TYPES OF MIDWIFERY TRAINING: AN ANTHROPOLOGICAL OVERVIEW
by Robbie Davis-Floyd PhD
This article appears in
Pathways to Becoming a Midwife: Getting an Education,
eds. Joel Southern, Jennifer Rosenberg, and Jan Tritten.
Eugene, Oregon: Midwifery Today, 1998, pp. 119-193.
Copyright is held both by Robbie E. Davis-Floyd and Midwifery Today, 1998.
Either copyright holder may give full permission for this article to be reprinted or reproduced.
Robbie E. Davis-Floyd hereby gives permission for this article to be copied and distributed
for educational and informational purposes.
Potential midwives reading this book will want help in picking their educational path. Hoping to be of assistance, I offer the following brief overview. (More thorough and detailed overviews can be found in Frye 1995: 22-26 and Rooks 1997:164-178, 258-268). As I worked on this overview, I found it extremely difficult to make any kind of generalization that I could be sure was true. The differences between types of midwifery training are no longer easy to define: what I witnessed as I talked to midwives about this article was what anthropologists might call an elision between models of midwifery training (to elide in linguistics means “to slur over in pronunciation”). As you will see below, these models are increasingly blurring into each other.
The only hard and fast distinction I can make is the one between programs accredited by the ACNM’s Division of Accreditation (DOA) and programs accredited by MANA’s affiliate, the Midwifery Education and Accreditation Council (MEAC). In terms of experience and longevity, these two are not appropriately comparable: the DOA (under various names) has been in operation since 1957. During that time, it has accredited well over 50 nurse-midwifery programs and has pre-accredited two direct-entry programs.1* MEAC has been in existence only since the early 1990s; it has accredited or pre-accredited 7 programs. If comparisons are to be made, it would be fairer to compare MEAC to the DOA as it was during its first decade. But this overview is not intended as an evaluation of either the DOA or MEAC, and I need a way of organizing the programs I will compare. Accordingly, I have organized this overview into two sections based on the distinction between DOA- and MEAC-accredited programs. Where I have enough information, I present the upside and the downside of each educational route.
Some of the information I present comes from the 60 interviews I have conducted over the past 4 years with both direct-entry and nurse-midwifery students or recent graduates. I make an effort to talk with them wherever I find them–I do not pretend that my sample here is representative. I include this kind of anecdotal information to help prospective students know in advance what to watch out for, so that they can work to obtain the best education possible through their chosen route.
The background knowledge necessary for a full understanding of this overview can be found in the preceding article on “The Ups and Downs of Nurse- and Direct-Entry Midwifery: An Anthropological Perspective.” In what follows, the reader’s familiarity with the information presented in that article is assumed. It is important to remember that first and foremost, the aspiring midwife should look clearly at her personal and career goals, her family and financial situation, and her learning style. Having taken stock, she should then explore all the options that offer what she needs.
ACNM DOA-ACCREDITED PROGRAMS
Fifty programs accredited by the ACNM’s Division of Accreditation were in operation at the end of 1996. All of them are university-affiliated or university-based, and all qualify their students to practice at a safe, beginning level, caring for women during pregnancy, birth, and the postpartum period (and now across the life cycle), and equipping them to participate in health care institutions (hospitals, birth centers, and managed care organizations) and sometimes to manage private practices. The majority of faculty in these programs must be CNMs; faculty positions can also be held by experts in a given area, including MDs, PhDs, nurse-practitioners, etc. Clinical supervision is always the responsibility of CNMs or CMs. In-hospital training is the norm. The availability and depth of both didactic teaching about and clinical experience in out-of-hospital birth can vary considerably from program to program. Out-of-hospital clinical experience is not required for certification or for program accreditation.
Every program includes specific criteria for entrance, structured learning objectives that work to ensure that every student masters the required body of knowledge, formalized didactic instruction, clinical experience with more than one clinical instructor, and involvement of several faculty members in judgment about the student’s ability to provide safe, effective beginning level midwifery care. (An update on the status and number of DOA-accredited programs is published every year in the Journal of Nurse-Midwifery. For up-to-the-minute information, contact the ACNM national office and ask to speak to staff members from the DOA.) Nurse-midwifery educators have long been leaders in educational innovation, and they continue to develop and refine creative and interactive learning and teaching methodologies.*2
While most DOA-accredited programs are well-established and solidly funded, like all academic programs some are subject to sudden budget cuts, departmental reorganizations, and streamlining procedures. It is important to research the refund policies, educational and disciplinary policies, reputation, and success rate of a school thoroughly before enrolling. Talk to enrolled students and graduates. Are they receiving or did they get what they expected? Are they happy with their education? Were all policies, fees, and expectations disclosed to them?
University-Based Programs
Upside: This kind of training is in alignment with the values, beliefs, and status consciousness of mainstream society; it is culturally thought of as the bottom line for white-collar professions. As a socially valued educational pathway, it carries concomitant benefits, including social recognition and prestige, easy access to government loans, and straightforward routes to advanced degrees, which bring prestige and salary raises and empower their recipients to teach, to start new programs, to effect changes in legislation, and to carry out research on client needs and various aspects of midwifery care. (In general, the higher the level of university training of a group of professionals, the higher the social prestige of the entire profession.) Being present on a university campus enables students to learn about and participate in a wide variety of learning experiences and gives them access to excellent libraries and other resources. University students have the opportunity to gain a liberal arts base in disciplines designed to expose the student to different points of view and ways of understanding the world, including the humanities, psychology, sociology, and the basic sciences, with the ultimate goal of making the student a “well-rounded” person.
While didactic learning is usually primary in universities, midwifery training, like training in other health care professions, always includes some form of preceptorship, in which students are exposed to one-on-one experiential learning with more than one preceptor. Because the clinical parts of university-based midwifery training are mostly carried out in hospitals (some university programs make an effort to provide their students with some—albeit limited–out-of-hospital experience), students also are exposed to and develop expertise in dealing with individuals of diverse sociocultural and economic backgrounds, a wide range of birth complications and unusual health conditions, and the latest and newest in medical technologies. Educators generally work with students to help them develop a critical sense of which technologies have efficacy, under which circumstances, and which ones do not. (The only currently operating DOA-accredited direct-entry program is university-based, at theSUNY-BrooklynHealthScienceCenterinNew York City(aka SUNY downstate).)
I have interviewed students from university-based programs across the country, includingNew YorkUniversityandColumbiaUniversityinNew York, theUniversityofPennsylvaniain Philadephia,CaseWesternUniversityinOhio, and theUniversityofCaliforniainSan Francisco; for the most part, they rate their programs very highly, usually giving them an 8 on a 10-point scale.
Downside: The vast majority of university-based programs require that the student leave home for an extended period to attend, and almost all still require nursing training, including the fast-track programs at Yale, Columbia, and UCSF. The 30 students I have interviewed about their nurse-midwifery educational experiences were unanimous in agreeing about the downside of nursing training: it socializes them into an attitude of subordination in the medical hierarchy that they must work to overcome once they begin clinical study as midwives. It can also derail their lives and career goals: there is a strong ethic in nursing that (1) you are not really a nurse unless you have practiced for at least 3 or 4 years, so students are expected by their nursing instructors to “put in their time” ; and that (2) you shouldn’t become a nurse-midwife without practicing as a labor and delivery nurse for several years first. The required nursing education can be completed in most programs within a year and a half, but some of the students I interviewed reported being heavily pressured to practice as nurses for an extended period before entering midwifery training. Some succumbed, some resisted, but all resented the pressure and the nursing belief that you are not well-qualified to be a midwife if you haven’t practiced as a nurse. Much less of this sort of pressure is experienced by students who enter the fast-track programs mentioned above, which are designed to make their students nurses solely so that they can become midwives; in such programs a briefer (one year) passage through nursing is the norm.
Tuitions in university-based programs range widely. Some university programs have tuitions of under $20,000. Three students I interviewed graduated with debts in student loans of over $100,000. More common were debts of around $70,000. If money is a major issue, the prospective student would do well to shop around. Some students manage to go through their entire nurse-midwifery education without incurring debt. They may participate in work-study programs or work part-time, often as nurses, and apply for scholarships and grants (Cecilia Wachdorf, personal communication.)
