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Tuesday
Mar252008

WHO's Midwife

Who is a midwife?

Many definitions abound, including the root of the word, “with woman.”

Is the term “midwife” self-defined? Would a midwife be someone who attends births… having had training or not? What if the training is adequate for one part of the world, but not another? Could there be a universal definition of who a midwife is and what her skills should be?

I thought I’d focus on the World Health Organization’s definition since it seems most closely aligned to my own.

From Chapter One of the “Care in Normal Birth: A Practical Guide.”:

"The midwife: the international definition of the midwife, according to WHO, ICM (International Confederation of Midwives) and FIGO (the International Federation of Obstetricians and Gynaecologists) is quite simple: if the education programme is recognized by the government that licenses the midwife to practice, that person is a midwife (Peters 1995)."

Does that mean if the person doesn't have the education a government sanctions that the person is not a midwife? Hmmm... something to consider, right?

"Generally he or she is a competent caregiver in obstetrics, especially trained in the care during normal birth. However, there are wide variations between countries with respect to training and tasks of midwives. In many industrialized countries midwives function in hospitals under supervision of obstetricians. Usually this means that the care in normal birth is part of the care in the whole obstetric department, and thus subject to the same rules and arrangements, with little distinction between high-risk and low-risk pregnancies."

"The effect of the International Definition of the Midwife is to acknowledge that different midwifery education programmes exist. These include the possibility of training as a midwife without any previous nursing qualification, or "direct entry" as it is widely known. This form of training exists in many countries, and is experiencing a new wave of popularity, both with governments and with aspiring midwives (Radford and Thompson 1987). Direct entry to a midwifery programme, with comprehensive training in obstetrics and related subjects such as paediatrics, family planning, epidemiology etc. has been acknowledged as both cost-effective and specifically focused on the needs of childbearing women and their newborn."

There’s been discussion of whether peds, family planning or well-woman care is a part of midwifery. It seems WHO believes it is and I agree with that. I definitely know I could use more training/information in those areas. I look forward to my upcoming Anatomy & Physiology classes to aid in my increasing comprehension of the nuances of a woman’s body. I know some (CPM/LM) training programs spend time on these topics and I applaud this. I believe all schools should have comprehensive information and require experience in these areas.

More important than the type of preparation for practice offered by any government is the midwife's competence and ability to act decisively and independently. For these reasons it is vital to ensure that any programme of midwifery education safeguards and promotes the midwives' ability to conduct most births, to ascertain risk and, where local need dictates, to manage complications of childbirth as they arise (Kwast 1995b, Peters 1995, Treffers 1995)."

I think these are phenomenal recommendations. I like, so much, that they understand that different locations will create different midwives.

One of my thoughts is that here in the United States, we see so many different cultures that it is really imperative that we learn as much as we can about them all. I am so glad when I hear midwifery schools talk about multi-cultural issues, but also hope they discuss the nuts and bolts aspects of diet choices, physical customs and the hierarchy of the family. I know that I learned the hard way that not all men are (or want to be!) a part of the birthing process.

I remember a dad who chose to sit in the reclining chair in the labor room, leaning back and snoozing. Judgmentally, I was angry at his lack of participation until a kind nurse took me aside and explained to me that in his culture, men were typically not anywhere near a woman in labor, so his being in the room was tremendous support for his wife. Once again, I had my veil of ethnocentricity pulled back, exposing me to ways that were not my own, but were/are just as valid nonetheless.

I adore what WHO says about midwifery. I encourage every midwife, midwifery supporter and every wanna-be midwife to read the entire text of “Care in Normal Birth: A Practical Guide.” Without knowing it, the words, beliefs and desires contained inside the text are exactly how I feel.

WHO acknowledges community midwives and stresses what type of education those midwives should be obtaining. A community midwife is a midwife who works outside of the hospital, but might work collaboratively with physicians. Sometimes, community midwives are far from any medical care and might be called on to perform skills some of us might never encounter. A community midwife is different than a Traditional Birth Attendant. TBA’s typically have very little training other than experience. It isn’t uncommon for a TBA to have learned her craft only through apprenticeship, many times female generational (grandmother to her daughter to her daughter).

