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Nursing Midwives in the Medical Field

Aug 17, 2007
Midwifery is the term traditionally used to describe the art of assisting a woman through the process of childbirth. In the modern context, this term is used to describe the activities of these health care providers who are experts in women's health care, which includes giving prenatal care to expecting mothers. They attend the birth of the infant and provide postpartum care to the infant and mother. Practitioners of midwifery are known as midwives, constituting a small but visible minority of the health care field.

Midwives are autonomous practitioners who are specialists in matters regarding normal pregnancy, childbirth and postpartum. They generally work to ensure that women under their care have a healthy pregnancy and natural birth experience. Recognized by most of the field as primary care givers, midwives are trained to recognize and deal with deviations from the norm. Obstetricians, on the other hand, are specialists in illnesses related to childbearing. The two professions can be complementary, but are often at odds with each other, since obstetricians are taught to actively manage labor, while midwives are taught not to intervene unless necessary.

Midwives refer a patient to an obstetrician when a woman requires care beyond her area of expertise. In many jurisdictions, these professions work together to provide care to childbearing women, while in others only the midwife is available to provide care. Midwives are trained to handle just a few situations that are considered abnormal, including breech birth and posterior position, using non-invasive techniques. In many areas of the world, traditional midwives, called "traditional birth attendants" by the World Health Organization (WHO), are the only available providers for childbearing women. In the United States, they are divided into nurse midwives and direct-entry midwives.

A nurse midwife is a midwife who enters midwifery after first completing a full accredited nursing education program. All nurse midwives have their Bachelor's degree, and the great majority have Master's degrees as well. Nurse midwives deliver about ten percent of the births in the United States, and a slightly greater percentage in most other Westernized countries. Most operate only out of hospitals, since they are prevented by malpractice insurance rules and other concerns from performing home deliveries. Many would prefer to have the option of also being allowed to work outside the hospital.

American nurse midwifery originated during the Great Depression as a service for poor families in rural areas with little access to physicians. They gradually shifted their focus to the inner city, which was becoming the locus of much of the poverty and poor medical care in America of that era. At first, nurse midwives were considered marginal members of the medical community at best, which considered delivering babies to be the exclusive domain of obstetricians. With years of lobbying and shifting cultural mores, they have gradually become accepted as full partners in the medical field. With this acceptance has come limitations; there are requirements that nurse midwives practice under the supervision of an obstetrician and meet restrictive insurance requirements preventing them from having the freedom in their practices that many would prefer.

Direct-entry midwives are a separate category. These are midwives who have entered the practice of midwifery directly, without first passing through nursing training. In the Western nations, direct-entry midwives handle only two percent of all births, with the exception of a few European countries where the number is closer to twenty-five percent. Modern direct-entry midwives have their origins in the lay midwifery movement of the 1970s, but as they gradually professionalized and gained a body of experience, many came to prefer the term direct-entry as a profession in it's own right.

Direct-entry midwives mostly deliver children in the home of the patient or in birth centers where they run their practices. Most direct-entry midwives are still not allowed hospital privileges at all, and their practice remains totally illegal in nine states in America, where they are liable to be arrested for practicing medicine without a license.

Direct-entry midwifery began as an organic response to the many counter-culture movements in the late 1960s and 1970s, based on a distrust of traditional procedure and unnecessary technology, and also the feminist call for a more woman-centered worldview. Direct-entry midwife centers sprang up independently in several different regions of the country, most notably in Santa Cruz, California, Vermont, and the commune known as "The Farm" in Tennessee, which was the home of founding mother Ina May Gaskin. At that time it was mostly an internal way of dealing with birth for drop-outs who had left most of the institutions of traditional society behind them to join the commune environment, but as those drop-outs began reintegrating themselves with mainstream culture in the 1980s and settling for the jobs and house in the suburbs after all, they took the practice of midwifery with them, and thus began a long process of making midwifery a profession all on it's own.

The controversy between nurse midwives and direct-entry midwives has been pretty stormy. Nurse-midwives feel that their direct-entry counterparts undermine the years of work they have done to have midwifery be accepted as a fully legitimate and scientific enterprise, and they tend to be suspicious of direct-entry midwives' lack of formal college-level training. Direct-entry midwives, from their side of the issue, criticize nurse-entry midwives as having abandoned the values which make midwifery distinct from obstetric practice. They also fear and resent the efforts which some nurse midwives have made to make the practice of midwifery without nurse's training illegal.

Nobody has said the word "monopoly" yet, but it's clear that midwives and particularly direct-entry midwives might feel that this is just what the child-birthing industry suffers under. In the United States, midwifery is still seen as a dodgy practice, and obstetricians range from acceptance to hot protest. Considering that there are many fields in medicine, such as physician's assistants, where practice is also not allowed without direct supervision by a more educated overseer, many have asked what would be the harm in nurse midwives practicing under supervision as they have been doing. This controversy may yet reveal deep-seated animosity between political camps of health care workers before it plays out.
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