  
• Gray, Phoebe. Personal interview. 10 September 1997.
  
• Macionis, John J. Society the Basics. 4th edition. New Jersey. Simon & Schuster, 1998.
  
• "Midwifery." Encyclopedia Britannica. 1992 ed.
  
• Midwives Alliance of North America. 12 March 1998. N. pag. Online. Internet. 20 April 1998. Available WWW: http://www.mana.org
  
• Moore, Yvonne. Personal interview. 23 April 1998.
  
• Rothman, Barbara Katz. In Labor Women and Power in the Birthplace. New York. W.W. Norton & Company, 1982.
  
• Sonnenstuhl, Pat. "Inter Nurse Midwifery usa page." Inter Nurse. n. pag.
  
• Online. Internet. 16 April 1998. Available WWW: http://www.wp.com/InterNurse/midwusa.html

[ Member of the March Mom's Webring ]

I would love to hear your questions, comments, or suggestions!
Please e-mail me! I love to get e-mail and I would love to hear from you!
Also, please visit my site - a place to find out and share information about women's health, pregnancy, and childbirth and sign my guestbook!
Thank you for spending some time there! J