WHO has a vested interest in midwives earning and retaining the respect of physicians around the world. In every crevice of the world, it is the physician that can save the life of the woman or baby who needs more care than a midwife can offer. Midwives need obstetricians. If only we could have more on our side. In a few places, OBs work beside midwives in a spirit of cohesiveness and collaboration; each profession respecting the others’ roles. I would love to see the same thing – and (idealistically) I believe it can be done. The more a midwife’s education level grows to look like something the medicos recognize, the higher the level of respect we will have. We are well on our way with MEAC-accredited schools and the homogenization of midwifery education.

I know that, for some (many?) homogenization seems a negative, even awful, but in our growing need for acceptance because of legislation and tightening rules, being alike can work towards our benefit. The definition of “midwife” becomes completely understood – in any context.

WHO says, “…the midwife appears to be the most appropriate and cost effective type of health care provider to be assigned to the care of normal pregnancy and normal birth, including risk assessment and the recognition of complications.” (From what I can decipher, the term “Direct-Entry Midwife” was changed to simply “Midwife” in 1995.)

Among the recommendations accepted by the General Assembly of the XIII World Congress of FIGO (International Federation of Gynaecology and Obstetrics) in Singapore 1991 (FIGO 1992) are the following:

• "To make (midwifery) more accessible to women in greatest need, each function of maternity care should be carried out at the most peripheral level at which it is feasible and safe."

I absolutely agree with this. I believe this is saying midwives should be the care providers for normal birth and obstetricians reserved for high risk pregnancies and births. You bet!

•"To make the most efficient use of available human resources, each function of maternity care should be carried out by the least trained persons able to provide that care safely and effectively."

To me, this speaks to the doctors, nurses and hospitals in our communities (and insurance companies?) that midwives need, if not deserve, support even though we/they might not be operating inside the hospital. Of course, this is if the first two points are being accomplished as well.

“These recommendations point to the midwife as the basic health care provider in obstetrics delivering care in small health centres, in villages and at home, and perhaps also in hospitals (WHO 1994). Midwives are the most appropriate primary health care provider to be assigned to the care of normal birth. However, in many developed and developing countries midwives are either absent or are present only in large hospitals where they may serve as assistants to the obstetricians.”

According to Nurses and Midwives for Health: A WHO Strategy for Nursing and Midwifery Education:

“…health care does not take place in isolation from political, economic and cultural realities…,’ so nursing and midwifery education and practice do not take place in isolation from the political, social, economic, environmental and cultural realities of the Member States; neither must they be seen in isolation from the various stages of health care reform and the dynamic nature, or otherwise, of progress.

I think this is part of what I am saying… that in today’s environment, we need to have as much education as is possible. If more education is needed for LMs/CPMs, finding a way for that to occur is really important. The political climate for midwives is changing and we need to change with it in order to keep up – and stay alive!

Instead of arguing for mediocrity, let’s move forward towards more knowledge and experience.

“Likewise, nurses and midwives do not practise in isolation from their colleagues in the other health care professions. Although each profession contributes unique knowledge and skills to health promotion and the care of patients, there is a need for much more multidisciplinary and interdisciplinary work, in a spirit of recognition and respect for each others’ authority, responsibility, ability and unique contribution. Thus, nurses and midwives must be educated to take their full part as members of the multiprofessional health care team, sharing both in the decision-making and, when appropriate, in taking responsibility for leadership of the team and for the outcomes of the work of the team.”

And, sure! The medicos need to acknowledge this as well. I agree!