A criticism often leveled at university training is that its standardization stifles individual creativity. I have not found this criticism to apply to the nurse-midwifery students I have interviewed. In our conversations, it was clear that they are accustomed to thinking “out of the box.” They reported that this kind of unbounded thinking is strongly encouraged by most of their teachers. Nevertheless, a very real downside to university-based nurse-midwifery education is that training offered in large cultural institutions such as universities will inevitably reflect hegemonic philosophies and practices. In the cultural realm of birth, the patriarchal medical model is hegemonic; midwifery training carried out in such institutions will inevitably incorporate many elements of a highly medicalized, patriarchal, and technocratic approach to birth. Thus, midwives will often be required to intervene in birth in ways contrary to the midwifery model in order to successfully graduate.
For example, some SNMs (student nurse-midwives) have discussed with me in interviews their distress over the unnecessary interventions they are often asked to perform. They report that they are usually able to resist cutting unnecessary episiotomies (four of my most recent interviewees had only cut one during their entire training), but that there is no way to get out of applying the other interventions that are standard in most hospitals, such as routine monitoring, labor induction and augmentation, IV administration, analgesia, etc. The early exposure to birth complications that many student midwives experience often makes them afraid of birth—a fear that can translate into overdependence on medical technologies and a lack of the confidence needed to become guardians and guides of the natural process of birth. It is important to know that the level of medicalization of nurse-midwifery education varies from program to program. Some university-based programs are highly humanistic and woman-centered in their approach; others are far more oriented toward technomedicine.
The graduates of university-based programs with whom I have spoken generally appreciate their training and value their technical skills. Some also express a fear of all the things that can go wrong at birth, note their dependence on support from other hospital personnel, and wonder how that fear and that dependence will affect their development as midwives.
Some students complained that they were ill-prepared for the private practices they tried to open because they were not taught business skills or how to deal with insurance forms and companies. Several recent grads have told me that they had tried to attend home births, but soon realized that they were totally unprepared for out-of-hospital practice. Indeed, lack of home birth training opportunities was a major complaint voiced by all of my student interviewees.
The second most serious complaint, also voiced by all my interviewees, was that during their training, their potential role as primary health care providers was heavily stressed, but upon graduation, none of them felt qualified to provide primary health care. (Some of their Instructors have told me that they shouldn’t worry: having obtained the theory and the knowledge in school, they will gain the necessary experience after graduation.) Two complained that they did not get enough practice in neonatal resuscitation and infant examinations, because those were taken care of by neonatal nurses in the hospitals where they were trained. And four complained about an abusive instructor or preceptor. (Since faculty in such programs are continuously evaluated, it is unlikely that such situations are allowed to continue.)
Another major source of stress was reported by SNMs who enter programs in which clinical and didactic components are separated in time. About half of my interviewees were in programs in which they studied didactically for a year before gaining any clinical experience. They found this both frustrating–a further delay in their desire to practice midwifery–and “disconnected.” They struggled to learn the didactics in isolation, often finding that the information made no sense in the absence of hands-on experience. Then later when they gained the hands-on experience, they had to link it back to a piece of information they had intellectually acquired over a year earlier. In group discussions between my interviewees, there was unanimous agreement that those who had been in progams in which clinical and didactic work happen in tandem from Day One had received a much more viable and rewarding training experience.
University-Affiliated Distance Learning Programs3*
Upside: These programs creatively combine formalized, modular education with community-based and at-home learning. They allow the midwife to learn in evaluable components, interacting via computer (and occasionally in person) with other students and with various faculty members, and to be preceptored one-on-one by a nurse-midwife in her community. Unlike the situation in university-based training programs where each student has a variety of preceptors, the student-preceptor relationship in distance programs may be a much closer one, more like the intimate, trusting relationships developed in apprenticeship training. Such a relationship can be an extremely productive context within which to develop both midwifery skills and self-confidence. And it is often supplemented by exposure to other preceptors when the student is trained in multiple sites. Distance programs also combine some of the advantages of university-based education (social prestige and status, access to advanced degrees), with the advantages, especially for women with children or other family demands, of becoming a nurse-midwife without having to leave home for more than brief periods every year. And they are more likely to include training for out-of-hospital birth than most university-based programs.
The largest DOA-accredited distance learning program is the Community-based Nurse-midwifery Educational Program, better known as CNEP. It was specifically designed “in response to the need to prepare more nurse-midwives, to prepare nurse-midwives for practice in birth centers, and to make it easier for women living in small towns and rural areas to become CNMs” (Rooks 1997: 167). This program has been extremely successful. From its inception it tapped into a large pool of obstetrical nurses who wanted to become nurse-midwives but were not free to leave home for the necessary two years of study. For the same reasons, it has also attracted many direct-entry midwives who wanted to become CNMs. By reputation, the CNMs produced by the CNEP program acquire the same level of technical expertise as other CNMs, yet are also among the most holistically oriented and least medicalized of nurse-midwives, and tend to be very community-oriented. (For a detailed description of the CNEP program, see Rooks 1997:167-170.) I have interviewed 5 recent CNEP graduates; all were in general very happy with their learning experience (the downside exceptions are described below).
A number of other DOA-accredited programs also offer distance tracks for nurse-midwifery students; check with ACNM for up-to-date information. I have not studied these programs, and thus cannot speak to their individual pros and cons. Should DOA-accredited distance programs for direct-entry students be developed, I’m sure they will be very successful; there are many women who want to be midwives but cannot leave home to study and do not want to become nurses. (SUNY downstate has recently hired a new faculty member to develop a distance direct-entry program.)
Downside: A student’s ability to enter a distance program will depend on whether she can find a CNM who practices within driving distance willing to serve as her preceptor. Should this one-on-one relationship not prove to be a compatible one, the student may have difficulties completing her training. I have been told of two incidences in which this preceptor-student relationship was extremely trying for the student; such problems seem rare.
Perhaps the major problem with distance programs is the sense of isolation students often experience–the feeling that “I am all alone with my computer.” Distance students often try to organize study groups with other students within driving distance, which sometimes works and sometimes doesn’t. “Nobody walks you through it,” said one student. “Nobody spoon-feeds you the information. You’ve got to be highly motivated to do the work on your own.” (This is also true in modular university-based programs in which the students must creatively problem-solve. “Spoon-feeding” is most common in programs based around the didactic lecture format.) For those who are highly motivated, such programs can be ideal. One of my CNEP interviewees, who had no family and “really got into it,” reported that she “whizzed through” the program. But the other four reported major difficulties in staying on track. They noted that those who are not so self-disciplined, or who try to work full- or part-time as nurses, have a family life, and still complete the CNEP program, often have bouts of succumbing to panic and despair. A common reaction is to avoid the computer for days or weeks at a time. Failing to log in regularly, my interviewees reported that they fell more and more behind, then were afraid to log in and find out how far everyone else had progressed. Each one of the four thought that she was the only one who had let this happen; all were surprised to find how much company they had had without knowing it! In the end, they all “got their act together” and got through; their advice to others is to “stay in touch with total regularity” and to report and ask for help with any problems. The help is there, they said, but you have to ask for it.4*
All five CNEP graduates reported that, as in some university-based programs discussed above, their didactic and clinical work was completely separate. The first year of study is spent on computer; none of them were allowed to begin clinical work with their preceptors until the second year. Those who were working as labor and delivery nurses didn’t mind this disjuncture so much, but those with little nursing experience, or who had not worked as nurses for some time, did find the same problems with this disjuncture that I describe above. On the other hand, there is value in working full time with a preceptor, which enables the student to offer and to learn about the importance of continuity of care, as opposed to participating in more structured university-based programs, where student’s busy schedules often do not allow them to stay the course with a given client.
Another downside of distance programs as of this writing is that all current DOA-accredited distance programs still require nursing training as a prerequisite (this will soon change). I do not have information about other potential downsides to distance programs; I have only interviewed a few CNEP graduates, who were all very happy with their education. I suggest that any students seeking to enter a particular distance program talk to a number of its graduates.
