Midwives are trained maternity care professionals who provide prenatal care, attendance at childbirth, postpartum care, education, counseling, and support for women and families during the pregnancy and childbearing process. They care for women who are likely to have uncomplicated pregnancies and deliveries. Historically, midwifery has always existed. The word midwife means "with woman" in Old English. Years ago, before hospitals and medical technology, all women had midwives for giving birth. In many countries, midwifery is the only birth option, with midwives delivering 80 percent of the babies born worldwide. In the United States, the percentage is much lower; approximately 5 percent, but more and more women are considering midwifery as a childbirth option.
Childbirth is one of the most powerful experiences for a woman and her family. Many women are interested in making the process individual, creative, and unique to themselves and their family. Midwifery encourages and allows women to design their own birth process while keeping the safety of the child and mother the first priority. For women considering midwifery, there are two options: lay or independent midwives, and certified nurse midwives.
Lay or independent midwives are midwives who primarily work in home settings with women and families who want a home birth. They are trained in all aspects of maternity care, but they are not physicians or nurses and are typically are not associated with a particular hospital. They focus on a natural birth process and minimize outside interventions such as drugs, epidurals, episiotomies, and other invasive procedures that are unnecessary during normal births. This chapter will focus primarily on the lay midwife.
Certified nurse midwives are traditionally trained nurses who receive additional training in midwifery. The certified nurse midwife was developed in the United States and Canada. In other parts of the world, nursing training is not required to be a midwife. Certified nurse midwives tend to work in hospitals, birth centers, and clinics and a small number work in homes. They also are concerned with a healthy, natural birth process, but due to their medical training, they can be more likely to use medical intervention. The certified nurse midwife appeals to many women because of the security of a hospital birth in conjunction with the benefits of midwifery. Most midwives are women.
Philosophy
"The body knows exactly what to do. The way the baby grows and develops, and how labor progresses-a woman's body was designed for childbirth. A midwife has to trust, respect, and believe in the power of the body."
-Nina Bassinge, Midwife
Midwifery is based on the fact that pregnancy and childbirth are normal, healthy, natural events. Childbirth is not considered a medical condition or a health problem, and thus within safety limits, midwives are committed to a philosophy of nonintervention during childbirth. They believe in a natural birth process free of medical and technological intervention, medication, and unnecessary medical procedures. They believe in the body's functioning and trust the woman's body to do what it is supposed to do during birth. They are committed to safe health care and childbirth. In the event of complications or high-risk pregnancies, lay midwives refer clients to physicians and hospitals and continue to support the woman during birth. This accounts for only about 10 percent of midwifery births with approximately 90 percent of births being normal and problem-free.
Midwives believe in a woman's right to take responsibility for her delivery. The pregnant woman is trusted and viewed as the one in charge of her birth. The midwife is a coach, counselor, teacher, and advocate rather than an "expert" who is going to control the birth. Midwives view family members as part of the experience, and family support is encouraged throughout the entire pregnancy and birth process. Midwives also expect women to be responsible during pregnancy with regards to lifestyle choices and in planning the birth process.
Midwives care for a pregnant woman throughout her whole pregnancy, during birth, and after birth. The biggest difference between a lay midwife and a certified nurse midwife or obstetrician is time. Lay midwives spend a great deal of time with clients. It begins with prenatal care. Prenatal care is considered vital for the pregnant woman. The midwife spends at least one hour a month with her clients until the seventh month of pregnancy. The hour-long visits are markedly different than the ten and fifteen minutes obstetricians and some certified nurse midwives have to spend with clients. Visits become bimonthly during the seventh and eighth month and weekly thereafter until the onset of labor. During this time the midwife monitors the health of the mother and baby and provides education and counseling. Midwives are trained to do the same things as certified nurse midwives or obstetricians. They do pelvic exams, pap smears, health status exams, fetal heart rate monitoring, and blood work. In addition they spend a great deal of time on education. They educate mothers about nutrition, exercise, fetal development, and the birth process. They typically provide or arrange for prenatal birthing classes, breastfeeding lasses, and newborn classes and are constantly educating the woman and her family about the changes happening to her body. The midwife proves a great deal of counseling and emotional support during this time. Labor and birth is the second major area of care given by midwives. Midwives deliver babies in home settings or in freestanding birth centre. The mother and the baby are carefully monitored and cared for ghoul labor and birth. The type of birth depends on individual client and desires, and midwives work with women and families to create that they want, within safety limits. Midwives offer home births or delivery at birthing centers. They use different tools than hospitals for making the birth as comfortable as possible. Some midwives bring stools, which women can sit on to have their babies. Other wants to lie in bed, be in the bathtub, walk, play music, dance, eat, priority of other things during labor. The midwife supports women and tries to make it as fun and relaxing as possible. During the birth process, the midwife guides the woman and baby. In a normal birth, the pregnant woman does the work and the midwife acts as a support. She will help the woman through the birth and catch the baby. All along, the midwife, who is trained to handle emergency situations, is watching for complications. Emergencies during a home birth are rare, but in the case of serious complications, the midwife will arrange and accompany the woman to the hospital and remain with her as a support. In most cases, once the baby is born, the midwife cuts the umbilical cord, delivers the afterbirth, and completes a newborn exam. Then the family celebrates!
