Midwifery, the Ancient Art of Birth

Home Birth If you're a healthy expectant mother having a normal pregnancy and you have no medical or obstetrical risk factors, giving birth at home may be an option for you. Giving birth at home allows you to labor and deliver in familiar and comfortable surroundings.

Water Birth Support in water is one of the most beneficial things that can be offered to a woman in labor. The water provides a calming influence and a peaceful relaxed atmosphere. Women report that they enjoy their labors and find that the water allows complete freedom of movement and deep concentration.

Benefits 

• Statistically as safe or safer than hospital birth
• Positive and pleasant experience
  
• Comfort, security, and familiarity in your own home
  
• One-to-one Midwife and/or Doula support
  
• Avoidance of sedation drugs... all natural!
  
• Freedom to walk around and be comfortable in the surroundings of your choice
  
• Easier to relax, let go and surrender at home
  
• Freedom to choose your place and position of birth
  
• Complication rates are lower than hospital births
  
• Labor is usually shorter than in a hospital
  
• Less blood loss
  
• No unnecessary inducement
  
• Relaxed and peaceful
  
• Water-birth is an option
  
• Not on your back or hooked up to machines
  
• Problems in labor usually develop slowly, allowing enough time to be transferred (if needed)
  
• Midwives carry all necessary equipment (Similar to an LDR or birth center)
  
• Less likely to need a cesarean section

Philosophy

• Birth is a natural process
• Women have given birth 'naturally' for centuries without interventions
  
• Take control of your experience
  
• Taking responsibility by making informed choices
  
• Healthier options for mother and baby
  
• Lower-cost that hospital birth
  
• Childbirth should be treated a celebration, not a disease
  
• Miraculous, in-the-moment and lower stress on both mother and baby
  
• Drugs can alter the natural healthy feedback mechanisms and are not good for the child
  
• Medical management of pregnancy and birth should be limited
  

Midwifery is the art of safeguarding the natural process of pregnancy, labor, and birth. A midwife is a trained professional with special expertise in supporting women in maintaining a healthy pregnancy, offering expert individualized care, education, counseling and support to a woman and her newborn throughout the childbearing cycle.

 A midwife works with each woman and her family to identify their unique physical, social and emotional needs. When the care required is outside the midwife's scope of practice or expertise, the woman is referred to other health care providers for additional consultation or care. The Midwives Alliance of North America, the North American Registry of Midwives, the Midwifery Education Accreditation Council and Citizens for Midwifery agreed on a short definition of what "midwifery care" means. However, just because a person is a midwife does not guarantee that they provide this kind of care; consumers looking for a midwife should ask questions to determine if a prospective caregiver will be able to provide the kind of care they seek.

Brief Overview

• Direct-Entry Midwives (including Licensed Midwives)
• Not required to be nurses.
• Multiple routes of education (apprenticeship, workshops, formal classes or programs, etc., usually a combination).
• May or may not have a college degree.
• May or may not be certified by a state or national organization.
• Legal status varies according to state.
• Licensed or regulated in 21 states.
• In most states, licensed midwives are not required to have any practice agreement with a doctor.
• Educational background requirements and licensing requirements vary by state.
• By and large, maintain autonomous practices outside of institutions.
• Train and practice most often in home or out-of-hospital birth center settings.

Certified Professional Midwives and NARM

• Not required to be nurses.
• Multiple routes of education recognized; direct-entry midwives and certified nurse midwives can qualify for this credential.
• Education programs accredited by the Midwifery Education Accreditation Council prepare students to meet the requirements for the CPM.
• The out-of-hospital birth experience is required.
• Have met rigorous requirements and passed written exam and hands-on skills evaluation.
• Administered by the North American Registry of Midwives.
• Legal status varies according to state.
• Practice most often in homes and birth centers.

Certified Nurse-Midwives (CNMs)

• Educated in both nursing and midwifery, primarily in the hospital setting; are "advanced practice nurses.
• Must have at least a Bachelors's Degree when training is complete.
• Have successfully completed a university-affiliated nurse-midwifery program accredited by the American College of Nurse-Midwives, and passed the exam.
• Out-of-hospital clinical experience is not required.
• Are legal and can be licensed in all states.
• Most practice in hospitals and birth centers.
• In most states must have some kind of agreement with a doctor for consultation and referral; practicing without such an agreement can lead to loss of license.

