Midwifery: The Art of Doing "Nothing" Well
by Nancy Sullivan, CNM, MS, FACNM
You might be surprised to learn that about 10% of all babies born in the United States today, up to 25% in some states, are delivered into the hands of a midwife. While it is the perception of many people that midwifery is as extinct as the dinosaur, the fact is that this very old and very new profession is alive and flourishing. Midwives are working, legally and with credentials, in every state in the union, in hospitals, birthing centers, and in the home. Why are so many parents opting to have their baby with a midwife?
Holly Powell Kennedy, a nurse-midwife and midwifery educator, studied "exemplary" midwives and their patients to try and learn what is unique and exemplary about the midwifery model of care. That is, what is different about the way that midwives provide care from the way that physicians provide care? She included both hospital-based, birth-center, and home-birth midwives in her study. The critical difference that emerged was the midwives' art of doing "nothing" well; that is, being present with the woman, being vigilant to assure that things were going well, but not intervening or using technology unless it was necessary. One woman summed it up by saying, "A large part of her providing the kind of care we wanted is what she didn't do . . . she didn't rush anything . . . she said to me your body knows what to do so just let it do it." Some of the qualities that were strongly identified by women with midwifery care in Kennedy's study were belief in the normalcy of birth, exceptional clinical skills and judgment, and commitment to the health of women and families. The following terms were also strongly identified by women with the midwives who cared for them: calm, patient, confident, decisive, intelligent, mature, persistent, honest, compassionate, trustworthy, flexible, understanding and supportive, warm, nonjudgmental, gentle, nurturing, not focused on self, realistic, reassuring and soothing, possessing a generous and loving spirit, possessing a sense of humor, and being personable.
Midwives consider themselves to be the experts in normal childbirth. In Europe, midwives provide the majority of maternity care. Midwifery care leads to excellent outcomes; the infant mortality rate is lower in those countries that rely on midwives to care for most pregnant women, such as Holland and the Scandinavian countries. In our country, midwives were common until the first decades of the twentieth century, when physicians decided that obstetrics should become a medical specialty and that birth should take place in the hospital. The women who had been cared for in their homes by midwives were considered potential "training material" for medical students, and midwives were considered competition. Consequently, even though there were no statistics to show that midwives' care resulted in worse outcomes, midwifery was made illegal in many states, and the number of practicing midwives dwindled. This situation endured until the sixties and seventies, when two very separate trends contributed to a renaissance of midwifery. First, there was a "physician shortage," particularly when it came to caring for poor and uninsured women. Nurse-midwives, trained as public health nurses and given additional education as midwives, were recruited to care for poor women in underserved rural and inner-city communities. Second, the state of childbirth in the hospital had become so cold, so impersonal, and so "medicalized" that consumers began to rebel and seek a different form of care. "Lay" midwives, at first with little or no formal education, started assisting their friends and communities in giving birth at home.
Two types of professional midwives developed from these early prototypes. Certified nurse-midwives (CNMs) and certified midwives (CMs) are educated in programs accredited by the American College of Nurse-Midwives and certified by the ACNM Certification Council. They are licensed in all fifty states. Although certified nurse-midwives continue to practice, for the most part, in the hospital setting and to a lesser extent in birth centers and the home, they strive to maintain the midwifery philosophy of care. Nonetheless, for some women, having a midwife-attended birth in the hospital is the perfect solution, since there is the option of high-tech procedures if they are needed. These might include epidural anesthesia, electronic monitoring, and intravenous medications. In addition, the midwife always has consultation and referral with an obstetrician readily available for complicated labors and possible operative deliveries.
Home-birth midwives, educated in formal midwifery schools accredited by the Midwifery Educator's Accreditation Council or in apprenticeships, may be certified as certified professional midwives (CPMs) by the North American Registry of Midwives. They practice legally in most states. Home-birth midwives, as well as midwives who practice in birth centers, should have strict criteria for women who are appropriate to deliver outside the hospital. They should have a plan for obstetric referral and hospital transfer if a problem should arise. For women who are low-risk and desire a home or birth-center birth, these options are safe and provide a level of comfort, familiarity, and intimacy for the family that is not possible in a hospital.