After birth, midwives refer newborns to a pediatrician within a few days. They also provide postpartum care to the woman and her family. This includes counseling and education on well-baby care, breastfeeding, dealing with siblings, parenting, and any other issue the family may have. They typically plan for the completion of the birth certificate and report the birth to the appropriate health departments. They also conduct a four to six-week postpartum exam, which includes a pelvic exam and pap smear for the mother and another check for the baby and family.
Midwives and clients often develop intimate relationships because of the time spent with each other. Midwives strive to get to know the family so everyone will feel comfortable when it comes time for the birth.
"My clients are all so happy and wonderful. I talk to many of them on a regular basis, and I try to stay in touch with all of them. You make friends for life!"
-Nina Bassinge, Midwife
Employment Settings and Working Conditions
In the United States, lay midwives do not work in hospitals. They are primarily self-employed working out of private offices or their homes. Some work in independent birthing centers and others form group practices working with other midwives, childbirth educators, breastfeeding counselors, doulas (birthing assistants), nutritionists, and counselors. Midwives can also be found teaching at midwifery schools or teaching childbearing classes and related workshops. A few write or get involved with other income-providing aspects of midwifery, such as selling midwifery related tools such as birthing stools, water birth tubs, and educational material.
Midwives typically keep clean, warm, and comfortable offices because they want to provide a pleasing environment for their clients, as well as themselves. Their work schedules vary greatly depending on the number of clients they have and when women go into labor. Midwives have control over their schedules with regard to prenatal care and scheduling appointments, which gives them a lot of flexibility in organizing their day. What they don't have control over is when they deliver babies. Midwives are constantly on call, twenty-four hours a day, every day, so the work can be unpredictable and untimely. Midwives must organize their lives to be available on a moment's notice, and this is something aspiring midwives must consider before entering the profession. Midwives typically wear beepers so they can be reached at all times, and they often work with clients within a restricted geographic region to ensure that they can get to clients quickly.
"You are always on call, and that means you have a hard time planning. I can't just pick up and go away for a couple days, and it is hard getting up at 2:00 AM. It is very demanding, but rewarding. I just love it!"
-Nina Bassinge, Midwife
In addition to caring for clients and families, midwives run their own businesses. As entrepreneurs, they are responsible for marketing and advertising their services. Marketing is necessary to maintain clientele, although many clients come from word of mouth and repeat business. Midwives also handle billing, record keeping, and taxes.
One of the challenges for lay midwives is the struggle for acceptance by the medical establishment and society. Most women in the United States are socialized to have their babies in a hospital under the care of a doctor. This ingrained system creates the need for lay midwives to defend their legitimacy. The satisfaction of their clients and a belief in the philosophy of natural childbirth compensates for the difficulty of being viewed as an alternative approach to childbirth.
Training and Qualifications
"I took a difficult route where I had to be very disciplined. I enrolled in a year-long course in Massachusetts where I went to class one day every three weeks and did a lot of home study. I took anatomy and physiology at the University of New Hampshire, and I did my practical training in Holland. I had to do my training this way because I have a family and couldn't just pick up and move to study at a midwifery school."
-Nina Bassinge, Midwife
There are several paths to becoming a lay midwife. Typically training takes the form of textbook study, classes, and an apprenticeship with an experienced midwife. One direct avenue, called "direct-entry," is to attend a midwifery school offering a traditional educational environment. The Seattle midwifery school, for example, offers a three-year training program. This includes classes on basic health/nursing skills, embryology and fetal development, genetics, gynecology and women's health, midwifery care, midwifery counseling skills, parental nutrition, pharmacological and alternative treatments, assessment of women, and a clinical seminar. After completion of courses in a classroom setting, students undertake an internship with an experienced midwife. Being a nurse or having health care training is not required to be a lay midwife, although midwifery programs may have other prerequisites for admission. These can include courses in anatomy and physiology, biology, nutrition, or some relevant women's health care experience. A traditionally designed midwifery school offers a structured path for becoming a lay midwife.
