MIDWIFERY

Midwifery is the age-old practice of assisting women throughout the processes of pregnancy, childbirth, and postpartum period (i.e., before, during, and after the birth). Most often practiced by women, midwifery is one of the oldest professions in the world, referenced in ancient texts and even mentioned throughout the Bible. Not surprisingly, both midwives and midwifery have undergone several transformations throughout history, surviving periods of intense persecution as well as enjoying periods of deserved respect and esteem. To chronicle the history of midwifery is to observe not only the historical transformations in our understandings of pregnancy and childbirth but also the professional battles over who should have jurisdiction over pregnant women’s bodies and the process of childbirth itself. One of the primary distinctions States, as well as several European countries, suggest that similar trends have emerged over time that have contributed to the modern state of midwifery (and, alternatively, obstetrics).

Many would argue that there have been at least three major shifts over time in the practice of midwifery. In the United States, for example, the 17th century was marked by the predominance of midwifeattended births. The midwives of this era were examples of what today would be considered “lay” practitioners (i.e., midwives who learned through observation, apprenticeship, and practical experience, without any formal or institutionalized medical education). These women were sometimes considered to be suspect, often by men, in terms of competence and were occasionally considered to be practitioners of witchcraft. The charge of witchcraft against midwives, however, is not unique to this era. During the Middle Ages, when many of the biological processes involved in pregnancy and childbirth were poorly understood, many midwives were feared to be “witches” who possessed power and information from supernatural sources. As a result, many of them were persecuted and even burned at the stake.

In the United States, accusations of witchcraft were emblematic of a more Puritanical era in which women who possessed knowledge or power in general were considered to be suspect and potentially dangerous. Slowly, however, as the 19th century approached, a shift occurred during which men began to infiltrate the previously women-centered realm of childbirth and midwifery. Male midwives sought to professionalize the field and increasingly limit jurisdiction over the process of delivery, which led to a third historical shift in childbirth care, toward the highly professionalized and medicalized modern obstetrics that has continued into the 21st century.

One might argue that there is evidence of a fourth shift on the horizon, as the use of modern midwives, certified nurse midwives (CNMs), is on the rise. In several countries throughout the world, there are institutionalized certification programs for nurses wishing to specialize in midwifery, contributing to both the public and professional confidence in midwifery and the increased utilization of certified nurse midwives. While midwife burning is largely a thing of the past, there are still heated debates among practitioners over who should have jurisdiction over childbirth. Exploring the history of midwifery highlights several factors that have accompanied the historical transitions in childbirth care that have come to demarcate one era from another. One of the most notable shifts was that from women assisting women as they delivered their babies (which characterized the periods in which early midwives were practicing) to men delivering babies for the women (marked by the transition into modern obstetrics). Today, of course, there are both male and female obstetricians, but the focus is still primarily on delivering the baby, as opposed to assisting the woman during her delivery. The recent shift—slow, though increasingly visible—toward the use of CNMs embodies a return to the more womancentered, midwife-assisting-mother approach.

Finally, it is important to note that in many countries, midwifery has remained a relatively stable and predominant model of childbirth assistance, whereas the medicalized, obstetric model of childbirth has been slower to take hold. In many countries in Africa and Latin America, for example, more traditional forms of medical care are still used to meet the primary and secondary health care needs of the population. For those who do not have access to more expensive forms of childbirth care, midwives are still frequently utilized and are considered to be normative and trusted medical practitioners.

The Natural Versus Medical Model of Childbirth

One of the primary distinctions that have been made between modern obstetrics and midwifery is in the philosophical approach to childbirth. The approach espoused by most midwives is that pregnancy and childbirth are normal, natural events that occur in the lives of healthy women whose bodies are naturally equipped to deal with these physiological processes. Alternatively, the obstetrical/gynecological approach tends to treat pregnancy and childbirth as medical events, transforming women into patients in need of care, observation, and intervention. This distinction is also illustrated by the move from home delivery to hospital delivery. Historically, and even today, it has been argued that poor maternal and infant mortality rates can be blamed on home births and poorly trained midwives, suggesting that the safest place to deliver babies is in a hospital under the supervision of an obstetrician. There is empirical evidence to suggest, however, that modern births assisted by midwives either at home or at birth centers are not only safe but also cost-effective relative to hospital births. Birth between health care practitioners who practice midwifery and those engaged in modern obstetrics surrounds the orientation toward birth as either a natural or medical event.

