Photo by Alissa De Leva

Midwifery Today, Issue 145, Spring 2023.
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In contemplating my approach to writing this article, I considered the traditional ways midwives have been identified and trained since the beginning of human existence. Until quite recently, midwives had been the wise elders of their communities: past childbearing and the concerns of child rearing, transformed to the role of grandmother, with time on their hands and enough life experience to know instinctively when to speak and when to be silent, when to act and when to wait.

In most indigenous communities the role of midwife was an honored position, combining perinatal care with healing throughout the lifecycle not only for birthing women, but for children and men as well. As an example, not long ago in Mexico a traditional midwife gave me her business card, stating her capabilities as partera (midwife), curandera (healer), and, additionally, bonesetter!

Midwifery was further understood to be a spiritual practice in that it involved the place between worlds, the mysteries of life and death. This included facilitating menarche and menopause ceremonies as well as death rites: “care from womb to tomb.” The role of midwife was held not by many, but by those few who were capable of honoring the deep spiritual foundations of their culture.

The rebirth of midwifery in the US happened with its own cultural foundations. The 1960s counterculture of youth espoused dramatically different values than those of the 1950s, and some women of this time felt called to fulfill these values in new roles, for example, the role of midwife. Many who did so had experienced a traumatic first birth in hospital and determined that homebirth was the only way to go the next time, even if unassisted. These pioneers were then called upon to help other women birth at home and, over time, some of those they assisted chose to train as midwives.

Keep in mind that, at the time, there were no schools for out-of-hospital midwifery. In many parts of the country, midwives practiced at risk of being jailed. They weren’t crazy, they were called, and they learned by apprenticeship, self-study and every training opportunity that came their way. In the vernacular of the time, midwife Raven Lang said, “Power to the people, and you can do it if you want to.” These students were self-starters, guided by experienced midwives to have the necessary knowledge and skill to practice safely, to keep their clients and themselves out of harm’s way.

Over the next few decades, as midwifery was legalized state-by-state, educational requirements were established to mandate training consistent with standard post-secondary learning, and midwifery schools emerged. At the same time, those pioneers who had trained by apprenticeship worked hard to retain this path to practice. This brings us to the present, where we can examine the pros and cons of institutionalized midwifery education—what is working and what is not (or is at least problematic).

Remember that until legalization and the establishment of schools, midwifery training was entirely one-on-one, senior midwife to apprentice. A great strength of this style of training was that it was tailored to the respective strengths and weaknesses of each student, modeling how as in midwifery practice we tailor our care to each client. Having trained numerous apprentices, I can attest that each required a unique approach and instructional strategy based on how prepared they were to navigate the responsibility of the work. Overconfident or under-confident, timid or bold, no two were alike, and so my approach to teaching varied according to need.

Ideally, individualized instruction can occur in a classroom setting, but this depends on class size and both the structure and content of curriculum. The larger the group, the more critical it is to facilitate each student’s self-awareness and sense of personal accountability. If we can agree that at its best midwifery is a holistic practice, it follows that learning activities should foster development of all critical aspects of wellness: emotional, physical, mental, spiritual. To this end, assignments in my Heart & Hands coursework are designed to help students do the following:

• Develop a healthy relationship to fear
• Identify personal biases regarding pregnant/birthing women and their partners that could undermine optimal care
• Discover their relationship to nourishment
• Learn more about their mother’s experience of birthing them and consider the impact this has had on their life
• Identify one action they will take to address the cesarean epidemic
• Identify which birth complication frightens them most and why
• Understand their personal learning style with regard to next steps in training

As for class size, limiting it to 12 students has allowed me to keep track of the progress of each—not just academically, but emotionally and spiritually. To promote personal accountability, I make clear at the beginning of the course that although I provide instruction, students must take responsibility for their learning by asking questions, tracking incomplete assignments, and making a plan to complete their work in a timely fashion. I also encourage them to form a private WhatsApp group for peer support and the opportunity to learn from and care for one another. Limiting group size helps make this feasible.

Don’t get me wrong; I realize that if we are to meet the goal of “a midwife for every woman,” we must have programs to educate large groups of students. The solution may lie in a format that most colleges have long been using: large group lecture with small, instructional sections. I emphasize instructional because numerous midwifery programs have small-group student support, but that is not the same thing. And the leaders of these instructional sections must be experienced post-secondary educators.