“In the face of fundamental health care reform the complex factors depicted in Figure 1 and the resulting social transformation, and because nursing and midwifery education and practice are at very different stages of development in the Member States, it is timely that the professions be proactive in preparing a WHO European Strategy for Nursing and Midwifery Education. This Strategy is intended to be applicable today, but it also looks ahead to the twenty-first century. Although the focus of the Strategy is on preparation for entry into the professions of nursing and midwifery, this education must be seen as the first step in a journey of lifelong professional learning. As research-based knowledge of nursing and midwifery education and practice grows, so all practising nurses and midwives must continue to learn throughout their professional lives – in some cases developing new knowledge for specialist nursing and midwifery practice, in others deepening their knowledge of an existing field of practice.”

In the “Purpose and Objectives of the Strategy,” WHO says, “…it is essential that the nursing and midwifery professions be committed to the need for change in nursing and midwifery education and practice, and that nurses and midwives themselves become more actively involved in the change process.

One of the issues I have with non-CNM midwives (that I’ve not yet seen discussed) is the tendency to embrace statistics/news that encourages letting go of technology whereas if statistics or news encourages more technology or a more hands-on approach appears, it either evaporates into the ether or is discounted en toto.

For example, in my on-going discussion about midwifery education, several people have brought up the World Health Organization’s statements that a midwife “…appears to be the most appropriate and cost effective type of health care provider to be assigned to the care of normal pregnancy and normal birth, including risk assessment and the recognition of complications.

However, in October 2006, WHO strongly advised the Active Management of Third Stage of Labor (AMTSL), but I haven’t heard of community midwives adopting that stance at all! AMTSL includes giving a medication to contract the uterus (Pitocin, Methergine or Cytotec), delayed cord clamping, controlled cord traction and uterine massage after the placenta is born. This is counter to what most midwives (myself included) are inclined to do (except for the delayed cord clamping), but here, sitting in front of us for over a year, is extremely well-documented information that, as far as I can tell, midwives aren’t listening to.

When it came time to toss aside the bulb syringe, most of us didn’t hesitate. Even when the information came out that oxygen isn’t the be all and end all in the first minute of resuscitation – that seems to have been easier to let go of for many midwives. The DeLee causing more problems than it helps? It disappeared from birth kits everywhere. Again, these are procedures that were on the more-invasive side and I find it’s not so painful to let those go. But, picking UP procedures is another story.

Why do any of us hesitate to utilize the information we have for the health and safety of our clients? It seems to run counter to being an LM or a CPM, but perhaps looking at new information is a part of our jobs, yes? What I would love to know is how many non-CNM midwives even know about AMTSL – and then, how many utilize it. Do non-CNMs utilize the information regularly? What do you tell your clients about it? Do you have a consent form detailing the options for AMTSL versus physiological third stage?

(It would be great to know how many CNMs also utilize AMTSL. Is it hard to do it after being so hands-off during the labor and birth? Has it changed the way you “manage” or not-manage third stage? What do the back-up docs say about it? Did you find out the information when it initially came out? Did you change your behavior/actions overnight?)

For my clients, I think I’m going to print out the information and make it a discussion topic during prenatals. I like that WHO says they specifically used the word “offer” instead of “use” so women could have the option of saying no, they didn’t want to have active management. Informed Consent, right?

In a time when so many midwifery websites quote the World Health Organization’s stand on midwifery, I would like to see us embracing their definition of a midwife. How many people who quote the statement that midwives should be the first line of defense for normal births have actually read through the entire treatise? I hope midwives and birth advocates will now go and read through it and really listen to what it says about risk, back-up, what is normal, how to attend to a myriad of situations and how vital midwifery is in our world today.

On every count, I couldn’t agree more.

References (1)

References allow you to track sources for this article, as well as articles that were written in response to this article.
  • Response
    Response: signs of hiv
    - Navelgazing Midwife Blog - WHO's Midwife

Reader Comments (16)

DeeLee has been used on at least three of my babies. Can you point me to some reading on this?

Blessings!
Dawn

March 25, 2008 | Unregistered CommenterAnonymous

I love your blog. I want to be a midwife soooo badly, but I have not a clue where to start. I'm an LPN already and live in a small town. I've heard of the free midwifery school in miami..but I live in arkansas...any tips?