MEAC-ACCREDITED PROGRAMS
All MEAC-accredited programs qualify their students to practice at a safe, beginning level, caring for women during pregnancy, birth, and the postpartum period, and equipping them to run independent midwifery practices. Most faculty in these programs are direct-entry midwives; some are CNMs. These programs prepare direct-entry midwives primarily for out-of-hospital practice. Hospital training is available in only a few such programs; such training is generally not required for certification or for program accreditation. All comply with MEAC standards relating to midwifery philosophy, curriculum, faculty, students, facilities and resources, credit hours, student services and resources, admissions and enrollment policies, financial management, and student success in relation to mission (Mary Ann Baul, personal communication). These programs have undergone comprehensive study and peer examination, which have ascertained that the program directors have set structured learning objectives, provided services that enable students to meet those objectives, and can, in fact, show that graduates have benefited from the learning experiences provided.
Every MEAC-accredited program offers a combination of formalized didactic instruction and one-on-one clinical experience, usually with more than one clinical instructor, and involvement of several faculty members in judgment about the student’s ability to provide safe, effective midwifery care from the prenatal through the postpartum period in out-of-hospital settings. MEAC accreditation indicates that the school adheres to established criteria, policies and standards, thereby providing an assurance of quality for employers, educators, government officials, and the public (Mary Ann Baul, personal communication). (For more detailed and up-to-date information about MEAC-accredited programs, contact MEAC, 220 W. Birch,Flagstaff,AZ86001, or electronically at amabaul@aol.com and/or see listings published annually in the MANA News.) MEAC educators are developing flexible, creative, and innovative models for on-site and distance learning that creatively combine didactic instruction and self-paced learning with apprenticeship.
One of the factors prospective students should evaluate is the financial stability and resources of the program. All accredited programs must have refund policies, and policies to finish training their enrolled students even if the school must close. It is important to research the policies, reputation, and success rate of a program thoroughly before enrolling. Talk to enrolled students and graduates. Are they receiving or did they get what they expected? Were all policies, fees, and expectations disclosed to them? Are they happy with their education?
College- or university-based direct-entry programs:
Confounding my attempts to use “university-based” to distinguish DOA- from MEAC-accredited programs is theMiami-DadeCommunity CollegeinMiami,Florida, which offers a three-year program (opened in 1996) leading to an associate in science degree in midwifery. In addition to didactic training in the basic sciences and humanities, the program includes a strong apprenticeship component. Additionally, students have access to high-tech equipment and a variety of clinical experiences in hospitals, public health facilities, birth centers, and home birth practices inFloridaand at a high-volume hospital inJamaica. Since ACNM will soon require the baccalaureate, this community college model, which combines the advantages of a college education with a deeply held commitment to independent midwifery, seems especially appropriate for replication elsewhere.
Further blurring the boundaries between DOA-accredited and other programs,BastyrUniversityinSeattle,Washingtonoffers midwifery training for naturopathic physicians in a program that blends these two complementary professions. I mention it only for its uniqueness; it does not properly belong in this discussion as it has not sought MEAC accreditation, but rather is accredited by the naturopathic accrediting body.
Private midwifery schools, some of which are degree-granting:
Upside: Private schools can create and teach any model of midwifery they please, free of the hegemonic influence of technomedicine that is pervasive in university-based training. They can offer highly tailored, focused, and formalized combinations of apprenticeship and didactic training that can meet established standards and be easily and continually evaluated, while at the same time keeping their philosophy and practice holistic and woman-centered. They usually offer courses not only in clinical training but also in midwifery philosophy and the practical side of how to run a midwifery business. And, unlike one-on-one apprenticeships, students in these schools have exposure to several primary faculty members who are in teaching positions because of their demonstrated expertise, and can interact with and learn from each other. Some schools offer extensive additional training in herbs, homeopathy, and/or other forms of alternative medicine. Most educators in these schools seek to imbue their students not only with technical knowledge but also with a philosophy that stresses the importance of honoring and respecting the sacredness of women’s bodies and the ever-present spiritual dimensions of pregnancy and birth.
Two of the private schools that are MEAC-accredited or in the process of becoming so offer advanced degrees recognized by the states in which they operate: the Utah School of Midwifery in Springville, Utah, which offers the Bachelor’s and Master’s degrees; and the National College of Midwifery in Taos, New Mexico, which offers degrees all the way up to the PhD. Both of these programs have strong apprenticeship components and are extremely affordable.
Downside: Some private midwifery schools are expensive and thus out of the reach of many potential students, while others are quite affordable: the tuitions of the MEAC-accredited private schools range from $8000 to $22,000 (for the whole program). The expense of these private programs can be quite a lot higher than the expense incurred in an apprenticeship. Universities may be equally or more expensive, but federal loans and grants are often available to help with university tuition; such aid is generally not available to students in private programs. (It will become available if MEAC is successful in gaining Department of Education recognition [see the preceding article, endnote 35.]).
Like university programs, private schools require moving from one’s home to the location of the school (unless they have a distance education element). They are often organized around the strong personalities of one or a few experienced midwives and will inevitably reflect their individual values and styles. Many private midwifery schools have an “overseas” component, which is an added expense. Like some nurse-midwifery programs, midwifery schools are continually challenged to find enough births, especially out-of-hospital births, to meet the experiential needs of students. Students may be “placed” with a midwife for an apprenticeship for a period of time. Usually this works well, because mentors are allowed to choose the students they wish to work with. I have heard of three instances of problems between the mentor and the student involving personality conflicts or the imposition of unusual and extreme duties. Such occurrences are rare: in accredited schools all mentors and faculty are evaluated and students have opportunity for feedback and grievance procedures, so that abusive or extremely demanding relationships are not allowed to continue.
Another problem faced by private schools is the fact that taking the middle ground of combining formalized education with MANA’s holistic midwifery model can subject them to criticism from both sides: (1) many in ACNM denigrate them as “trade schools” that do not guarantee the broad education that university training does; and (2) some proponents of apprenticeship training occasionally criticize them for offering a didactic approach that over-emphasizes what can go wrong and, like university-based CNM programs, can sometimes produce midwives who fear birth.
While the caveats are many, the rewards can also be great: the 7 graduates of private midwifery schools whom I have interviewed generally seem thrilled with the individualized education they have received and the holistic, woman-centered philosophy that permeates their education.
Distance learning programs (see endote 3), which now include apprenticeship.
Distance direct-entry programs like the National College of Midwifery inTaos(which has applied for MEAC accreditation) and the two MEAC-accredited distance programs offered by the Utah School of Midwifery and the Midwifery Institute of California will no doubt form a major part of the wave of the future in direct-entry education. Whether under the aegis of MANA or the ACNM, the benefits of programs that allow student midwives to remain in their own communities are clear.
Apprenticeship
Upside: Midwifery educator Sharon Wells provides the following apt description of apprenticeship:
This student is in an experientially-based educational setting that is client-centered. This student’s education is self-paced, self-motivated and community-oriented. The learning occurs within the setting of the midwifery practice and not at a separate clinical site. Most learning is experiential and/or problem solving in nature. The didactic occurs by self-study, guided study courses, or workshops. The educational focus is upon normal pregnancy, labor, delivery, postpartum and the newborn. This midwifery student learns continuity of care, counseling skills, and to trust her own intuition in addition to her midwifery skills. The length of this educational process depends upon the apprentice and the midwife, but usually lasts from two to four years. The mentor may suggest using core competencies and a skills check list if they are available. “Graduation” occurs when the senior midwife and the apprentice think the apprentice is ready to function as a midwife safely on her own. Most births occur at home.5*
Apprenticeship learning involves the whole human being–body, emotions, mind, spirit– and therefore is the most powerful form of learning there is. We all learn to be full members of our cultures through this kind of experiential learning. Pure apprenticeship learning is connection-based, as opposed to didactic learning which can seem to take place in a vacuum, with no apparent connection to anything. If the apprentice attends a birth with her mentor, for example, during which the woman hemorrhages, the apprentice will spend the next day studying every book she can find on postpartum hemorrhage and quizzing her mentor about its management. She knows, in an immediate and visceral sense, why this knowledge matters.6*
Because birth turns out well most of the time, apprentices attending home and birth center births usually are not exposed early on to pathology, and have the time to build up a profound trust in process of birth and in women’s ability to give birth. Their training gives them a much broader experience of the wide range “normal” birth can take when it is not technologically controlled. (See preceding article, endnote 8.) The establishment of this kind of trust can have a great deal to do with the relationship between the apprentice and her mentor. I have interviewed a number of apprentices and mentors around the country, and am always impressed by the special quality of their relationship. Most mentors care deeply about the apprentices they take on, get to know them intimately, become committed to making sure they obtain the best education possible, and work to bolster the student’s trust both in birth and in herself as she learns.