Cultivating accountability also involves trauma awareness and release. Trauma-informed care is a catch phase these days, but it usually refers to what practitioners provide to their clients, rather than their awareness and processing of their own trauma. This must be addressed, because the more we understand the deeper physiology of birth—especially how changes in brainwave states during labor may cause traumatic memories to emerge not only in the woman giving birth, but in her care provider—the more crucial it is to provide our students tools to identify trauma and heal from it (Davis 2019, ch. 4). To help with this, I suggest that students use the Mother’s Confidential Worksheet in my text Heart & Hands to assess their own experiences of trauma, in combination with class discussion of the most effective healing modalities (Davis 2019, p. 273).

Academic content in my coursework is presented in natural progression: care in pregnancy, birth, postpartum, and for non-pregnant clients. But there is also fluidity according to student levels of knowledge and experience, facilitated by work in small groups where the more experienced students can offer insight to those just starting out, and by time in class to discuss any births that students have recently attended.

Personalized instruction is further challenged by standardized curriculum. I strongly believe that no student passionate about learning should be made to do work below their level of knowledge and experience. Nor should they be required to take prerequisites with questionable relevance to midwifery practice. For example, although it is essential that students understand female reproductive anatomy, must they take an entire anatomy course, particularly when so little time is spent on their area of concentration? Do they really need a full course in microbiology? Midwifery studies should have a practical focus, with immediate applicability to clinical issues and concerns. The National Midwifery Institute (NMI), of which I am co-founder, has the sciences woven into the curriculum and also allows students to work on modules according to issues arising clinically or based on their own assessment of subjects on which they have a pressing need for more information.

Yet another learning activity for my advanced students involves expanding the Midwifery Model of Care document to reflect core tenets of holism: equality of midwife and client, transparency for the sake of establishing and maintaining trust, active listening, and assisting clients to articulate their own health status, including any areas of weakness that could use some attention. As regards the latter, holistic care is distinct from other models in that the care provider avoids giving advice and instead solicits the client’s ideas for healing/improvement. This is a major key to sustainability in practice; the last thing we want is for our clients to feel dependent on us. And the same goes for the instructor-student relationship: a checkpoint for students on their educational experience is whether or not they feel empowered to articulate their needs in terms of learning and to take initiative in the process. The most bottom-line assessment tool students can use to evaluate their educational experience is found in the following question: Am I becoming the kind of midwife I would want at my own birth?

And yet another challenge: lately, with the economy being what it is, most students worry about how long it will take to complete their training; they are in a hurry to start practicing and making money. I gently remind them that the road to practice is not a straight line; that slower periods of birth attendance or the detours required to address personal issues should not be seen as setbacks but instead as purposeful—much like the plateaus in labor. Being a midwife requires a high degree of maturity and, particularly for a young person, this may take some time to develop. Also, much as with labor, time on the midwifery road is quite elastic—sometimes change occurs quickly, and we must be ready for this.

Students also worry about remembering everything they have studied, especially if they are accustomed to conventional learning situations of cramming for a test and then promptly forgetting most of the information. In this respect, I reassure my students that the midwifery road is more like a spiral in that they will pass through essential topics repeatedly; first at an introductory level, then with more in-depth study, clinically in the assistant role, and finally in doing supervised primary care, thus there is plenty of opportunity to learn what is needed to safely begin practice.

Knowing our limits is often learned the hard way; it’s a lifelong process of trial and error. And our limits change from time to time due to our current health status, traumatic events, and the need for integrative time. Similarly, our midwifery practice will fluctuate: we may need to do fewer births occasionally, or take a complete break. I think one of the best ways a midwifery educator can impart this crucial information is to share their stories of mistakes, and their state of mind and body when those mistakes occurred. It isn’t easy to be vulnerable with our students this way, but if we walk our talk on transparency, they find that we are just like them.

In conclusion, midwifery education today is a work in progress; we are learning as we grow. Despite the challenges, there is no denying that one of the great beauties of being a midwifery educator is sharing the experience of lifelong learning with our students as we realize the blending of the old ways with the new. What an honor it is to teach the next generation, as they open their hearts to us and teach us, too!

Source:

• Davis, Elizabeth. 2019. Heart & Hands: A Midwife’s Guide to Pregnancy and Birth, Revised 5th Ed. (Ten Speed Press: Berkeley, California), chapter 4.