March 25, 2008 | Unregistered CommenterKelsi

Bravo! I agree 100%. I am particularly struck by your question about maintaining mediocrity instead of pursueing excellence and higher standards ( I'm paraphrasing and inserting my own bias here ) as this is very much how I hear the objections to my own similar observations. I was told that the BMJ study "proves" that "more education doesn't improve outcomes". Huh????? Was that the purpose of the study? Is that what it was designed to do? I think not. So what is implied here when this logic comes from a person in a position of some authority in Midwifery? Dingdingding....it means that the logic is flawed and defensive and not actionable in any long term plan for the future of Midwifery. Thanks for the post; I like it!

March 25, 2008 | Unregistered CommenterKneelingwoman

Thank you for posting this. My CNM practice (well, the midwife who attended my daughter's birth) used AMTSL for me. It was kind of traumatic, I have to say, and I've always wondered secretly how data driven the uterine massage, cord traction, and Pit were. I'm glad to hear WHO, whose recommendations I tend to regard highly, recommends it if I had to have it...

March 25, 2008 | Unregistered CommenterAnonymous

On Active Management of Third Stage, I think there is room for discussion, because the studies on which that WHO guidance is based defines PPH as a loss over 500mls, rather than whether the woman is symptomatic. No other medical specialty defines haemorrhage purely by volume in this way. It also focussed on immediate blood loss, and there is lack of clarity over whether there is actually a difference over a 24-36 hour period between PTS and AMTS. The dangers of the blood loss depend on the Hb prior to the loss as well as the volume lost.

We have recently switched from using syntometrine (commerical preparation mixing ergotmetrine and syntocinon (oxytocin)) to using syntocinon only, on grounds that syntocinon is kinder to the woman (doesn't cause the sickness of ergot). But syntocinon is not nearly as effective, and you expect more loss with it than with syntometrine. Because of this PTS has become a little more popular with some hospital midwives I know, since they can't see the point of administering an oxytocic drug if you don't get the full benefit (they are used to the efficacy of syntometrine).

In the developing world (depending on scarcity of resources) there are further reasons not to use AMTS: Most women don't bleed excessively, and it's a waste of oxytocin, syringes and needles which should be reserved for those who really are bleeding. Controlled Cord Traction has a few increased risks (cord breaking resulting in retained placenta, uterine inversion) which can only be well managed close to medical care, so not appropriate in situations far from a hospital with a theatre. (Of course, does not apply in urban areas/developed countries with good transfer arrangements).

Most women will not bleed excessively with a PTS, even if blood loss is greater than it would have been with AMTS, and some women do not want to be given a drug prophylactically, but should be given informed choice.

March 26, 2008 | Unregistered CommenterYehudit

NM,

I've been reading these discussions on midwifery education eagerly---and really appreciated reading the WHO report. I love love that they keep reiterating the motto "In normal birth there should a valid reason to interfere with the natural process."

It's frustrating that so many of the things they recommend AGAINST (most specifically amniotomies and directed pushing, routine IV placement) are used on 95% of patients in my hospital. However, I trust that WHO has made a thorough study of the subject and so some of the recommendations (on latent labor or slowed first stage) surprised me, but are making me look twice and my previous thoughts.

I was waffling before, but I've made the decision to be a CNM instead of a CPM. I think my reasons are much of what your's ultimately are--greater need, greater ability to make a difference--also, for me, it's the challenge of trying to change the system from the inside. I didn't want to do that--and perhaps I'm being naive--but now I think it's the only way to impact the majority of birthing women in the U.S.

Good luck to you--

March 26, 2008 | Unregistered Commentercileag

Here in the UK we have a national governing body which oversees midwifery education, midwives etc.There is a link here to one of the publications, Rules and Conduct http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=169, which all midwives receive and must adhere to whether they work within hospitals, public or private, in the community, or are independent.
With regarg to Active Management in the Third Stage, where does the uterine massage come in other than with a PPH? That's 'fundus fiddling' and should be avoided unless there is a relaxed uterus + excessive bleeding.

