Dynamics of the Twenty-First-Century Midwifery Practice

Abstract

Globally, midwifery is the safest, most cost-effective, and most satisfying method of birth assistance. This age-old profession embraces the most non-interventionist philosophy that childbirth is a natural and normal process in which the attendant merely assists in the healthy routine progression. Midwifery is commonly assumed to be all about assisting labor and childbirth, but there is more to it than that. This noble profession entails skilled, knowledgeable, and compassionate care for childbearing women, newborn infants, and families across the continuum throughout pre-pregnancy, and pre, intra, and postpartum periods. Over decades, midwifery has evolved from being informal and invisible to independent professional practice with major shifts in the scope of practice, gender, economic, and career dynamics concerning the profession. With maternal and child health being at the center of most important developments, the midwife stands out in his/her role as a primary care provider, advocate, and teacher.

1. Introduction

The practice of midwifery worldwide is the safest, most cost-effective, and most satisfying method of birth assistance. This age-old profession embraces the most non-interventionist philosophy that childbirth is a natural and normal process in which the attendant merely assists in the healthy routine progression [1].

Midwifery is commonly assumed to be all about assisting labor and childbirth, but there is more to it than that. This noble profession entails skilled, knowledgeable, and compassionate care for childbearing women, newborn infants, and families across the continuum throughout pre-pregnancy, pregnancy, birth, postpartum, and the early weeks of life. Additionally, the scope of midwifery practice includes family planning and the provision of reproductive health services. Midwifery services are a core part of universal health coverage, not a narrow segment. These services extend beyond the confines of the hospital settings to the communities and beyond [2]. This ancient art has evolved over centuries from being an informal practice to being an advanced, globally recognized, and regulated professional practice in the twenty-first century [3]. This chapter presents highlights of midwifery and key advances in the profession in this age.

2. History of midwifery

One of the most ancient fields of art, the origin of midwifery dates back to the ancient stone age era around 40,000 Before Christ (BC), through the dark ages, the Biblical era, up to date. Women have always instinctively supported each other during pregnancy and childbirth [4]. In the Paleolithic age (50,000–9000 BC), women supported each other during childbirth based on observation of behaviors of animals such as squatting while giving birth, cutting the umbilical cord to separate the mother from the newborn, providing warmth to the infant, and initiating breastfeeding [5]. The Biblical era also termed the golden era between 2200 BC–1700 BC upheld midwifery as a socially respectable art practiced by women who managed normal pregnancies and deliveries by performing skilled vaginal examinations, with religion and witchcraft as a basis of practice brought forth women’s empowerment, family-centered care, and key milestones in the development of professionalism in midwifery practice [5, 6]. Midwifery in the modern era (seventeenth to eighteenth century) saw major advances like instrumental deliveries for difficult births and training of males in midwife-training institutions [7, 8]. Throughout the nineteenth century before the evolution of the nursing profession, midwives remained the main provider of obstetric care services in most countries [9]. From the twentieth to the current twenty-first-century change has been a constant occurrence in all arenas of human development including cultures, societies, technologies, and knowledge and this is reciprocated in the evolution of midwifery too [10].

3. The role of a midwife

Over decades, midwifery has evolved from being informal and invisible to independent professional practice with major shifts in the scope of practice, gender, economic, and career dynamics concerning the profession. New and expanded roles in midwifery practice are key to the provision of high-quality care and professionalism [11]. Maternal and child health being at the center of most important developments, the midwife stands out in his/her role as a primary care provider, advocate, and teacher as they provide multidisciplinary, non-hierarchical patient-centered care to their clients [12].

Health promotion is one of the key roles played by a midwife [13] some of which include Health education, screening, immunization, prophylactic treatments, contraception, and domiciliary care services. Midwives are taking a leading role in developing, implementing, and evaluating these new models of care to ensure that they reflect the principles of women-centered continuity of midwifery care. At the policy level, midwives are also influencing changes in systems of care and service birth [14].

4. Current trends in midwifery

4.1 Regulation of practice

As a matter of course, midwifery was an unregulated art that involved females taking initiatives informed by their society’s needs and previous practices passed on from elderly women [9]. These traditional birth attendants(midwives) have been an integral part of pregnancy and childbirth to this day and some parts of the globe have taken the initiative to provide basic formal training to them. This integrates them into the healthcare system and encourages collaboration, allowing them to be able to identify abnormalities and provide early referrals to qualified professionals. Being a predominantly female profession, midwives struggled to achieve due recognition given the status of women in society at that time. This backdrop and fear of extinction of the practice gave birth to a movement that later on came to be known as the International Midwives Union (IMU) [4, 9].

