We Are All Midwives
by Debbie A. Díaz Ortiz
© 2006 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today Issue 80, Winter 2006.]
Centuries ago names meaning midwife or matron were recorded in the Bible and on every continent to define a wise woman who has specific skills to assist the mother and her baby during the periods of pregnancy, birth and postpartum. What are the origins of this name and its attributes? Although various regions may have different histories, one commonality is that for centuries the profession has been taught by women to other women in their own social environment.
Most midwives look at their history with admiration, respect, dignity and the honor it deserves. Nowadays, traditional midwives in Latin American and in some countries in the Caribbean are recognized as midwives by their communities and/or by the governments of the countries where they practice. However, the International Confederation of Midwives (ICM) and the World Health Organization (WHO) use another definition and recognize as midwives only those individuals who (1) have completed a recognized educational programme and (2) are licensed or legally registered. Regrettably, these organizations do not have a noble definition for traditional midwife or empirical midwife and instead substitute these terms with the phrase traditional birth attendant—avoiding the centuries-old title midwife.
When WHO or ICM go into a country, albeit with good intentions, they first change the name of the profession and then expect the traditional midwives to work only as assistants of other primary providers. They fail to consider the traditional midwives' culture, their experience and strength of vocation, the success of interdisciplinary collaboration—in conjunction with educational programmes and the community's social and economic realities.
Who Is the Midwife?
After my tenth year as a midwife I started to feel fearful about my work; this lasted for approximately three years. Rully Delgado, our traditional midwife and a colleague of mine, accompanied me and always helped me. Another colleague developed this fear after almost twenty-five years of practice, and the youngest of the group experienced similar fear during her first six years of practice. I know that during these years of fear some midwives leave the profession, which is understandable. I was able to help the young midwife by telling her the following: "To verify the health of the mother we have all the necessary laboratory tests, excellent equipment, up-to-date emergency procedures, immediate ambulance service, telephones and, in most cases, a hospital no more than a twenty-minute drive from the mother's home. We choose our clients and have all the necessary tools to verify their health adequately. It is okay to be afraid; it is even good. Identify your fear and read about it in your many reference books and remember that even though the percentage is very low, birth and death are related."
I can imagine having the same conversation with midwives in isolated places on poor continents, where the houses are perhaps made of straw and bamboo and the roads are of dirt and stone and where the nearest hospital is from two to six hours away, if a vehicle is available and it is not the rainy season. Women with a dangerous health history in any other scenario would be directed to the hospital by the midwives, but due to geography and poor resources, this is not possible. The conversation of a midwife helping a colleague during a period of fear might then be: "We know about how to make the mother feel well; about manipulations to help her and her baby; about herbs, teas and how to stop bleeding; we know how to heal. Use these remedies. All women are our clients. The majority bear many children; they are poor; some are dearly loved and others are abused. They live just like we do. We know their housing is not adequate and at times it is shared with animals. Keep everything as clean as possible. Watch for signs of disease and teach them how to time other pregnancies. You will see death—some mothers will die and some babies may be born sick and die. It is not your fault that we are poor and isolated. You will have to be strong and alert. Our neighbors believe in us because we are the midwives and they have nobody else. I will share all I know with you. Stay in the profession—it is profoundly beautiful and heart-rending. Treat your mothers with dignity. They will respect you. Stay, because you are very important; you carry the lineage. You are one of our community's midwives."
We Are All Midwives
Several years ago I worked with the midwives from an area of El Salvador. I asked them if they knew about ICM and they said they did not. I asked them what they were called in their country and they said "midwives." I asked them if they had heard the phrase traditional birth attendant used to define their work and their reply was "no." I told them that some organizations use this phrase instead of midwife, that ICM and the WHO give the title of midwife only to a woman who studies her trade in an educational programme recognized in its country. I told them that this started about a quarter of a century ago. The women were disconcerted and started shaking their heads; one of them exclaimed from her soul, "But I am the midwife!" and the rest agreed with her.
I did research to find out who is called a midwife in different countries in the Caribbean, Central and South America and I couldn't find any country where the phrase "traditional birth attendant" is used to identify midwives socially or legally.
Being known as a midwife carries with it profound respect, pride and honor; when that dignity is tampered with, it causes pain.
What Can We Do?
Spend time with midwives in isolated places and tell them to appreciate and continue to use the title midwife. Also, explain the importance of being called midwives by the mothers in their communities as a way to show recognition of and respect for the duties they perform in their countries.
- Request a referendum to change the language used by ICM/WHO to acknowledge traditional midwives as midwives and not "birth attendants," if possible with representation and input by all midwives, regardless of membership in ICM (Many countries affected by the ICM position are not part of this organization).
- Insist that when ICM or the WHO representatives come to our countries, they respect the fact that in their home nations, traditional midwives are considered midwives and not "birth attendants."
- Ensure that educational materials reflect the culture and practices regarding midwives, emphasizing that the terms traditional or empirical midwife are honorable.
- Avoid explicitly and implicitly influencing the names by which midwives are called in their countries. (Individually, most traditional midwives don't have a clear understanding of the term "traditional birth attendant"; they are unaware of the intent to make a political change to their title and duties.)