Classical Traditional Midwife (CM)

The Certified Midwife (CM) is an apprenticed trained midwife without medical training but highly knowledgable of classical midwifery skills. She leans on the ancient art of midwifery and the tools, tricks, and knowledge of the ancient wisdom of Midwives around the world. Yesterday, today and tomorrow these midwives are an endangered species

Licensed Direct Entry Midwives  

A licensed and direct-entry midwife is educated in the discipline of midwifery in a program or path that does not also require her to become educated as a nurse. Direct-entry midwives learn midwifery through self-study, apprenticeship, a midwifery school, or a college- or university-based program distinct from the discipline of nursing. A direct-entry midwife is trained to provide the Midwives Model of Care to healthy women and newborns throughout the childbearing cycle primarily in out-of-hospital settings.

Under the umbrella of "direct-entry midwife" are several types of midwives:

A Certified Professional Midwife (CPM) is a knowledgeable, skilled and professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives (NARM) and is qualified to provide the midwives model of care. The CPM is the only US credential that requires knowledge about and experience in out-of-hospital settings. At present, there are approximately 900 CPMs practicing in the US.

A Licensed Midwife is a midwife who is licensed to practice in a particular state. Currently, licensure for direct-entry midwives is available in 24 states. 

The term Traditional or Lay Midwife has been used to designate an uncertified or unlicensed midwife who was educated through a self-study or formal apprenticeship route rather than through a medical program.

This term does not necessarily mean a low level of education, just that the midwife either chose not to become certified or licensed, or there was no certification available for her type of education (as was the fact before the Certified Professional Midwife credential was available).

The Appointment

When making the appointment, make sure you let the midwife know that this is for an interview and that you will not be getting an exam. Bring your questions with you along with a pen. Take notes and go down your list of questions. Don't try to memorize your questions because they may get overlooked. Before concluding the interview, double-check your questions to make sure every question has been answered to your satisfaction.

Questions To Consider

• How long have you been a midwife?
• What credentials and certifications do you have?
• Approximately how many births have you attended?
• What is your Cesarean rate?
• What percentage of patients have you had to transport to a hospital?
• Will I always see you during appointments? If not, who else would I see?
• Do you have any vacations or trips scheduled during my pregnancy or near my due date? If so, is there a backup midwife or doula available?
• What are your usual recommendations for IVs, Pitocin, Prostaglandin gel, amniotomy, epidurals, EFM and so on?
• How many people can I have during my labor and birth?
• How often do women under your care give birth with no medication? How many with minimal medication? How often do you induce labor?
• What is our episiotomy rate? How often do you resort to forceps delivery or vacuum extraction?
• Do others in your practice share the same philosophies and practices?
• What prenatal procedures and tests do you recommend?
• Do you have any books you recommend?
• What would you suggest if my baby were breech?
• What happens if I needed to be transported to the hospital? Will you be there?
• Under what circumstances would you recommend a cesarean?

Cesarean Birth, Additional Questions to Ask

• Approximately how many VBACs have you attended?
• Of all your clients that wanted VBACs, how many were successful?
• What do you think my chances of VBAC are, considering my history?

"Due to its importance, it is assumed that midwifery has existed as long as human civilization".

In ancient Egypt, midwifery was a recognized female occupation, as attested by the Ebers papyrus which dates from 1900 to 1550 BCE. Five columns of this papyrus deal with obstetrics and gynecology, especially concerning the acceleration of parturition and the birth prognosis of the newborn. The Westcar Papyrus, dated to 1700 BCE, includes instructions for calculating the expected date of confinement and describes different styles of birth chairs. Bas relief's in the royal birth rooms at Luxor and other temples also attest to the heavy presence of midwifery in this culture.

Midwifery in Greco-Roman antiquity covered a wide range of women, including old women who continued folk medical traditions in the villages of the Roman Empire, trained midwives who garnered their knowledge from a variety of sources, and highly trained women who were considered female physicians. However, there were certain characteristics desired in a “good” midwife, as described by the physician Soranus in the second century. He states in his work, Gynaecology, that “a suitable person will be literate, with her wits about her, possessed of a good memory, loving work, respectable and generally not unduly handicapped as regards her senses [i.e., sight, smell, hearing], sound of limb, robust, and, according to some people, endowed with long slim fingers and short nails at her fingertips.” Soranus also recommends that the midwife is of sympathetic disposition (although she need not have borne a child herself) and that she keep her hands soft for the comfort of both mother and child. Plainly, another physician from this time valued nobility and a quiet and inconspicuous disposition in a midwife. A woman who possessed this combination of physique, virtue, skill, and education must have been difficult to find in antiquity. Consequently, there appears to have been three “grades” of midwives present in ancient times. The first was technically proficient; the second may have read some of the texts on obstetrics and gynecology, but the third was highly trained and reasonably considered a medical specialist with a concentration in midwifery.