March 26, 2008 | Unregistered Commentermidwifemuse

Me again! We have also switched to using syntocinon from syntometrine and the PPH rate has increased. My thoughts are that if you are going to active manage then use something that makes it worth the intervention

March 26, 2008 | Unregistered Commentermidwifemuse

I wonder if the general recommendation to Actively Manage Third Stage comes as a sort of a package deal assuming a few other things about the birth or the birthing woman. Maybe someone who has been somewhat "managed" throughout her labor might be in more "need" of a managed third stage, whereas maybe an upright autonomous private hands-off birth scene, it is still hard for me to picture there being problems across the board with mothers birthing their placentas. It is all very interesting, thought-provoking stuff and keep up the great posts!

March 26, 2008 | Unregistered CommenterHousefairy

Fundus fiddling to me is doing *anything* with the uterus WITH the placenta still inside. I've not heard the term used post-placenta.

March 26, 2008 | Unregistered CommenterNavelgazing Midwife

Right on, housefairy. "Maybe someone who has been somewhat "managed" throughout her labor might be in more "need" of a managed third stage, whereas maybe an upright autonomous private hands-off birth scene, it is still hard for me to picture there being problems across the board with mothers birthing their placentas."

I'd really love to see statistics on pure homebirth outcomes between AMTSL and physiological third stage. Especially before midwives start adding in procedures that include other risk factors as it seems you're advocating for. It seems logical to me that without the added benefit of the major oxytocin flood that relaxed mothers birthing at home receive, then yeah, AMTSL might be more beneficial. But just because something shows up statistically better in the hospital certainly does not mean it's better across the board. You've got inherently flawed births from the outset there, and births that have been "managed" from the word go, so it only makes sense that by the time you get to the end, the mother's body doesn't have the ability to manage its own functions anymore. But that doesn't mean if it were left alone from the beginning the same holds true.

The CNM's I have worked with as a doula and the ones who caught my first baby did not use AMTSL. The only time I have seen an actively managed third stage used by a CNM is with a mother whose uterus had been progressively tiring during second stage and was clearly at a greater risk of hemorrhage.

March 26, 2008 | Unregistered CommenterAmie

WHOs recommendations are covering a very broad spectrum of women and situations. North American home birthing women (hereafter, NAHBW) tend to be very well-nourished, not anemic, and to have a lot more resources for self-care than mothers in the developing world. I would suspect expectant management of third stage to be less dangerous for the NAHBW than for a woman in the developing world in terms of risk of PPH, and I have no doubt that it is less potentially disasterous in the event that a PPH occurs.

A Canadian midwifery student doing a clinical term in Uganda wrote, "In a place where many pregnant women are anemic, more than 10% are HIV positive, and IV fluids and blood for transfusion is scarce, active management makes good sense and I've certainly embraced this policy. The problem that we've encountered, however, is that often labour wards don't have oxytocin. And so they're using ergometrine for active management instead. ...It's given like oxytocin would be - intramuscularly within one minute of the birth. We've been providing oxytocin on labour wards in both Masaka and here in Kampala because it often seems that it's just not available. But more than that, it seems that many midwives don't understand that ergometrine isn't an appropriate drug to be using in this manner. While they know that oxytocin is better, the potential complications of using ergometrine aren't recognized. It feels like we're frequently discussing appropriate active management of third stage and encouraging midwives and students to use oxytocin. But what do you do when there's no oxy available? "

I think that I, too, would embrace AMTSL if I was doing a clinical term in a Ugandan hospital. But with a healthy, well-nourished, upper-middle-class Midwestern woman who is not anemic and has given no indication that she is in any way likely to have a PPH... what possible benefit is there to poking her with a needle and pulling out her placenta rather than respectfully and carefully observing her and her baby in the first moments after birth?