Midwives spend time with woman, both during the prenatal visits and during labor. They expect questions. They encourage the women in their care to seek information and to come to their births as knowledgeable as possible, since knowledge is power. Nonetheless, they also encourage an attitude of flexibility, since every woman and every birth is unique and cannot be predicted. Midwives, like physicians, measure bellies, listen to baby heart rates, ask for urine samples and order ultrasounds, but they are interested in more than the physical progress of a woman's pregnancy and labor. They know that relationships and support systems; emotional and social stressors; spiritual beliefs; the childbirth experiences of their mothers, sisters and friends; and many other factors contribute to a woman's chances for a successful birth. They are concerned with good nutrition for a healthy baby and with exercise to optimize chances that the baby will come down the birth canal the right way. They are open to complementary treatments such as acupuncture, hypnotherapy, water birth, and massage. Above all, they believe that birth is a normal, physiological process that proceeds in the best way if left alone. Of course, there are situations in which pregnancy, labor, and birth are not normal. The midwife is trained to identify these cases and treat them if they are in her scope of practice, or consult or refer with her collaborating physician if necessary.
Midwifery care is supported by research. Many of the strategies used by midwives are supported by the Cochrane Collaboration, a systematic review of the research evidence about the effects of care given to women during pregnancy and childbirth. The Coalition for Improving Maternity Services, a group of individuals and national organizations with concern for the care and well-being of mothers, babies, and families offers an excellent document named, "Having a Baby? Ten Questions to Ask" which will get you started thinking about your choices for childbirth and reassure you that midwifery care is based on sound principles derived from scientific research, as well as on an art that has been passed down from our foremothers. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness, and emphasized the midwife as the primary provider of maternity care. Another document to get you started thinking about your birth is the "Statement of the Rights of Childbearing Women," from the Maternity Center Association.
How can you find a midwife in your community? You can start by asking friends who have used a midwife for their birth. If none have, check the yellow pages under "Midwife," or call your local hospital and ask if they can recommend a midwife. There are several online directories of midwives, listed below. When you contact a midwife, ask to meet with her (or him; there are male midwives, too). Ask how she was trained or educated, what credentials she has, and how many births she has attended. Ask about her philosophy of care. Ask how she provides obstetric back-up in the case of complications. Ask her the "Ten Questions" mentioned above. Ask if she supports the "Statement of the Rights of Childbearing Women" published by the Maternity Center Association.
Midwifery care is not for everyone. If you have a chronic medical problem, such as diabetes, prior to becoming pregnant, or if your pregnancy becomes "high-risk" due to such problems as premature labor or hypertension, you need the specialized medical care offered by an obstetrician or perinatologist. If trying to safeguard the normalcy of your childbirth experience is not a priority, or if you want all the technology that modern medicine has to offer, you would probably be more comfortable with physician care. However, if you are intrigued by the possibility of making your birth a powerful and empowering experience, consider a midwife! To find out more about midwifery, access the resources listed below.
- www.midwifeinfo.com provides information and resources for midwives, aspiring midwives, midwifery students and midwifery consumers; includes a directory of midwives across the country
- www.midwife.org, the website of the American College of Nurse Midwives; includes a directory of certified nurse-midwives and certified midwives
- www.mana.org, the website of the Midwives Alliance of North America
- www.motherfriendly.org, the website of the Coalition for Improving Maternity Services
- Heart and Hands: A midwife's guide to pregnancy and birth, 3rd Edition by Elizabeth Davis. Celestial Arts, 1997. ISBN: 0890878382.
- Midwifery and Childbirth in America by Judith Pence Rooks. Temple University Press, 1999. This is the ultimate resource on the topic of midwifery in America; covers the history and development of nurse-midwifery and direct-entry midwifery; the quality, effectiveness, and safety of midwifery; midwifery in other countries, and much more. The author makes recommendations to improve childbirth in the future. ISBN: 1566397111.
- Paths to Becoming a Midwife: getting an education. Midwifery Today Magazine, 1998. ISBN: 1890446009.
- Spiritual Midwifery by Ina May Gaskin. Book Publishing Co., 1990. The classic work about the renaissance of midwifery and home birth in the counter-culture revolution. ISBN: 0913990639.
- Birth Partner: Everything You Need to Know to Help a Woman Through Childbirth by Penny Simkin. Harvard Common Press, 1989. ISBN: 1558320105.
- The Thinking Woman's Guide to a Better Birth by Henci Goer. Perigee Books, 1999. ISBN: 0399525173.
About the author: Nancy Sullivan, CNM, MS, FACNM is a midwife and midwifery educator at Oregon Health Sciences University in Portland, Oregon. Since receiving her midwifery education at Columbia University in New York City in the early 1980s, she has helped over 1000 babies into the world. She is the founder and editor of www.midwifeinfo.com. Her daughter Megan is studying to be a midwife. To contact Nancy Sullivan: Telephone 503-284-3771, FAX 413-513-3746, email firstname.lastname@example.org, address 1915 NE Wasco Street, Portland OR 97232
Copyright © 2001 Nancy Sullivan, CNM, MS, FACNM. All rights reserved.
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