To fear birth is to generate complications that result from the fear. Midwives who trust birth profoundly tend to help women give birth more effectively: to trust a woman to give birth is to help her trust herself–this is part of the magic and the great strength of apprenticeship training. Another part of that magic and strength is continuity of care. In high-volume programs, continuity of care can be very hard to achieve. But it constitutes part of the essence of apprenticeship training, where the student accompanies her mentor not only to the birth of a given client but also to every prenatal and postpartum visit. It is apprenticeship training that establishes the midwifery ideal for continuity of care, an ideal that other training programs do the best they can to emulate.
As Wells indicates above, pure apprenticeship training, which includes few didactic elements, is increasingly rare. Today’s apprentices are developing experiential trust in birth and learning continuity of care in the context of semi-structured curricula that their mentors design to make sure the training meets the standards set by NARM. These curricula include a tremendous amount of reading and often involve weekly classes taught by midwives in their communities, which may be supplemented with college courses in the basic sciences and other relevant areas. Many apprentices complete their training by working in high-volume clinics in theU.S.or theThird Worldwhere they can be exposed to multiple complications of birth and can learn to deal with them effectively.
An additional benefit is that apprenticeship is both financially and geographically accessible. Women who do not have the money or the mobility to attend a private school or university-based program can still learn how to be competent practitioners and build an economically viable business to support their families while serving their communities.
Downside: Apprenticeship learning, because it is so fluid, can be hard to evaluate for efficacy. The success of the process can depend on the skills of the mentor; having just one person involved can offer opportunities for subjectivity that are reduced when several faculty have had experience with a student. Pure apprenticeship is only as excellent as the teacher and the student make it. If the learner is not motivated, the greatest teachers cannot help her. If the teacher is not a good teacher, the learner will be challenged to obtain the needed education. There is the additional risk that the learner may not be able to judge whether she is getting a quality, thorough preparation. If the student has only one mentor, and if that mentor is deficient either in knowledge, clinical judgment, skills, or the abiliity to interact with clients, the student can be at risk, and therefore the future clients she may serve. If the apprentice does not learn sufficient skills for entry-level practice, then moves to a different community, there may be no one to judge her competence. These are in fact some of the reasons why many direct-entry educators are working to combine apprenticeships with more didactic models.
Apprenticeships can span the spectrum from inspiring, loving mentorships to abusive, traumatic relationships. (Of course, so can clinical preceptorships within universities, much like what residents/interns go through in the last years of medical school.) Abusive student-mentor relationships should under no circumstances be allowed to continue. In a school or university setting the student will be helped to end such a relationship and will be encouraged to give feedback so that other students will not have to endure the same. Ending one-on-one apprenticeships without such institutional support can be more difficult for the student. (On the positive side, I have interviewed over 20 apprentices and many of their mentors across the country, and in general find this to be a very special and mutually nurturant relationship in which the mentor is almost always deeply committed to responsibly working with and caring for her student.) Most experienced direct-entry midwives take very seriously their obligation to mentor the students seeking to follow in their footsteps. But at present there are relatively few experienced direct-entry midwives available to serve as mentors. As their numbers increase, more student options will obviously become available. Students should know that many apprentices work with more than one mentor, sometimes traveling to live with their second mentor for extended periods, in order to ensure that they have exposure to more than one style of practice.7*
Until recently, apprenticeship training in midwifery carried no certification and had no standards—in part, CPM certification was developed to address this lack. Apprenticeship training alone is in general not recognized in the technocracy as a valid educational route in most professions, although because of its unique combination of intimacy and efficacy, there is a growing trend in adult education toward re-valuing apprenticeship (aka mentorship) as a viable educational style for the 21st century.*8
And as I hope all the above has made clear, there is also a growing convergence between experiential apprenticeship models and more formalized didactic midwifery education. Good luck, and don’t forget to honor your sisters and their educational choices!
Endnotes
1. The two direct-entry programs I know of that have been pre-accredited by the DOA are at SUNY-Brooklyn and at Education Program Associates (EPA) inSan Jose,California. Due to financial difficulties, the entire EPA program, including both its nursing and direct-entry tracks, has been closed.
2. Johnson, Peter G. and Judith T. Fullerton. “Midwifery Education Models: A Contemporary Review.” Journal of Nurse-Midwifery 43 (4); Sept/Oct 1998, in press.
3. Mary Ann Baul, the Executive Secretary of MEAC, provided the following useful overview of distance learning (personal communication 1998):
Distance learning, in order to be effective, should offer a complete program, in as much depth and with the opportunity for student support as in an onsite program. It should be collaborative (that is–there should be interaction between faculty and students, and even better, interaction among different students in the program, whether real-time or time-delayed.) It should have specific learning outcomes for each course, and a way to evaluate those outcomes based on standards. Its faculty should be well-qualified as both instructors and also have training in distance learning and education technologies. There should be a strong commitment by the program to provide support for both faculty and student services. The program should have very clear expectations and guidelines, with appropriate access to needed resources. it should be evaluated as to its efficacy regularly, by students, administrators and instructors. Of course, there is no way to learn midwifery solely by distance education. There must be a very strong, highly supported and guided preceptor or mentor in the student’s community in order to teach her the clinical skills required to complement the didactic learning at a distance. There are five types of distance learning, with upsides and downsides to each type. They appeal to and are successful for different types of learners. I will list them and briefly go over benefits and disadvantages.
1. Correspondence courses. These are paper-based, so they don’t require a lot of technology, but students taking them rarely talk to faculty or other students. Such courses may not have deadlines, so student must be very motivated with lots of self-discipline to finish the program.
2. Mentored or directed study. Can also be paper based, or partly on computer, but student has communication with a faculty member. Usually there are fewer deadlines or scheduled interactions than in on-site programs, so again, students must be very self-directed and motivated.
3. Online education. Here, students use a variety of interactive technologies, such as logging on to a chat room, to discuss ideas and work on projects with other students, as well as doing outside reading and assignments. There are regularly scheduled times for work together and with instructors, which are very good for interaction with other students and faculty. However, this can be very time-consuming, and the technology can be challenging and complex. The student will have great need for techological support to get the work done, unless she has excellent computer skills.
4. Internet-based education. This is where the instructor speaks to the student over the Internet (like television), but then is also able to interact with the student and expect assignments within limited time periods. (SUNY-Stonybrook’s entire distance program is available via the Internet.) The instructor guides the student to research on the Internet. The technology can also be intimidating to the student here.
5. Video correspondence. An instructor is taped on site giving a class. The video is sent to the distance student, along with reading and work assignments. The upside is that the student gets to see hands-on demonstrations and note how other students are reacting to the instructor. The downside is that her particular questions may not be answered.
The two distance learning types most commonly used in direct-entry midwifery education are correspondence, and directed study; online education is sure to follow. Nurse-midwifery programs like CNEP make extensive use of online education, Internet chat groups and bulletin boards, etc. Students should know that completion or success rates are higher for students who have scheduled class periods, clear assignments, and deadlines, as well as interactions with other students and teachers for support during the learning process. If distance learning encompasses these components, the student has a better chance of succeeding.
4. Researchers Carr, Fullterton, Severino, and McHugh (1996) found that the degree of dedication to the program of study, the amount of time students set aside to study, and whether or not the students had a study partner were all significant predictors of whether individuals would drop out or would complete the distance program in which they were enrolled. (Katherine C. Carr, Judith Fullerton, R. Severino, and M. Kate McHugh. 1996. Barriers to Completion of a Nurse-Midwifery Distance Education Program.” Journal of Distance Education 9:111-131.)
5. Sharon Wells, “Caught in the Middle of the Maternity Care Crisis and a Political-Educational Debate,” Birth Gazette, Spring 1993 9 (2):16-19.