- Understand that very few of the thousands of isolated places receive any assistance, and when they do it is usually sporadic, for short periods of time or not enough. Money is practically nonexistent in marginal communities and the expectation that families will move close to health clinics or birth centers without housing is unrealistic. Furthermore, leaving their other children behind is inconceivable for an event that is considered natural.
- Recognize traditional midwives, respecting their work as primary caretakers, and understand that most of the time they go to work alone.
- Supply traditional midwives with basic medication for hemorrhages, convulsions, neonatal ophthalmia and tetanus and give them telephones for emergencies. If this is done pregnancy will be safer. If they perceive their work is threatened, they will go back underground.
- Create a close interdisciplinary collaboration with traditional midwives. A collaborator can see the mothers, if possible, once every trimester, be present at some of the births assisted by traditional midwives to help if needed, and visit postpartum. The collaborator would be there not to supervise but to collaborate and to share knowledge. Avoid written or verbal communications that mention supervision so the natural autonomy the midwives already have in many instances is respected.
- Study training programmes for traditional midwives that have been proven successful, been cost-effective and significantly reduced mother-child mortality and morbidity, while remaining simple and all-inclusive. Educational programs that have failed should be evaluated to correct and amend.
Some traditional midwives will gladly change roles and work as assistants if a skilled attendant is available. The sensible view and challenge, however, is to work with and recognize the midwives who have a deep commitment to their vocation and/or great experience as a primary birth attendant without de-stabilizing the reality of their lives and communities, and yet enriching their practices.
What to Expect
History has taught us several things. Organizations take time to grow. Throughout history groups of people with power (usually from developed countries) have had great difficulty understanding the idiosyncrasies of other countries and have failed to recognize their own lack of knowledge. Be aware that these international organizations can only influence and cannot force a country to establish certain legal dispositions.
If traditional midwives are alienated, the Latin American midwifery system could conceivably collapse, with domination by other professionals and with fewer mothers seeking midwives, as happened in the US with the schism between nurse-midwives and midwives. On the other hand, if traditional midwives are considered part of the team, the monies of poor countries may be used for their professional development, making them more versatile. This would require collaboration with other midwives and the health ministers, with the intent of working towards a healthcare system in which women in isolated places can make their voices heard. (These women widely prefer traditional midwives as primary care providers.)
If traditional midwives are accepted as true midwives, the base of midwifery as a profession will only become stronger. Outsiders see us as one group whether we accept this or not. In many Latin-American countries the term traditional birth attendant is not used: Here, we are all midwives.
- That very few people have the courage to work with the birthing process in isolated places in their countries. Traditional midwives offer this service.
- That traditional midwives are a reality that cannot be removed.
- That traditional midwives are considered to be midwives in their own countries.
- That the union of midwives with formal and informal schooling can be strengthened and maintained in many countries.
- That, as a matter of fact, the traditional midwives are the most skilled and have the best connection with the health systems in their communities and the support of their governments.
- Traditional midwives are usually permanent residents and their constant presence in the community makes them a real alternative for mothers.
- Their socioeconomic level is similar to that of their clients, so they are accessible.
Many studies demonstrate that traditional midwives are capable of integrating new training and their services are accessible, cost-effective and improve outcomes for mothers and babies. They also have been shown to be a useful component that can be integrated of a safe motherhood program.
Eliminating this position of primary caretaker in countries with isolated areas and complicated health systems would only increase maternal and neonatal mortality. Poor outcomes in these countries have been found to be linked to poverty, insufficient supplies, isolation and lack of family planning and interdisciplinary collaboration, rather than by the work of traditional midwives. Experience has shown that, given the opportunity, traditional midwives of all ages are interested in learning, have the ability to use medication for emergencies and are capable of interacting with the formal health care system, particularly other midwives.
Since 1919 the ICM has done a titanic job of maintaining an organization of midwives that competes and associates with the most powerful organizations in the world. They have demonstrated a belief in the inherent health and well-being of gestating women, in the autonomy and decision-making power of midwives and in the commitment of midwives to help in educating alienated groups. Their declarations about midwifery are accessible to midwives of all nations. They work with studies that strengthen most of our positions and among others, have established an International Midwife Day. On the 5th of May, all the midwives around the world celebrate our existence and our many accomplishments.
Nevertheless, their decision to not consider traditional midwives as midwives was an insensitive and unacceptable error. Despite this, the International Alliance of Midwives (IAM) will continue to honor all midwives by using their true title, and these midwives will continue to be "with women."
Understand but recognize the limits of what we can accept. Nobody changes anybody but we inevitably grow. May this process of birthing result in homogeneous admiration, respect and recognition of our history, the acceptance of the term traditional midwife and the implications of using this name. Meanwhile, let us be considerate with each other because more things unite us than separate us. After all, we are all descended from the same lineage and belong to one family. We are all midwives.
Debbie A. Díaz Ortiz, CPM, MPH, is a midwife and member of the Latin-American and Caribbean Network for the Humanization of Childbirth.
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