Midwifery as a Sustainable Community Model For Providing Women's Health Care

It is no news to anyone that America's healthcare system is in crisis. Nor is it surprising to find that certain groups, such as the elderly and the poor, lack adequate healthcare. It may be more surprising to learn that the healthcare for our nation's women, in general, is at a very serious crossroads. This includes scores of women, young and old, women of all races, educational backgrounds, and socio-economic levels. The first comprehensive national health survey of American women, conducted by the Commonwealth Fund in 1995, found American women to be at significant risk. Risks included the following general areas: lack of needed medical care, under utilization of preventive services, depression and low self-esteem, abuse, and poor physician communication. The study went on to elaborate on the conditions that limit the quality of life of millions of women. In terms of health care this study states that thousands of American women do not get what they need from the existing system.

What changes need to be made for this national trend to reverse itself and what is happening locally to address these issues? Part of the concept of sustainability is that we must scrutinize the current system for what works and what doesn't and we must embraces new ways of envisioning other possibilities. I would like to propose that the midwifery model of caring for women, although it is eons old, is not only a sustainable model, but it addresses many of the issues women find so important.

Let's start with pregnancy and birth, the arena in which midwives are most likely to be associated with regarding women's health care. Although the process of pregnancy and birth has changed very little since the dawn of civilization, our attitudes and mythology about pregnancy and birth has changed dramatically, particularly in the later half of the twentieth century (Rooks, 1997). What has been considered a woman-centered rite of passage and a normal physiological process occurring within the family structure for eons, has evolved into a technology-centered medical event occurring out of the home and away from the family unit in less than half a century (Davis-Floyd, 1992). From our earliest recorded history, midwives have been the traditional birth attendant in all cultures. In 1920 midwives attended 95% of all births in the United States. By 1975 physicians attended 95% of all births (Rooks, 1997).

What caused this paradigm shift? As we grapple to create and embrace health care systems that meet the needs of our community members, are cost effective, and are sustainable, what place can the midwifery model of care occupy in meeting these goals?

According to the "Sustainability Project" in Olympia, Washington, there are six tenets of sustainable development, including 1) being long term rather than short term orientation, 2) means-oriented rather than goal-oriented, 3) natural rather than artificial, 4) holistic/interconnected rather than hierarchical/ separated, 5) participatory rather than autocratic, and 6) bounded by limits rather than lacking natural restraints (Crowfoot, 1998). How does midwifery as a model of care support these tenets of sustainability?

First of all it is important to give a brief history of midwifery and its development as a profession in order to define it as a model of health care. Women have always helped other women give birth. In early human communities the birth attendant was usually an older woman experienced in both giving birth and in helping other women to give birth. Her knowledge was based on observation and experience and her skills were often handed down from generation to generation of such women (Rooks, 1997). These women learned by trial and error, gaining experience as they cared for each woman. These women are called traditional birth attendants (TBA's). In many of the world's oldest indigenous societies this tradition still exists. In these cultures the midwives were called "wise women" or "sage femme" because of their hard won empirical knowledge and wisdom in pregnancy, birth, and women's health (Goldsmith, 1990). As other societies evolved into more complex communities, TBA's evolved into professional midwives, women who earned their living by attending births and dispensing healthcare to women. "In most cultures, men (beginning with shamans, followed by priest or rabbis, and later by doctors or barber surgeons) were called only to deal with dangerous complications" (Rousch, 1979). The first documented midwifery training program is in the fifth century B.C. In this program two kinds of midwives are recognized, ordinary midwives (who attended normal births) and midwives with advanced training who could handle complications. Still, all but the rare birth was guided by one of these two categories of midwives, all of whom were women.

Midwives are an integral part of every known human culture (and they exist in other mammalian populations as well). In Europe, women attended births from ancient days to the Renaissance. Gradually, as the science of medicine developed, European midwives became part of the established medical system. With the acceptance of the bio-medical model in the 1600s, pregnancy and birth were considered a disease to be managed and the body was seen as a mechanical unit to be explored, rearranged, and repaired by expert medical mechanics called surgeons (Capra, 1982). This was a new notion in human thought. This view made the birthing woman "the object upon whom the art and science of obstetrics was practice by male midwives called obstetricians" (Katz-Rothman, 1991). By Renaissance times in Europe, midwives only practiced under the supervision and control of physicians.