Other options for midwifery training require independent learning. Many programs are designed to offer a flexible, albeit independent approach to learning. These programs typically include a number of correspondence courses in which the student does independent study and research. In addition to independent study, day-long, week-long, or occasional weekend workshops are offered to supplement the home study. Finally, an apprenticeship is required, which is usually set up by students in their home areas. This approach to training works well for nontraditional students who need a more flexible training program, or for those who do not live in close proximity to a midwifery school. The challenge of these programs is the self discipline required to maintain the self study and learning independently.
Another option for aspiring midwives is to piece their training together rather than attend one specific program. The midwifery profession is governed at the state level, each having its own laws and requirements to practice midwifery. All aspiring midwives should contact their state governments to learn about these requirements. Upon doing this, some students follow their state requirements as a guideline for their training. With this approach, aspiring midwives can use multiple avenues for training as long as they complete all the requirements. For example, a student might take a class at a local college, take a few courses at one or several midwifery schools, and then organize an apprenticeship with a local midwife. Again, this allows great deal of flexibility and control over training but requires a lot of research and legwork to put together an individual training program.
As mentioned above, lay midwifery is regulated by individual state law. State laws and training requirements should be researched before beginning midwifery training. Upon completion of training, most states require passing an exam to receive a practice license or certificate. On a national level, Midwives Alliance of North America (MANA), the largest midwifery professional association, has an exam and is working toward national certification. MANA also accredits midwifery schools, and attendance and completion of training at a MANA accredited school earns graduates the title of Certified Professional Midwife. This title is not required to be a midwife, but it can make the process of meeting state requirements easier, as well as being a credential to demonstrate competency to clients.
There are also many programs available for registered nurses who want to become certified nurse midwives. The main requirement for certified nurse midwives is being a registered nurse. Typically one must work as a nurse before returning to school to specialize in midwifery. In some cases registered nurses attend one of the MANA accredited midwifery schools and return to working in the hospital setting. Usually nurses attend programs that are specifically designed to award the credential of certified nurse midwife. These schools are often associated with hospitals. There are nine to twelve-month certificate programs and programs awarding a master's degree in nurse midwifery. The master's degree usually takes sixteen to twenty-four months. The American College of Nurse Midwives oversees and approves certified nurse midwife programs.
Job Outlook and Salary
"People are certainly becoming more aware of midwifery. You see it with the popularity of supplements and herbs people are taking. They are more aware of different health care options, midwifery, and home births."
-Nina Bassinge, Midwife
Currently health care is the largest growing area of the employment sector. It is difficult to tease out exactly how fast the midwifery area is expanding. With the overall growth in health care, and the increasing interest in holistic alternatives, it appears midwifery will continue to grow. More and more women are turning to midwifery because they view mid-wives as more personal than busy obstetricians. The drug-free and non-institutional settings are an appealing alternative for many women. In addition, the sustained popularity of midwifery in other countries demonstrates the timelessness of this profession.
The salary of a lay midwife varies depending on the number of clients she can attract. Most women do not enter this profession for the financial rewards, and midwives tend to have reasonable fees that are much lower than the cost of a traditional hospital birth. A typical fee for a midwife is approximately $2000 per birth. Midwives tend to charge one fee, which encompasses the entire package of care: prenatal, birth, and postpartum care. The yearly salary depends on the number of women in the area having babies and how well the midwife can market her services. Many midwives in private practice start their business slowly. Twelve to fifteen births a year could be considered the equivalent of working part-time. There are midwives working in clinics or group practices who deliver many babies each month. The earning potential varies depending on geographic location, proximity to hospitals, work setting, and competition from other midwives or certified nurse midwives.
Insurance coverage of midwifery services will help increase the number of women who can afford to use a lay midwife. Currently, most clients pay out of pocket. Some insurance companies are starting to cover lay midwifery services because it is more cost effective compared to hospital births.
Certified nurse midwives often earn higher salaries than lay midwives because they tend to work for hospitals or obstetric groups. A typical salary for a nurse midwife is $55,000 to $70,000 annually. They also receive benefits and can have a more structured schedule because they share being on call with other doctors and certified nurse midwives. Insurance companies typically cover certified nurse midwife care.