6. Nurse-midwifery educators point out that this kind of connected learning is not unique to apprenticeship, but is a common feature of nurse-midwifery education as well. I find that it is a question of emphasis—nurse-midwifery programs stress didactic learning according to a pre-set study schedule; aside from that, the student is also free, if she has time, to study whatever she likes on her own and to discuss whatever comes up with her preceptor. Apprenticeship programs stress experiential learning according to the rhythms of individual women and individual births; didactic learning takes place away from the client and thus tends to be less immediately connected to the situation at hand. But some university-based programs utilize a case study approach, which combines experiential learning with synthesis of new information and critical thinking and analysis
7. An example of the eclectic form many contemporary apprenticeships take is provided by well-known childbirth educator and author Nancy Wainer Cohen, who underwent two years of apprenticeship training with a midwife inBostonwhere she lives, interspersed with periodic trips toMichiganfor weeks at a time to apprentice with Valerie El Halta. Toward the end of this process, she spent 8 weeks inEl Pasoat Casa de Nacimiento and two weeks with Shari Daniels inJamaica; in both places, she attended many births in short order and learned to deal with a wide range of complications.
8. An example comes from the high-tech computer industry, in which many young people without college degrees are receiving on-the-job training from mentors within a given company in specialized computer skills not taught in universities (Kate Bowland, personal communication).
Author bio:
Robbie Davis-Floyd, PhD, is a Research Fellow in the Department of Anthropology at the University of Texas, Austin. She is author of Birth as an American Rite of Passage (1992), co-author of From Doctor to Healer: The Transformative Journey (1998), and coeditor of Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives (1997), Intuition: The Inside Story (1997) and Cyborg Babies: From Techno-Sex to Techno-Tots (1998). She lectures nationally and internationally on these and related topics. Her current research investigates contemporary transformations in midwifery in the U. S. and Mexico. Books in progress include Midwives in the Mainstream: The Politics of Change; a coedited collection on Midwives in Mexico: Continuity, Controversy, and Change; and The Power of Ritual.
0in’?” 3<p?? 8?? ‘font-family:”Verdana”,”sans-serif”‘>And I really had to evaluate, and look at my charts with somebody else, before I could come up with a picture of me as a midwife, and what I resolved for me is that where birth is not normal, part of a midwife’s job is to return it to normal. For example, in the case of a VBAC, which is regarded medically as high risk and almost universally by midwives as not high risk, what we’re doing in that case is returning birth to normal. And when we go four, five, six hours of pushing, we are also returning birth to normal, a normal that says if the woman pushes for three hours and she’s exhausted, then she can take a rest, and maybe in a couple of hours, she’ll get her strength up, and then she’ll be able to push again–she willget her baby out. When we do things like that, we’re returning birth to normal.
Rather than de-and reconstructing labor to fit abstract and narrowly drawn technocratic parameters of normal–a process that often results in major surgery as the final reconstructive step–what Maggie and her sister midwives do is to continually redraw the parameters, processually expanding their definitions of normal to encompass the range of behaviors and signs actually exhibited by pregnant women as they labor and birth. In short, these midwives are willing to expand protocol parameters to reflect the realities of individual labors, rather than reshaping labor to fit protocol parameters. They see a labor that is unlike other labors, not as a dysfunction to be mechanistically normalized according to the standardized technomedical system of authoritative knowledge, but as a meaningful expression of the birthing woman’s uniqueness, to be understood on its own terms.22
Normalizing Uniqueness: The Connective Dance
The midwifery normalization of uniqueness must be understood in the context of the technomedical pathologization of uniqueness. The technocratic model of birth defines as “normal” only those births that fall within specific parameters–twelve hours for labor, cervical dilation of 1 centimeter per hour, steady fetal heart tones, etc. Labors that take too little or too much time, cervixes that remain “stuck” at four centimeters for hours on end, heart tones that speed up or slow down, meconium in the amniotic fluid–all are defined as dysfunctional “deviations from the norm.” Aware of technomedical parameters, midwives must constantly weigh their trust in and acceptance of women’s individual rhythms against the consequences of straying too far outside of the medical protocols that are regarded as authoritative in the courts.
As in Maggie Bennett’s story above, this tension between the technomedical pathologization and the midwifery normalization of uniqueness is reflected in the following story told byVermontmidwife Judy Luce:
A woman came to me…she was 39 and pregnant with her third child. The first child had been born by cesarean after 37 hours of labor. [The child had a severe genetic defect, and died at the age of three.] And within eight months of that her second child was born, prematurely–a vaginal birth but 31 hours of labor, four hours of pushing, and a forceps delivery for a six-pound ten-ounce baby. So she’s due at the end of September, and wants to have a home birth. She is an artist, she does huge oil paintings, brilliant…incredible intensity, vibrant colors, and she did a whole series that tell stories of her first child’s birth, of the sickness, the dying, the death, and the grieving. Just a whole series which were so amazing and intense. So, the weight–the birth felt very heavy to me. There was a lot staked, not just on having another child, but also on what the birth was going to mean, and you know, the due date came and went and lots of early labor, but nothing happening. You know, it would begin–all night backaches–but never really taking off…
Finally she called and said “My water just broke, and it’s really–it has brown meconium in it.” So I go dashing over there again, and you know, the pad, her underpants, the floor, it’s thick brown. And it’s not thin–there’s nothing thin about this. I listened to the baby through a couple of contractions, and the baby was wonderful, real reactive…And I felt deeply, intuitively, that this baby was fine, but there was a weight around the whole birth…If she had the baby in an hour, I could stay and deal with this, but [she was only two-to-three centimeters dilated, and] what am I going to do if it’s 20 or 30 hours of labor, like the first two times? And how do you defend yourself in court, if the baby aspirates meconium, when you’d have to say, 20 hours ago, I knew this was here?
[So I call my physician backup, and then I talk the couple into going to the hospital.] And the mother felt too dirty and grungy to go to the hospital without a bath, so she got in the shower at about 6:08, and I go in, and she’s standing there, trying to get out, holding her stomach and going “Unnnhhhhhh” [a common sound women make when they push]. So I get her in the bedroom and check her, and the baby’s head is just coming into my hand. And at 6:28 she had an eight-pound baby girl, beautiful birth, no tearing. The baby was clear as a bell, but every bit of the fluid was just filled with meconium–you could just stir it around.
Afterwards, she said to me that when she got in the shower, out of this place she couldn’t even touch, this immense grief came up and she cried, she just sobbed. Her husband said, “What’s the matter?” and she said, “I just need to cry.” And she opened, you know. That sobbing–everything opened. And that baby was born. And I think it’s about holding on to the integrity of what you’re feeling. It’s not because you’re right–there was a dance that went on between us about that decision-making, and that space was big enough for that birth to happen. It was just immensely powerful.
Knowing that “there are no guarantees, even with intuition,” Judy had been planning, “with grief,” as she put it, to take the mother to the hospital in accordance with medical protocols, a decision to which the mother herself had acquiesed. Both of them apparently felt that the mutuality of the decision-making process left room enough, space enough, for the birth to happen at home after all. It was not a question of imposing authority, or even, in this particular case, of anyone holding the key to a particular kind of knowledge that either of them considered authoritative. They both knew that technomedical protocols indicated immediate transport in the case of thick meconium in the amniotic fluid, as the baby is in danger of aspirating the meconium. The midwife also knew from experience that meconium aspiration happens a good deal in the hospital (usually when the umbilical cord is cut too quickly, forcing the baby to breathe strongly before its airway can be completely cleared) but is rare at home (midwives usually wait to cut the cord until it stops pulsating). So, even though the midwife decided on transport, she was not anxious or nervous, but relaxed–her intuition told her the baby was fine, and her reason told her there was no cause for undue alarm, as even with meconium, the baby might be better off at home. The midwife’s relaxed and accepting attitude allowed the woman the time and space to take the shower and thus to experience the emotional release she needed to be able to open up and give birth. Together, even as they both surrendered to the authoritative technomedical protocols that indicated transport, they still managed to hold a consensual space of connection in which the birth could happen at home–the “decision-making dance,” as the midwife called it. In the eyes of midwives, birth has been made abnormal by technocratic medicine. As Judy’s story illustrates, the give-and-take of this “dance” is instrumental in midwives’ ongoing efforts to normalize uniqueness in birth.23
In a recent paper, Brigitte Jordan, whom we honor in this collection, speaks of authoritative knowledge as grounded in a community of practice, adding that within that community:
authoritative knowledge is persuasive because it seems natural, reasonable, and consensually constructed. For the same reason, it also carries the possibility of powerful sanctions, ranging from exclusions from the social group to physical coerciveness. [1992:3]
Certainly this is true of the authoritative knowledge of the technomedical community. But midwives who act on intuition do so in opposition to the cultural consensus on what constitutes authoritative knowledge in birth. Their protocols are their link to that larger biomedical system of authoritative knowledge; like physicians in the hospital, the farther they stray from those parameters, the more they place themselves at risk of the powerful sanctions of whichJordan speaks.