Midwifery took a different path in the United States. The indigenous people of North America continued the use of midwives as primary practitioners in the arena of women's health care, and some modern societies, such as the Hopi's still do (Goldsmith, 1990). For colonial women, birth was outside the realm of medicine and was the exclusive territory of women. In addition, there were few physicians among the early colonialists, and therefore, much of the medical care rested with the women healers (Chaney, 1979). However, in the early 20th century as the medical profession was becoming organized, doctors called for the outright elimination of the midwife (Devitt, 1979). But even without formal training, the American midwife had lower rates of infant and maternal mortality than physicians (Davis-Floyd, 1995). Due to the strong and organized American Medical Association (AMA) lobby, midwifery in America was almost wiped out and the influence of women healers and midwives came to a virtual end in the early part of the twentieth century.

However, midwifery did not die, probably because of the public health movement in the early 1900's, which helped to launch the profession of nurse-midwifery in this country primarily to serve the nation's poor women. As the "second wave" of the feminist movement was born in the 1960's, women both individually and collectively realized that they lacked control and power in their lives. Among the myriad of issues that women raised, women's health became a political issue, as did the role of women as health care providers. It is at this time that the resurgence of traditional midwifery, also called lay-midwifery, occurred and, with it, a return to homebirth.

Like their nurse-midwife counterparts, lay or direct-entry midwives achieved impressive results in birth safety, and often, among poor populations, with home being the primary place of birth. Because both groups of midwives have proven, through scientific studies, that midwifery care is safe and satisfying while being cost effective, the profession of midwifery is becoming a larger part of women's healthcare, although midwives nation-wide still struggle for a foothold in the competitive healthcare industry.

This review of midwifery's historical roots illustrates the longevity of the midwifery model of care within human communities. The discussion that follows will help to illustrate how midwifery fits many of the tenets of a sustainable model of providing healthcare within a community, which includes the following concepts:

• Midwifery care is oriented toward the long term rather than the short term.

• Midwifery care is a means-oriented model rather than a goal-oriented model.

• Midwifery care is oriented toward natural rather than artificial.

• Midwifery care is holistic/interconnected rather than hierarchical/separated.

• Midwifery care is participatory rather than autocratic.

• Midwifery care is bounded by limits rather than lacking natural restraints.

What is interesting is that although midwives have been part of human culture from earliest times, our society lacks accurate information about who modern midwives are, how they are trained, and what services they offer. What picture comes to mind when you hear the word "midwife"? Although midwives deliver eighty percent of the world's babies today, they deliver only about five percent of babies born in the U.S. There are many kinds of midwives (see definitions listed below) who serve a wide spectrum of women, such as poor disadvantaged women, well-educated professional women, religious groups, and every type of woman in between, in both rural and urban settings and in a variety of sites such as homes, clinics, birth centers, and hospitals across the country. This broad spectrum of providers serving a broad spectrum of consumers helps to keep midwifery care open-ended and sustainable.

Models of healthcare that are sustainable require new ways of meeting peoples' basic needs, new means of being interdependent, ways to incorporate visions and behaviors that are cooperative and collaborative, and the means for providing satisfying and compassionate care. These are some of the ways in which local midwives are rising to meet these challenges. First of all, there are about a dozen midwives offering a colorful tapestry of services in our community. These services include the care of women and babies during pregnancy, labor, and birth in a variety of settings and gynecological care for all women from teens to elders. Although these services are also provided by local physicians, what women seem to really appreciate about this style of care is that midwives tend to spend more time with their clients during office visits with teaching, listening, and sharing their clients' concerns. There is an emphasis on building a relationship of mutual trust and respect. Although midwives have a variety of technologies at their disposal they tend to emphasize the normality of birth, and they know that "normal" can vary from woman to woman. They expect things to go right while being prepared to handle deviations from the norm and complications. In addition to this traditional role, local midwives are forging new territory by offering clinical care and educational forums for many aspects of women's health including, preconception, family planning, well-woman care, preparation for parenting, breast-feeding, first menarche, nutrition, use of herbal remedies and homeopathy, healthy life-styles, body image and sexuality, peri-menopausal support and menopausal care including alternatives to hormone replacement therapy, spiritual dimensions, and women's rights of passage. Some local midwives offer apprenticeships in midwifery and maternity aide training so that community members can work within the women's health care arena, from casual to professional involvement.