The international confederation of Midwives (ICM) which was formed from the International Midwives’ Union (IMU) in 1922 is an international umbrella that unites midwives and midwifery organizations in various countries across all the continents across the globe. In 2011, the International Confederation of Midwives released Global Standards for Midwifery Education, Regulation, and Association, guiding international midwifery for the first time [15]. However specific regulation of the profession, the scope of practice, and training are variable in the different countries worldwide [4].

Regulation of midwifery practice varies from place to place. In the African continent, Stakeholders such as nursing associations and academicians have varied and complementary roles concerning reforming professional practice and education regulation [16]. Nursing and Midwifery Council (NMC) has powers to regulate midwifery and nursing in the United Kingdom. The council retains the powers to establish and maintain a register of all qualified midwives, and to take needed action in case set standards are questioned [17]. In Australia, the recognition of midwifery as a separate profession from nursing has been a recent phenomenon and has been surrounded by considerable debate and discussion within both professions [14]. Today, midwifery gallantly stands out as a profession that has a regulated scope of practice [18] with well-organized and recognized structures.

4.2 Gender dynamics

The word woman from which “midwife” is coined is frequently associated with care and empathy while “man” is more often associated with masculine roles such as protection and provision, so originally only women were involved in childbirth and all that was entailed in caring for a pregnant woman. However, that has changed in our era, Key advances in the practice include male involvement (men-wifery), which was unheard of in a predominantly female profession. More males than ever have ventured into and embraced midwifery as a career.

This transition has been faced with criticism and fears from women, husbands, communities, regulatory bodies, policymakers, and even the health workforce to date.

Even as much as males have ventured into the profession, we cannot conclude that there is diversity. In the United States, only 2% of midwives are male [19] while in Afghanistan, Brunei, Cambodia, Japan, and Saudi Arabia males are completely prohibited from enrolling for midwifery for cultural and religious reasons [20]. In the Ugandan context, male midwives are only trained from bachelorette level and beyond, certificate and diploma training is open to nursing and other professions, except midwifery [21].

4.3 Scope of practice

Being one of the most diverse professions of all time, there is a medley of roles encompassed in midwifery today; from being birth assistants (clinical practice) primarily to comprehensive maternal and child care. The triad of competition from doctors (obstetricians/gynecologists), increased hospital deliveries, and advancements in medical interventions such as cesarean section, labor monitoring, vacuum assisted delivery have rather reshaped the practice of a midwife [9]. The midwife is now not only concerned with providing direct clinical care during pregnancy and childbirth but even her family and community she hails from, provision of other sexual and reproductive health services, research, academia, leadership, policy formation, and even more roles.

4.4 Technology in healthcare

While the rest of the world enjoys advances in technological development, reproductive health is not spared. Assisted Reproductive Technologies (ART) have sprouted in various forms to make it easier for infertile women to enjoy the privilege of parenthood, complex diagnostic procedures, advanced treatment and monitoring options, and beyond.

Invitro fertilization, genetic engineering, cloning, surrogacy, artificial wombs, and various other modifications in the modes of reproduction have birthed major shifts in the type and mode of care provided to clients, as well as a range of ethical issues that the midwife must negotiate in the daily practice of the profession. While ARTs have become more normalized as a means of achieving parenthood, there may be associated risks. Midwives, as the main caregivers for pregnant women need to be well informed, and mindful of the potential risks to the mother and her baby whilst providing care that is the most appropriate and supportive, to enable these women to achieve a safe and satisfying childbirth experience [22].

4.5 Ethical issues arising

The Hippocratic oath forms an ethical foundation that governs morally acceptable midwifery practice through principles such as respect for persons, justice, beneficence, and non-maleficence which often conflict with the morals of individual professionals, patients, health system policies, cultural and societal norms, and several other factors and result in ethical dilemmas [23, 24]. Such include issues surrounding informed consent, surrogacy, shared decision making, patient preference vis a vis professional recommendation, religious and cultural conflicts with professional care.

Therefore, continuous increases in the level of education coupled with technological advances present a need to improve and updated professional and ethical codes that guide conduct and professional practice [25].

4.6 Midwife-led care

The term mid-wife-led care is a model of patient care where a midwife is the lead health-professional responsible for the planning, organization, and delivery of care given to a woman and her family during preconception, antenatal care, delivery, and through the postnatal period. It ensures woman-centered care and advocates for minimal interventions on assumptions that pregnancy and childbirth are normal events [26, 27]. This model is based on the perception that pregnancy and childbirth are naturally occurring physiological processes and it is associated with better client outcomes, high effectiveness, and efficiency among professionals [28, 29, 30].

However, due to socio-cultural factors, overlap in professional roles and responsibilities among various health professionals [31], and medicalization of childbirth and reproductive health services midwives are placed in a passive role in regards to the scope of work they should making it challenging to fully achieve midwife-led care [28].