Yet within the midwifery community, intuition does count as authoritative knowledge–to quote Jordan again, “the knowledge that participants agree counts in a given situation, that they see as consequential, on the basis of which they make decisions and provide justifications for courses of action” (1992:3; emphasis in original). When Maggie shared her records with other midwives for peer review and evaluation, she was greeted with reassurance and acceptance; in spite of its devaluation, or simply nonrecognition by the larger culture, these midwives too valued intuition as authoritative.
Jordan points out that “to legitimize one kind of knowing devalues, often totally dismisses, all other ways of knowing, [so that] those who espouse alternative knowledge systems are often seen as backward, ignorant, or naive troublemakers” (1992:2). Her words capture in a nutshell what the larger technomedical culture has done, in this country and many others, to the alternative knowledge systems of midwifery. Hanging out on the ragged edge, far outside of the safety net of cultural consensus, these women of tremendous hearts find their courage not in the normalizing performance of standardized routines, but in their connectedness to the women and babies they attend. As Maggie put it:
Mothers and midwives mirror one another. I know that I get all of my courage from the mother. And I bounce it back to her, and she gets her courage from me….It’s a dance–the woman has to trust her midwife, and the midwife has to trust her woman for that bouncing back.
Sanctioning Intuition as Authoritative Knowledge
The midwife provides care according to the following principles:
Midwives work as autonomous practitioners, collaborating with other health and social service providers when necessary.
Midwives understand that physical, emotional, psycho-social and spiritual factors synergistically comprise the health of individuals and affect the childbearing process.
Midwives recognize that a woman is the only direct care provider for herself and her unborn baby; thus the most important determinant of a healthy pregnancy is the mother herself.
Midwives synthesize clinical observations, theoretical knowledge, intuitive assessment, and spiritual awareness as components of a competent decision-making process.
–Excerpts from the “MANA Core Competencies for Midwifery Practice,” a five-page document approved in final form by the Board of the Midwives’AllianceofNorth America,October 3, 199424
Until recently, homebirth midwives’ use of intuition as authoritative knowledge at births has been entirely informal, experienced in the uniqueness of the situation, talked about in wonder and awe among themselves and with the mothers25 they attend, but not formally encoded as an official source of authoritative knowledge. With the finalization and approval-by-consensus of the “MANA Statement of Values and Ethics” (quoted earlier) at the MANA business meeting on November 13, 1992 in New York City, and the 1994 approval of the “MANA Core Competencies” quoted above, intuition received formal recognition from midwives themselves as an integral aspect of competent midwifery practice. Some new challenges thereby arose.
One of the most pressing issues facing postmodern homebirth midwives is that of certification and licensure. Midwives in many states have been lobbying for legalization and licensing for years, and increasingly are achieving these goals. Members of MANA have been well aware that if they do not establish their own testing and certification process, others–state governments, theAmericanCollegeof Nurse-Midwives, medical boards–will establish one for them. So MANA has created NARM–the North American Registry of Midwives–as a separate, nonprofit corporation, and empowered the seven members of the NARM board to develop and implement a national certification process for direct-entry midwives, guided by a Certification Task Force of approximately 40 state representatives.
This in itself is a somewhat oxymoronic situation. MANA prides itself on its inclusivity, yet the essence of certification is some degree of exclusivity. When tests and standards are created that all midwives must meet, some will pass and some will fail, and, quite possibly, midwives who are competent at births will remain uncertified simply because they do not test well. In an effort to minimize this type of exclusionary outcome, which would limit homebirth midwifery to those who excel at ratiocinative thinking, the members of the Certification Task Force are trying very hard to create testing and evaluation systems that will be fair to all. Agreeing that written (ratiocinative) tests, while the easiest to administer, cannot provide the whole picture, task force members considered the idea of multiple options for demonstrating skill, including a simulated skills exam, in which the aspiring licensee could come to a central site and demonstrate her skills on plastic models of a birthing woman and child. When this idea was presented to the general membership of MANA, a common response was exemplified by one midwife who exclaimed in dismay, “My spiritual guides are the ones who tell me what to do at births, but they will not be there if I am working on plastic dummies!” Another midwife emphasizes intuition’s central role:
Let’s decide how a midwife should be tested, and let’s test her that way. Let’s not kiss up to the standards of the medical profession in order to satisfy them that we are competent. Let’s satisfy ourselves that we are competent–and we’ll know that competency if our hearts are true, and if we’re honest about our intuitive skills. Intuition is often what makes us smart, what makes us do the work best, what makes us able to pick up problems earlier than anyone else and therefore deal with them more effectively. [Jill Breen, community midwife, quoted in Chester 1994:3)]
In response to such appeals, the NARM board has developed a certification process for the Certified Professinal Midwife (CPM) that is balanced between the ratiocinative and the hands-on: it requires (1) that the applicant be checked off on a long list of required skills by her midwifery mentor, who will have many opportunties to see her demonstrate those skills during the course of her training in a connective context in which she can indeed listen to her guides and inner voices; (2) passing a challenging day-long written exam that tests the extent and depth of her knowledge; (3) passing a hands-on skills assessment exam administered by an experienced midwife. The proposal’s balance, as well as MANA’s Statement of Values and Ethics and Core Competencies, indicates the increasing determination of these midwives to honor both ratiocination and intuition as communally sanctioned and respected sources of authoritative knowledge.26
Conclusion
In this article we have sought to examine the phenomenon of midwives’ occasional willingness to rely on intuition as a primary source of authoritative knowledge in a society that grants conceptual and legal legitimacy only to ratiocination. We have seen that the trust these midwives place in inner knowing is a seamless part of their overall philosophy, as expressed in the “MANA Statement of Values and Ethics,” and as exemplified in the stories they tell about their individual experiences with intuition and birth. In contrast to the technocratic model, which charters an ever-expanding plethora of separation-based diagnostic and remedial technologies, this holistic midwifery philosophy supervalues inter- and intrapersonal connection, and charters a range of behaviors expressive of that connective “dance.”
Intuition, in these midwives’ view, emerges out of their own inner connectedness to the deepest bodily and spiritual aspects of their being, as well as out of their physical and psychic connections to the mother and the child. The trustworthiness of intuition is intrinsically related to its emergence from that matrix of physical, emotional, and spiritual connection–a matrix that gives intuition more power and credibility, in these midwives’ eyes, than the information that arises from the technologies of separation. That midwives nevertheless carry with them and freely utilize such technologies demonstrates not only that they also value ratiocination, but that they are becoming experts at balancing the protocols and demands of technologically obtained information with their intuitive acceptance of women’s uniqueness during labor and birth. We submit that their deep, connective, woman-to-woman webs, woven so lovingly in a society that grants those connections no authority of knowledge and precious little conceptual reality, hold rich potential for restoring the balance of intimacy to the multiple alienations of technocratic life.
Notes
Acknowledgments. We wish to thank Carolyn Sargent, Ann Millard, Gay Becker, and midwives Judy Luce, Karen Erlich, Penfield Chester, Anne Fry, Marimikel Penn, and Sharon Wells for their excellent editorial assistance, four anonymous reviewers for their useful suggestions, and our midwife-interviewees for giving so generously of their time and experience.
Correspondence may be addressed to the first author at 1301 Capital of Texas Hwy. B128, Austin TX 78746; (512)327-4726; fax (512)327-3459; davis-floyd@mail.utexas.edu.
1. It is common usage among mothers and midwives in the alternative birth movement to refer to birth at home as “homebirth”–especially when used as an adjective, as in “homebirth mothers”; I follow that usage here.