Midwives were known by many different titles in antiquity, ranging from iatrinē, maia, obstetric, and medical. It appears as though midwifery was treated differently in the Eastern end of the Mediterranean basin as opposed to the West. In the East, some women advanced beyond the profession of a midwife (maia) to that of obstetricians (iatros gynaikeios), for which formal training was required. Also, there were some gynecological tracts circulating in the medical and educated circles of the East that were written by women with Greek names, although these women were few in number. Based on these facts, it would appear that midwifery in the East was a respectable profession in which respectable women could earn their livelihoods and enough esteem to publish works read and cited by male physicians. In fact, a number of Roman legal provisions strongly suggest that midwives enjoyed status and remuneration comparable to that of male doctors. One example of such a cited midwife is Salpe of Lemnos, who wrote on women’s diseases and was mentioned several times in the works of Pliny.

However, in the Roman West, our knowledge of practicing midwives comes mainly from funerary epitaphs. Two hypotheses are suggested by looking at a small sample of these epitaphs. The first is the midwifery was not a profession to which freeborn women of families that had enjoyed free status of several generations were attracted; therefore it seems that most midwives were of servile origin. Second, since most of these funeral epitaphs describe the women as freed, it can be proposed that midwives were generally valued enough, and earned enough income, to be able to gain their freedom. It is not known from these epitaphs how certain slave women were selected for training as midwives. Slave girls may have been apprenticed, and it is most likely that mothers taught their daughters.

The actual duties of the midwife in antiquity consisted mainly of assisting in the birthing process, although they could also help in other medical problems relating to women if needed. Often, the midwife would also call in a physician to be on-call with her in case a more difficult procedure was needed during an abnormal delivery; and in most cases, she brought along two or three assistants. In antiquity, it was believed by both midwives and physicians that a normal delivery was made easier when a woman sat upright. Therefore, during parturition, midwives brought a stool to the home where the delivery was to take place. In the seat of the chair was a crescent-shaped hole through which the baby would be delivered. The chair also had armrests for the mother to grasp during the delivery. Most chairs had backs that the patient could press against, but Soranus suggests that in some cases the chairs were backless and an assistant had to stand behind the patient and support her. The midwife then faced the patient, gently dilating and pulling the fetus forward, all the while instructing the mother on proper breathing and how to push downwards during a contraction. The assistants helped by pushing downwards on the patient’s abdomen. Finally, the midwife received the infant, placed it in pieces of cloth, cut the umbilical cord, and cleansed the baby. The child was sprinkled with “fine and powdery salt, or natron or aphrodite” to soak up the birth residue, rinsed, and then powdered and rinsed again. Next, the midwives cleared away any and all mucus present from the nose, mouth, ears, or anus. Midwives were encouraged by Soranus to put olive oil in the baby’s eyes to cleanse away any birth residue and to place a piece of wool soaked in olive oil over the umbilical cord. After the delivery, the midwife made the initial call on whether or not an infant was healthy and fit to rear. She inspected the newborn for congenital deformities and testing its cry to hear whether or not it was robust and hearty. Ultimately, midwives made a determination about the chances for an infant’s survival and likely recommended that a newborn with any severe deformities be exposed.

The services of a midwife were not inexpensive; this fact that suggests poorer women who could not afford the services of a professional midwife often had to make do with female relatives. Many wealthier families had their own midwives. However, the vast majority of women in the Greco-Roman world very likely received their maternity care from hired midwives, either highly trained or possessing a rudimentary knowledge of obstetrics. Also, many families had a choice of whether or not they wanted to employ a midwife who practiced traditional folk medicine or the newer methods of professional parturition. Like a lot of other factors in antiquity, quality gynecological care often depended heavily on the socioeconomic status of the patient.

It is from the perspective of Classical Midwifery that Celesta approaches Women's Health, Childbearing and Newborns. The knowledge passed down from senior midwife to apprentice midwives all around the world for ancient days. A lost art that Celesta and the midwives of A Celebration of Birth and Life strives to preserve and celebrate.