As a midwifery student and a NAHBW I would be very hesitant to suggest AMTSL for the general population of NAHBW on the basis of WHO's recommendation... not because I am unaware of AMTSL, or think that it is never appropriate, but because I'm not convinced that the recommendations make sense in this practice context. If one is operating from a paradigm of needing a justification for each intervention in the natural process of labor and birth -- a justification that is individually applicable to a particular mother and baby -- then it makes sense to reject the routine use of bulb syringes and oxygen without embracing AMTSL for every woman.

March 26, 2008 | Unregistered CommenterSora

Hey housefairy of mine: That's my girl! Loveyou. M.

March 26, 2008 | Unregistered CommenterKneelingwoman

I agree with sora on the use of AMTSL. I'm a huge fan of Cochrane and when their review promoted active management, I was surprised. However, when I review the primary data, I'm not sure that it's that relevant to my own practice. First of all, I have much lower rates of postpartum hemorrhage than seen in the studies. They report a number needed to treat to prevent one PPH of 12, but I'm not seeing anywhere near 1 in 12 bleed heavily. Second, I have low rates of oxytocin induction or augmentation (this is a hospital practice, but my own clients are getting oxytocin in pretty low rates.) Third, my clients' preferences frequently include physiologic third stage. I use active management on occasion (like the recent 4th time mom I had who has had 3 previous postpartum hemorrhages!) but I'm not a fan of routine use and don't feel routine use in my specific practice would have a positive risk-benefit ratio. I think the studies to date have not included several things I need to help me see if there is truly benefit in my own practice - namely, risks factors in the women studied, and true patient outcome endpoints such as symptomatic hemorrhage or need for transfusion rather than secondary outcomes like amount of blood lost or hematocrit fall (amount of blood loss is frequently so subjective also - it is quite difficult to judge how much blood is on a pad, on the sheets, on the floor, lost in the toilet, etc, so just the > 500 ml number doesn't feel accurate to me.)
I think it is important for all birth attendants to stay on top of the evidence, and also to evaluate that evidence critically, no matter what their level. I also think that one of the most important parts of being a good health care provider is knowing what you don't know and having a willingness to go for help when you reach that point. Some of the safest providers I've ever dealt with had relatively less education, but no ego problem going for help, while I've seen some highly educated people make horrible decisions and refuse to admit they might ever need help.
I know your focus is your own world and experience to date, and I'd certainly encourage ANY provider at ANY level to get more education, but I'm not sure education alone makes a better provider, or we'd hopefully see better practice out of a lot of obstetricians. I frankly have not met a lot of obstetricians who can even quote the tenets of AMTSL, or many other recent evidence based recommendations. I think the concern some have in the homebirth world is that historically the push for more education has also led to increased pathologizing of the birth process. I know it's quite possible to practice using modern evidence without believing every birth is a disaster waiting to happen - I hope that's what I do! Just because most of the time I sit around and knit doesn't mean I'm not ready to act well and quickly if I'm really needed, I just try hard to keep my hands to myself when I'm not. I could not agree more that the providers of maternity care by default should be midwives (or perhaps primary care docs like myelf, too?) and not surgeons. I think it is very possible to provide good, evidence based care based on a broad education and training without turning into a medicalized, intervention-happy junior surgeon. But I think I can understand why some in the homebirth world feel threatened by a provider feeling she has to move out of that world to provide better care. Are homebirth midwives really "arguing for mediocrity," or are they just frightened by the idea that if they are viewed as being less educated and therefore unsuitable to provide care, there will be a return to the anti-midwife campaigns seen as physicians rallied to push birth into the hospital to begin with?

March 27, 2008 | Unregistered Commenterdoctorjen

"Just because most of the time I sit around and knit doesn't mean I'm not ready to act well and quickly if I'm really needed, I just try hard to keep my hands to myself when I'm not."

I love this line. I think I'd like to make it my motto when I'm a midwife!

March 27, 2008 | Unregistered CommenterSora

Fundus fiddling refers to any manual stimulation of the uterus pre or post placental delivery. Interesting discussion on pros and cons here - http://www.gentlebirth.org/archives/thirdstg.html#Massage

March 27, 2008 | Unregistered Commentermidwifemuse

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