2. Non-nurse midwives in the U.S. used to be known as “lay midwives.” But in recent years, such midwives, including those who are apprentice-trained, have developed an extensive array of skills including the ability to use various high technologies (see note 11), have banded together in professional associations, and have organized politically to create a national certification program and to fight for state licensure. Thus many of them have come to think of themselves as professionals, and to resent the appellation “lay,” which we do not use in this article.
3. The global scope of postmodern midwifery was evidenced by the attendance of over 3000 midwives from 44 countries at the 1993 convention of the International Confederation of Midwives (ICM) in Vancouver, Canada. Members of the ICM share in common a commitment to the midwifery (“with woman”) approach to prenatal, natal, and postnatal care, and a growing concern for an increasingly compromised scope of practice. In Germany, for example, midwives may assist delivery but can do no prenatal care; in France they may do prenatal care but are greatly restricted in deliveries; and, as we have seen elsewhere in this volume, in the Third World the midwife’s role is increasingly constrained by biomedicine. Generally, the ICM represents midwives with professional academic preparation, but its membership is increasingly beginning to reflect a determination on the part of midwives in both developed and underdeveloped countries to ensure the continued viability of the independent midwife able to assist birth in any setting, particularly the home.
4. In Hawaiian, “mana” means “an underlying, vital energy that infuses, creates, and sustains the physical body” (MANA News 1990). As one of our anonymous reviewers aptly pointed out, mana in Greek is the affectionate term for “mother.” And of course, in Hebrew and Greek, manna means divinely supplied spiritual nourishment.
5. There have been and still exist sharp divisions and disagreements between ACNM and MANA over the nature of midwifery and the definition of what constitutes appropriate midwifery education and competent midwifery care. Nevertheless, these two organizations do both place high value on coexistence and cooperation, and have enacted those values for the past several years through the Carnegie Interorganizational Workgroup on Midwifery Education, created and funded by the Carnegie Foundation. This group included an equal number of representatives from ACNM and MANA. During lengthy deliberations, the ACNM representatives agreed to accept the concept of another type of certifiable midwife besides the medically trained CNM. After enormous effort, group members reached consensus on the definition of the certified nurse-midwife (CNM) and the certified midwife (CM*) in a “joint statement on certification” endorsed by both MANA and ACNM in 1993. This statement makes it clear that, while educational preparation and accountability mechanisms vary, the CNM and the CM will share a common scope of practice: both will be certified to offer full-spectrum midwifery care. Since 1993, MANA members have been actively establishing verification and testing procedures for certification of the CM (see concluding section). [*At a meeting of the Certification Task Force on October 4, 1994, by consensus, CM was changed to CPM--Certified Professional Midwife. The word "professional" had been the subject of debate in MANA over its exclusionary connotations; nevertheless, the 40 members of the task force came to consensus on its use, in part out of strong feelings that the competence of independent midwives has been fully demonstrated and that they deserve to claim full professional status equal, not subordinate, to that of CNMs.]
6. This issue of apprenticeship is a major impediment to continued consensus between MANA and the ACNM, which honors only formal educational training as an appropriate route to midwifery, and insists that apprenticeship is not a valid educational route. (See Jordan 1993 Ch. 7 for a detailed discussion of the differences between experiential and didactic learning.) The question of apprenticeship has proved to be so divisive that it has resulted in a fresh controversy between these two organizations. In June 1994, the ACNM voted to accredit direct-entry midwives (which in this case means midwives with no training in nursing) who are educated in university-based midwifery programs. At the time, members of MANA perceived this as an act overtly subversive of their efforts to create their own certification process for the CM–certified midwife–who can qualify for certification through either formal schooling or hands-on experiential apprenticeship training (or a combination of both). The fact that they agreed by consensus to change CM to CPM reflects their strong belief that both competence and professionalism can be achieved through either route. The coauthors of this article are presently engaged in research and writing on this highly contested issue in postmodern midwifery.
7. Copies of the MANA Statement of Values and Ethics can be obtained from Signe Rogers, Editor, MANA News, P.O. Box 175, Newton KS 67114.
8. Contemporary CNMs, many of whom are or wish to be in independent practice, seriously question the limitations imposed by their structural subordination to physicians. Some members and officials of the American College of Nurse-Midwives are currently contemplating a focused effort to re-create nurse-midwifery as an independent primary health care profession, subject not to nursing but to autonomous midwifery boards.
9. Breastfeeding constitutes a good example of the pragmatic ramifications of insisting on the value of connection. 98 per cent of American women give birth in hospitals; around 50 per cent of them breastfeed their babies during the early months of life. Of the 2 per cent of women who give birth at home or in freestanding birth centers–in other words, in accordance with the connection-based holistic model of birth–close to 100 per cent choose to breastfeed (Arms 1994:201). That connectedness also facilitates birth itself has been amply demonstrated by the doula studies, which show beyond a doubt that the nurturing presence of a woman companion during labor reduces length of labor, lessens perceptions of pain, and improves birth outcomes, both physical and emotional (Sosa et al. 1980, Kennell et al. 1988).
10. The importance of the web metaphor to the members of MANA as an expression of their lived experience was demonstrated during the closing ceremonies of the 1993 San Francisco conference. Four hundred and fifty midwives formed a giant circle around the edges of an otherwise-empty ballroom. They passed balls of yarn in many colors around the circle; each participant looped each color of yarn that came to her around her wrist, until all were physically connected. Then they tossed many more balls of yarn across the floor to each other, tying those around their wrists also, until all that yarn formed a giant rainbow-hued spider web that filled the ballroom floor, linking everyone to everyone through myriad connections. Spontaneously lifting the giant web into the air by lifting their arms, the midwives quickly discovered that, if one person moved her arm, the whole web would move in response. And if a ball of yarn got stuck in the middle of the floor, at least 30 people had to move in synchrony for one person to retrieve it. This of course was a perfect ritual and symbolic enactment of the high value these midwives place on human interconnectedness.
11. Interviewees Maggie Bennett, Jeannette Breen, Elizabeth Davis, and Judy Luce insisted on being identified by their own names, in keeping with their strong beliefs in the value of their work and of their intuitive experiences. All other names following quotations are pseudonyms.
12. Items that a typical postmodern midwife carries with her to a home birth include: a pager and/or a cellular phone; a blood pressure cuff; a stethoscope; a fetoscope and a Doppler–an electronic amplifier of the baby’s heartbeat (for monitoring fetal heart tones); sterile gauze; antiseptics–alcohol, peroxide, betadine, or hibiclens; alcohol prep pads, alcohol swabs; Q-tips and cotton balls; flashlights; urinalysis strips (to test for glucose, ketones, PH, blood, and protein); Fleet enema (rarely used); nitrazen paper (to test for leaks in the amniotic sac); culture tubes (for taking a baseline culture of the amniotic fluid); equipment for drawing blood to send to a lab for a white count (to check for infection); urinary catheter kits; sterile KY jelly; a variety of herbs, tinctures, and homeopathic remedies, including rescue remedy (for severe stress), goldenseal (for drying the cord stump after it is cleaned with alcohol), arnica salve (for skin swelling and trauma), black and blue cohosh and colophyllum (for enhancing contractions), evening primrose oil (for assisting cervical dilation), spirits of peppermint (for assisting bladder function–often can be used instead of a catheter), angelica (for assisting placental expulsion), shepherd’s purse (for preventing postpartum hemmorrhage), Crampease (a mixture of herbs) for afterpains, black haw (for postpartum cramps), and valerian (for relaxation); olive oil for perineal massage; a birthing stool; an amni-hook for breaking the waters if they are still intact when the baby crowns (so that they won’t break all over the midwife–AIDS can be transmitted through the amniotic fluid); waterproof pads and sheets; an oxygen tank, mask for the mother, and infant resuscitation bag and mask (rarely used); special scissors for cutting an episiotomy (rarely used); syringes and drugs (injectable pitocin, injectable methergine, and oral methergine) to stop a postpartum hemorrhage; IV lines and fluids; instruments and sutures for repairing vaginal tears; sheets to create a sterile barrier field while suturing; a tensor or desk lamp (for visibility during suturing); a local anesthetic (xylocaine or 1 or 2per cent lidocaine) for pain relief during suturing; a heating pad to assist in warming the baby; a bulb syringe (for suctioning the baby’s airways) and DeLee suction catheters (for sucking amniotic fluid out of the deeper respiratory passages of the newborn–rarely used); assorted hemostats and clamps; special scissors for cutting the cord; scales for weighing the baby and a tape measure; oral vitamin K; erythromycin ointment (to place in the baby’s eyes to prevent blindness from venereal disease–a requirement in most states); footprint pads in multi-colors (for taking the baby’s footprint for the birth certificate); sitzbath herbs (for soothing the woman’s vaginal area postpartum); red-top sterile vacuum tubes (for collecting umbilical cord blood for testing); and a file full of papers for charting, preparing the birth certificate, etc. Most midwives carry enough supplies with them at any one time to attend three births in a row without repacking.