In the profession of midwifery, as in other professions, there is a range of styles of practitioners, although most midwives fall within the humanistic and holistic models of healthcare (see definitions in previous article). Many midwives work inside of the established healthcare system while others work outside of the system. In her book, In Labor (1991), medical sociologist Barbara Katz-Rothman defines two models for providing maternity care in the U.S.: the medical model and the midwifery model. Katz-Rothman states "the medical model has developed out of the technocratic bio-medical ideology which is patriarchal, (which literally means authority of men and fathers), whereas the midwifery model rises out of a woman-centered ideology" (p. 24). Because of these divergent world views, each model differs in its perception of the mother and fetus relationship, the care of the child-bearing woman, its view of what is safe and proper in pregnancy and birth, and the role of the mother in relation to her birth attendants. For example, "in the medical model the woman is a patient presenting herself for needed medical services. Responsibility and decision-making pass to the doctor. In the midwifery model, responsibility remains with the mother (and father)…personal responsibility is a major concern, and midwives expect parents to share responsibility for their pregnancies and births" (p. 278). Responsibility is viewed as teamwork between the parents and the midwife. This viewpoint supports sustainability tenets of participatory rather than autocratic care, and interconnection rather than separation of client and practitioner. Another contrasting viewpoint is that physicians tend to rely heavily on technology for treatment and diagnosis and although midwives have many of the same technologies available to them, they tend to also rely on non-tangible skills, such as intuition and respect for the value of "inner knowing" both of the mother and of the midwife. Anthropologist Davis-Floyd wrote an article called, "Intuition as Authoritative Knowledge in Midwifery and Homebirth" to demonstrate how this skill is successfully and skillfully utilized. Again this supports sustainability tenets of reliance on natural rather than artificial means. And finally, midwives are generally focused on the quality of the entire process of pregnancy, labor, birth, lactation, and family relationships, and not simply the final product of these events. For example, while every midwife values the final outcome of pregnancy to be a healthy baby, she also values each moment of the process of creating, growing, birthing, and nuturing the child as well as the emotional, environmental, spiritual, and community aspects of child-bearing and child-rearing. Midwives spend much of their time with clients in addressing their clients non-physical concerns This attention to all of these aspects supports the sustainability tenets of "means-oriented rather than goal-oriented care" and "long-term rather than short-term care". One of the biggest advantages of midwifery care, in terms of sustainability, is that it is tremendously cost-effective. It is safe and satisfying care at a great price.

I believe that midwives, called the "daughters of time" by sociologist Katz-Rothman, carry both the vision and skill required to bring forward the best of the old world view and to forge the new frontiers in women's healthcare that serves the individual, the family, the community, and the world in a wholesome, enriching, and sustainable manner.

In order to offer practical information to community members through this article I polled all of the local midwives in our region as to the services they provide. The following information is from those midwives who responded to my questionnaire:

Local Midwife Services

New Life Nurse-Midwifery Service: Pamela Wyatt Bradshaw, CNM and Mary M. (Peg) Dunn, CNM, offering care in pregnancy at office in Traverse City, with satellite offices in Beulah and Fife Lake. Births are at Munson Medical Center. 503 Hastings Street, Traverse City, MI, 49686, (616) 929-1606, FAX (616) 929-0715.

Dance of Life: Kathi Mulder, CPM, offering complete maternity services for homebirth. I offer water birth and have experience with twins and breeches. I am willing to travel up to an hour radius of Traverse City. Kathi Mulder, CPM, 530 W. Eleventh Street, Traverse City, MI, 49684, (616) 929-3563, e-mail kmulder@pilot.msu.edu.

Birthways Midwifery: Geradine Simkins, CNM, MSN, twenty-two years of experience in our community offering complete maternity services for homebirth and well-woman care. I also offer nurse-midwifery care to migrant farmworkers at the Migrant Health Program (NMHSI). Birthways, 275 Cemetery Road, Maple City, MI, 49664, (616) 228-5857, NMHSI- (616) 947-0351. e-mail gera@aliens.com. Nancy Curley, DEM and Kim O'Black, RN, CM also provide maternity services with Birthways.