4.7 Advances in education, research, and advocacy

Nursing and midwifery form the backbone of health service delivery and patient satisfaction depending on their competencies [32]. They can help countries optimally contribute to achieving universal health coverage, equity, and other population health goals. This section’s emphasis however is on the midwife - their training, research, and advocacy relevance regarding their practice.

4.8 Education

There are various levels of midwifery training, and what distinguishes them is the quality of practice each does in a role [33]. Here is a list of levels and their differences.

Level 1: Basic Midwifery- The midwife performs elementary midwifery skills but cannot perform any other additional skills beyond what is required for conducting normal deliveries.

Level 2: Advanced Midwifery- A midwife provides basic skills to deliver the baby and can also perform other basic medical care besides delivery.

Level 3: Advanced Midwifery with Advanced Practice- Midwife provides skills to deliver the baby including difficult deliveries perform medical care and do advanced midwifery skills which may involve research, advocacy, and public health.

Level 4: Advanced Midwifery with Advanced Practice and Advanced Service Delivery- the midwife provides skills to deliver a baby including all difficult deliveries performs advanced midwifery skills including research, advocacy, public health, and education, and demonstrates advanced service delivery models.

Of note, the best midwives are not necessarily the ones with the most training highest level of certification. A good midwife rather pays attention to the detail of the person in front of them. They listen to their concerns, take care of their needs and do everything they can to make the time they spend with them as comfortable as possible. A qualified midwife is skilled in the care of a woman and their babies at/during childbirth and can provide medical care and comfort to a woman during childbirth. Today midwives are qualified by having a higher education certification, diploma, or degree, however, qualification is not only about being able to pass exams but explicit exhibition of quality care and or service delivery.

4.9 What is happening?

The midwifery profession is evolving despite various qualifications and cadres of midwifery training- and what differentiates them is the quality of output each does on a role. When you go through these roles, it’s not just a matter of how long you have been studying but - how much you have learned, how well you have been trained, and how much you have had to work for it.

Right now, the midwifery profession is going through a transition trying to recognize the value of work that is being done by valuing the knowledge and skills being passed on. We are taking what has been traditionally seen as a profession and making it into a more - respected and valued profession.

4.10 Research

Being a focal point of maternal care, midwives ought to continuously strive towards providing individualized, appropriate, family-centered care, prioritizing not only the women but also their families, communities, and social and cultural backgrounds. If care is to be appropriate and effective, there needs to be an assessment at a community and individual level, this is what makes practice and service delivery advanced and different – being able to realize patient needs beyond physical conditions and advocate for patient needs through root cause analysis. Health needs assessment is a systematic method for reviewing the health issues facing a population, which informs policy and sets priorities for appropriate resources to improve health and reduce inequalities [34].

4.11 To achieve this - advocacy

You will need the information to persuade policymakers to change their policies, laws, or implementation, whether through direct lobbying or other means such as provoking an official investigation or influencing public opinion [35]. You will need to conduct somewhat research to obtain this preliminary survey information. This in turn requires advanced research skills and expressiveness in communication when caring for the patient and her relatives.

To be concise, this presents an opportunity to engage with local communities, other healthcare providers, and commissioners, and provides the evidence to plan appropriate services, targeted at those most in need - improving health service delivery and health equity in such needy communities.

The section sought to stress the importance of education, research, and advocacy concerning the midwifery practice in addressing the key health challenges today by equipping the midwife with the necessary tools to promote health equity.

4.12 Gap - research

Currently, there is a scarcity of research in midwifery practice which if not dealt with promptly may result in a disastrous glitch after a given period vis-à-vis the expected roles of the midwife firstly in clinical practice, research, and advocacy in promoting evidence-based quality care to patients to achieve health equity and universal health coverage [36].

It is important therefore to note that, research and innovation remain the basic cornerstone upon which new advancements and guidelines for clinical practice are based and developed [37]. The provision of adequate health care for the finest patient management outcomes is pivoted on the interplay between unwavering clinical practice and medical research without ignoring advocacy for marginalized people to promote health equity in care and practice.

5. Conclusion

“In all cultures, the midwife’s place is on the threshold of life, where intense emotions, fear, hope, longing, triumph, and incredible physical power enable a new human being to emerge. Her vocation is unique”- Sheila Kitzinger.

Therefore, as man lives in a changing society so does his environment, culture, and practices in reciprocity. Midwifery, being one of the most ancient professions has experienced revolutionization over the ages as knowledge advances, cultures, and societies and this has led to a more organized and recognized global profession, but its goal remains to promote the well-being of the woman and her baby.