Some midwives also carry: physician-prescribed antibiotics, and Phenergan suppositories for stopping violent vomiting; a laryingiscope (for looking into the baby’s trachea and larynges if there is reason to believe the baby may have aspirated meconium) and sterile saline (to wash the baby’s vocal chords if necessary)–these are very rarely used; breast shields (for cracked nipples) and breast shells (for helping the nipples to become more prominent so the baby can more easily latch on to the breast); and a newborn screening kit (this kit consists of a syringe and a specially treated piece of paper, on which the midwife places samples of the baby’s blood to be sent to the health department and checked for metabolic disorders). (The above information was gleaned from a questionnare handed out to 30 and returned by 25 homebirth midwives, all of whom are members of MANA, and most of whom serve on the CPM Certification Task Force (see note 5).)
13. Meconium is the babyís first bowel movement. If present in the amniotic fluid, it is sometimes associated with fetal distress, which is usually also indicated by fetal heart patterns. It is generally recognized, even in most hospitals, that thin or light meconium staining during labor is not problematic, especially when the heart rate patterns fall within a normal range. Heavy, thick, and chunky meconium in the amniotic fluid is usually indicative of fetal distress.
14. Decelerations of the fetal heart rate, as recorded on the electronic fetal monitor, are sometimes indicative of fetal distress.
15. The Apgar score provides a standardized means by which birth attendants can assess the baby’s condition at birth. Signs rated at two points each on a preprinted chart are skin color, muscle tone, breathing attempts, heartbeat, and response to stimulus, such as a touch or pin-prick. Babies are rated twice, at one minute after birth and again at five minutes, because many babies, especially anesthetized ones, take some time to turn pink and begin full breathing on their own. Ten is the highest obtainable score. Babies with Apgars of 2 and 2 (2 at one minute, and still 2 at five minutes) are severely distressed.
16. “Slantboarding” is a midwifery technique that often proves effective in getting breech babies to turn before delivery. The mother must get her head lower than her pelvis. A bean bag chair can be used, or an ironing board (or door) can be placed against a sofa or heavy chair at a 45 degree angle; the pregnant woman lies on her back, head down on the board with her feet pointing upwards for fifteen to twenty minutes, two or three times a day. During this time she is encouraged to relax and to visualize the baby turning. (For other such techniques, see Kitzinger 1991:98.)
17. Hospital labors are usually artificially speeded up with drugs, episiotomies, forceps, or cesarean section. Home birth labors, which are allowed to take their natural course, tend to take far more time than hospital births do. During a long labor, it is essential for a mother (and indeed, her birth attendants) to keep up their strength by eating and drinking plenty of nutritious food and fluids. Homebirth midwives recognize that contractions that have been going on for 18 hours and are still 5 minutes apart mean that the mother is still in “early labor”–”active labor” has not yet kicked in–and there is plenty of time for the midwife to go out for food.
18. Note Maggieís refusal to adopt the physicianís technomedical discourse here–a discourse that simultaneously reduces the differences between cesarean and vaginal birth to a matter of geography and subtly expresses the value that this culture consistently places on “above” in relation to “below.”
19. Hospital practitioners generally allow one, and a maximum of two, hours for pushing, after which a cesarean will usually be performed. Homebirth midwives accept a wide range of pushing stages, but more than four hours of pushing is rather unusual, even at home.
20. Following is a brief summary of Maggie Bennett’s personal protocols:
To qualify for staying at home for the birth:
Mother:
Blood pressure has to be no more than 20 pts. diastolic above her baseline.
Dilation should take place at the general rate of 1/2 cm./hr. after 4 cm.; one 3-hour plateau (in which no dilation takes place) is acceptable. [Authorsí note: Hospital protocols usually call for birth to take place within 26 hours of entry into the hospital, period. For many women, it can take days of "early labor" to reach 4 cm. If such women enter the hospital, they end up with cesareans.]
Good labor should be established within 24 hours after rupture of membranes.
Birth should take place within 72 hours after rupture of membranes.
[Hospital protocols call for birth to take place with 24 hours of rupture of membranes, due to the danger of infection, which is increased by the frequent vaginal examinations performed in the hospital. Midwives at home avoid performing such exams as much as possible in cases of prematurely ruptured membranes.]
Birth should take place within 4 hours from the time the mother learns to push. [As noted above, hospital protocols generally allow a maximum of two hours for pushing, and do not mention the motherís "learning to push." Here again, we see the midwifeís woman-centered focus, her respect for the mother as active birth-giver.]
No temperature. Not too fatigued.
Baby
Fetal heart between 124-160 and in accordance with baby’s baseline.
Good beat-to-beat variability. No heavy meconium–light ok.
21. Our interviewees also agreed that, in the rare instances in which the mother and the midwife have conflicting intuitions about a potential problem during labor, they are clearly not connected. In such a situation, they feel that transport is essential, as this “total lack of synergy” seriously impedes their ability to provide good, empathic–i.e., connected–care.
22. It is important to note that this appreciation of women’s uniqueness can extend even to crises and complications that midwives cannot handle at home, as is evidenced in the following story from Elizabeth Davis:
Sometimes if a woman has had a difficult birth, part of the reason why it’s been difficult is that things have come up for her that she has not worked through…I think of a Japanese woman with a Chinese husband who was culturally supposed to have a son, and it was a girl, and you can bet that nothing I said or did stopped her trickle bleeding from a partially separated placenta that finally took us to the hospital. When she felt safe enough in the hospital, she staged this massive hemorrhage, and rallied her husband to her side, where he had not been since he saw the sex of the baby.
So you know, the choreography of the woman’s expression of need is something that’s really beyond the practitioner–it’s really none of your business. But it is your business to maintain the parameters of safety, as we say, so some part of your attention has to turn to doing as much as you can in advance to raise those issues, and help a woman cope with them. It’s a fine line–permission to have your birth be whatever it is going to be, and the midwife’s skill and also her need to have a safe outcome. I think really most of us struggle with that.
23. As one anonymous reviewer aptly pointed out, the words “normal” and “abnormal” may not even be appropriate when talking about birth from the standpoint of intuitive knowing, as the concept “normal” “has long been grounded in a worldview that is based on ratiocinative reasoning and the averaging of all experiences into one standardized experience….Foucault’s concept of “normalization” might be an interesting springboard here.” Space does not allow us to further address the issue of midwives’ efforts to normalize uniqueness vs. medicine’s efforts to pathologize it as “deviance,” but it is an issue deserving of scholarly probing, and we call attention to it here in the hopes of stimulating further research and analysis.
24. Copies of the MANA Core Competencies can be obtained from Signe Rogers, Editor, MANA News, P.O. Box 175, Newton KS 67114.
25. Homebirth mothers themselves often have rich intuitive experiences worthy of anthropological study in their own right, as do mothers in general, about birth, about childraising, etc. We call attention to this understudied subject in hopes of generating more academic research into women’s perceptions of and experiences with intuition. Additionally, we call for more research into how midwives negotiate childbirth with their clients and the role that intuition plays in these negotiations. What difference does it make, for example, when women hire midwives to save money rather than because of a shared worldview?
26. This national certification process is now in place and functioning, making national certification for direct-entry and independent midwives a reality for the first time in United States history. Several hundred midwives have taken the NARM exam; the first to successfully pass through the complete certification process was Abby J. Kinne, who was formally certified as a CPM (Certified Professional Midwife) on November 10, 1994. As of this date of writing (April 1, 1996), approximately 100 midwives have become CPMs. This first group to pass through the first phase of the certification process consists primarily of experienced midwives who have been in practice for at least five years. The next phase is about to begin: NARM is poised to process applications from entry-level midwives; at present, 120 entry-level applications are pending.
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