Women First: Jan McAllister, CNM, offering complete prenatal care, attendance of labor and birth at Munson Medical Center. Also offering women's health care, well woman gynecology, and family planning. Jan McAllister, CNM, 10767 E. Traverse Hwy, Suite B, Traverse City, MI, 49684, (616) 947-6113, FAX (616) 947-2384.

Blessings of the Womb Midwifery Service: Robin Lavis, Traditional Midwife, offers these services: free initial consultation, nutrition counseling, prenatal care, childbirth classes, homebirth including underwater birth, postpartum care, newborn care and education, breast-feeding information and counseling. Robin Lavis, 8927 Crockett Rd, Williamsburg, MI, 49690, (616) 938-1819.

 

Definitions of types of midwives in the U.S.:

Traditional birth attendant (TBA)&emdash; women who are not formally trained, learn about birth through experiencing it themselves and by helping other women, and from knowledge passed down from female relatives. Sometimes called "granny midwives."

Lay-midwife (LM)&emdash; or traditional midwife, is a person who has learned about midwifery through self-study, experience and/or apprenticeship. Lay midwives attend homebirths.

Direct-Entry Midwife (DEM)&emdash; a midwife who has completed a prescribed course of training, either in a school of midwifery or through an apprenticeship, which meets the requirements for state licensing or for certification by a state midwifery association.

Certified midwife (CM)&emdash; This designation actually has two meanings. When a DEM who completes a course of training and applies for certification through a state professional group, such as the Michigan Midwives Association, meets those requirements, she becomes a CM. Very recently, the American College of Nurse-Midwives Certification Council (ACC), who credentials nurse-midwives, has used the "CM" designation for graduates of formal midwifery programs identical to those attended by CNM's but who are not nurses. The latter group is sometimes called ACC CM's.

Certified Professional Midwife (CPM)&emdash; a title given to direct-entry midwives, developed by the North American Registry of Midwives (NARM), which was formed by the Midwives Alliance of North American (MANA). This process for examining and certifying DEM's was developed in 1994. CPMs attend births at home.

Certified Nurse-Midwife (CNM)&emdash; an individual educated in the two disciplines of nursing and midwifery. A CNM is a registered nurse who has completed an accredited program of midwifery study at the graduate level, has passed a certification examination given by the ACNM, and has received state licensing. CNMs attend births at home, in birth centers, but primarily, in hospitals.

The purpose of these definitions is to distinguish between midwives who have met formal educational and other standards and those who have not. Many midwives would prefer to unite under the generic title of "midwife", but others prefer their own designation.

References:

Capra, Fritjof, (1982). The Turning Point, New York:NY: Bantam Books.

Chaney, J. (1979). "Birthing in early America", Journal of Nurse-Midwifery, 25 (2), 5-13.

Crowfoot, Jim, (1998). "Resources for Sustainable Local Communities&emdash;Part Three", Synapse, Issue 43.

Davis-Floyd, Robbie, (1992). Birth as an American Right of Passage. Berkeley, CA: University of California Press.

Davis-Floyd, Robbie, (1995). Perils and Politics of Post-Modern Midwifery.

Austin, TX: Midwives Alliance of North America Conference.

Devitt, N (1979). "he statistical case for the elimination of the midwife: Fact versus prejudice", 1890-1935 (part I). Women & Health, 4(1), 81-95.

Goldsmith, Judith, (1990). Birth in Four Cultures, Brookline, MA: East West Health Books.

Kath-Rothman, Barbara, (1991). In Labor: Women and Power in the Birthplace. New York,NY:W.W. Norton & Company.

Northrup, Christiane. (1994). Women's Bodies, Women's Wisdom. New York, NY: Bantam Books.

Rooks, Judith, (1997) Midwifery and Childbirth in America. Philadelphia, PA:Temple University Press.

Rousch, R.E., (1979). "The development of midwifery&emdash;male and female, yesterday and today". Journal of Nurse-Midwifery, 24 (3), 27-37.

Wertz, R.W, & Wertz, D.C., (1979). Lying-in: A history of childbirth in America. New York: NY: Schocken Books.

Return to the Index of Synapse 44, Summer 1998