Historical Transformations

In the United States, as well as in many other nations, the predominance of one model of childbirth over the other has shifted historically. As transformations occur in the ways childbirth is defined, so do the types of providers that are given jurisdiction over the process of childbirth. A number of historical accounts chronicling the history of childbirth care in the United centers are often thought to serve as a “safe” alternative to home births because they are affiliated with hospitals, where more technically complicated births can be handled in the case of an emergency, while still providing the more holistic service of midwives and a more natural, woman-centered birth experience.

Differences in Beliefs and Practices Regarding the Use of Technical Interventions During Childbirth

In addition to espousing different beliefs about the nature of childbirth, midwives and obstetricians also employ very different practices when caring for birthing women. The management of pain during childbirth serves as an illustrative example. Early midwives and birth attendants typically offered women natural remedies like herbs or drinking mixtures and sometimes even liquor, as well as other forms of relief, such as massage. The move toward the obstetrical management of childbirth, however, harkened a new era of medicalized intervention.Many of the early interventions were desired by women to lessen the pain or to assist in more difficult pregnancies, but they occasionally ended up being extremely dangerous. For example, Jessica Mitford chronicles many of these early interventions in her examination of birth in America, such as the use of chloroform, ether, and “Twilight Sleep,” which was a hypodermic injection of morphine combined with scopolamine (a hallucinogenic and amnesiac) and pentobarbital sodium. Other examples of pain relief have included morphine and hot-air enemas, as well as other narcotics, sedatives, and early forms of anesthesia.

While modern obstetricians have moved away from the use of many of these early remedies, they are still proponents of using various forms of anesthesia and drugs to treat pain, such as epidurals and Demerol. Other common technological interventions include the use of Pitocin to induce labor, forceps delivery, electronic fetal monitoring, vacuum extraction, membrane rupturing, and surgical interventions, such as episiotomies and cesarean sections. The use of medical and technological interventions is markedly reduced in births attended by midwives, who tend to approach issues of pain and other “complications” in less intrusive, more natural ways. For example, rather than using Pitocin to induce labor, midwives will often have women move around, instead of lying on their backs in a supine position. Also, instead of using surgical interventions like episiotomies in order to widen the area available for birth, many midwives will use techniques such as vaginal massage. These are just a few examples, but they serve to illustrate how different philosophical approaches toward birth are translated into the actual care birthing women receive from midwives and their obstetrical counterparts.

Midwifery Today

Today, relative to the past, midwifery is enjoying a period of professional advancement, expansion, and recognition. Although there are still lay midwife practitioners throughout the world, many midwives have completed certification and training through professional programs, often affiliated with medical schools and practice as CNMs. While many midwives work out of birth centers or attend home births, some actually work alongside obstetricians in the hospital setting, although this is a less common practice. In addition to enjoying increasing professional status, many midwives are assisted by doulas, or midwife assistants, who offer emotional support and encouragement to laboring women throughout the birth process. Some midwives and doulas also serve as postpartum companions, assisting new mothers as they make the transition from pregnancy to motherhood.

Today, there are thousands of CNMs practicing across the world who attend hundreds of thousands of births annually. They work in a variety of settings, serving women from various socioeconomic backgrounds, often offering a more cost-effective alternative to more traditional medical care. In addition, many midwives maintain close connections to hospitals and obstetricians in order to ensure their patients more-specialized care in the event of a complicated pregnancy or delivery. Finally, midwives are increasingly enjoying a resurgence of maternal interest in childbirth education and more natural childbirth experiences, as the demand for women-centered, midwifeattended births continues to rise.

By Ryan Claire Reikowsky in "Encyclopedia of Gender and Society" edited by Jodi O’Brien, Sage Publications, USA, 2009, excerpts p. 562-564. Adapted and illustrated to be posted by Leopoldo Costa.

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