Midwifery Education for Autonomous Practice: The Time Is Now!
Editor’s note: This article first appeared in Midwifery Today, Issue 123, Autumn 2017.
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As midwifery is increasingly mainstreamed, so too is midwifery education. Those of us who have been in the field for 40 plus years hoped this day would come, but at the same time, we must reckon our losses with our gains—in fact, as elders, it is our role to do so. Even more critically, we must use this reckoning to envision our future. As I have often said, “It is no longer a question of whether we will have midwives but, rather, what kind of midwives will we have?” With deep contemplation of this question, the ideal should emerge, along with the educational model to best support it.
One of the easiest ways for a student to frame this question is to ask, “What kind of midwife would I want at my birth?” And then, “Is my educational program preparing me to be this kind of midwife?” Often, the answer to the latter question is either “no,” or a very conditional “yes.” Perhaps this is because, in the course of mainstreaming our profession in the United States, we have found it necessary to develop an infrastructure to support our work—certification, accreditation, legal advocacy, legislative strategy and public education. All of these require a certain interface with the powers that be, which have presented a series of legitimacy hoops we’ve had to jump through to gain credibility. But, in the process, the focus has shifted from what a midwife is to what she knows. And, as I always tell my students, almost anyone can master the knowledge and skill necessary to practice, but the personal growth and preparedness aspect—now that’s the hard part!
Not only national, but also international, midwifery politics have played a role in shaping our future. The International Confederation of Midwives (ICM) 2010 document, “Essential Competencies for Midwifery Practice,” articulates and extends midwifery care to include non-pregnant client care throughout the life cycle and well-baby care for up to two months (International Confederation of Midwives 2010). However, when the Midwifery Education Accreditation Council (MEAC) decided to adopt this standard for accrediting schools in the United States, an increased level of academic preparation was necessary. Overall, this may be seen as a good thing, but I can see the downside. In general, when midwifery instruction overemphasizes theoretical preparation, and clinical training is not integrated throughout, qualities of compassion, intuition, insight and initiative that are the hallmarks of true midwifery care are often sacrificed.
And despite our struggles for legitimacy in the US, midwifery continues to be subjugated internationally to obstetrical standards of practice and political machinations—which has worked against appropriate legislation, legal defense and professional autonomy. Organized medicine continues to demonstrate its greed for the revenues of childbirth and the power of position that assisting birth accords. In the Netherlands, under the guise of “consumer choice,” the obstetrical lobby managed to undermine the long-standing tradition that all pregnant women start care with a midwife; and the midwives, having grown complacent over time, scrambled for a solution as the homebirth rate sharply declined and the cesarean rate skyrocketed. In Germany, the law states that a midwife must be present whenever a woman gives birth, but soaring malpractice premiums predicated on newly imposed obstetrical practice guidelines have driven many out of practice. In Australia, the inability of homebirth midwives to get malpractice insurance has caused many to seek other placement or simply go rogue. And in Hungary, we have only to look at the case of Ágnes Geréb (Harman 2012) to understand the vehemence with which the obstetrical ruling class intends to hold onto its unfounded authority—no matter what.
Thus it has never been more imperative that midwives fight for their autonomy by articulating their unique approach to caregiving and the core skills that uphold the efficacy of midwifery care. We must make sure that our educational programs teach this to the fullest, without equivocation. Even more importantly, students must be equipped with the personal strength and political know-how to take up (and maintain) the fight for autonomous practice.
I am convinced that for midwifery to advance to its full potential and true nature, it must embrace the model of holism, as must midwifery education. Perhaps you are already familiar with Robbie Davis-Floyd’s groundbreaking articulation of the three models of health care provision (Davis-Floyd 2001). Here is a brief summary:
The technocratic model is based on beliefs that the body is a machine, that disease comes from without, that standardized care is best because it minimizes the risk of the unexpected and that practitioner knows best. In short, it is a model based on control.
The humanistic model would modify the tenets of the technocratic model by making practices more humane, by allowing a bit more time for care, by emphasizing bedside manner and concern for a client’s needs and feelings. It is a model based on kindness and good intentions.
The holistic model redefines the client as a decision-maker in the health care experience, the authority on her own health status, responsible for educating herself on care options and for self-care, with her health a manifestation of emotional, psychological and physical factors. It is a model based on education and empowerment.
Note that although the humanistic model acknowledges the emotions, in practice it may be little more than a kinder, gentler technocracy, in that the practitioner gives care rather than encouraging the client to care for herself. The holistic model redefines the practitioner/client relationship as one of equals—which has both benefits and pitfalls, especially for the practitioner schooled in technocracy or humanism.
How does this apply to midwifery education? Technocratic programs are almost unheard of, humanistic programs are common and holistic programs are on the rise.
Humanistic programs typically pose problems because of confused values: partly technocratic, partly holistic. Concepts of care may be based more on ideals than on practice realities, and idealistic providers tend to give all they can—often more than is appropriate. Co-dependence is a real pitfall here, as the provider may feel inadequate for “not doing enough,” or conversely, may feel resentful at having no personal space, time or respect. The same is often true of students being schooled in this model. Humanism is the bridge between technocracy and holism but, at times, the bridge can feel shaky, without solid footing on either end.
Holistic education is a radical departure from humanism in that the hierarchy between teacher and student is dissolved. No matter their personal circumstances, the two are on a level playing field, with the understanding that they are both adults, with their own life experiences and expertise. In practical terms, holistic education does not just “value” student input, it depends on it. The interaction between teacher and student is a two-way street, with healthy function based on honesty, integrity and transparency. Nobody gets to pull rank, because there is no rank.
At first glance, teaching (or practicing) holistically may appear threatening to one’s privacy or personal space; but the key is communication. I make it a regular practice to check in with my students at the beginning of each class session. We go around the circle and tell the truth about the energy—physical, emotional or mental—we are bringing to the day’s work. The first time we do this, I make clear that the goal is to speak from the heart, not the head—as the latter can lead to lengthy (and tedious) processing. In my early days of teaching I considered checking in to be a waste of precious time, but then I discovered that without it, we would energetically track each other and become distracted by what we discerned had not been named. Bringing the truth into the open each time we meet has more than proven its value in the way we are able to fully focus on our studies and get things done.
One of my favorite examples to help differentiate humanistic from holistic care is the task of nutritional counseling. The humanistic practitioner will be full of ideas on what the client should eat, perhaps with handouts or other resources offered, regardless of the client’s participation. But the holistic practitioner deliberately avoids giving advice, instead asking the client how she feels eating as she does, if she is craving or denying herself any foods and, if so, what obstacles are in the way. The holistic practitioner does not deny her own expertise; for example, she may note a protein deficiency, but rather than make recommendations, she will ask the client about favorite protein foods and which ones she would most like to increase. The psychological impacts of this kind of care are subtle but significant: The client is put in charge of defining and improving her own health status and the practitioner is freed of emotional and mental entanglements that would otherwise be based on her client’s dependence. This is particularly important in midwifery, as we must be ready for the next birth with our most recent client/family on firm footing.
Yet another more personal example: Imagine that you, a holistic midwife, are about to see a client after a horrible argument with your partner or a very difficult birth with an upsetting outcome. Working in transparency, you expect your client to notice changes in your mood or affect and, bottom line, you want her to notice, as that is your commitment to each other. In humanism, you might try to hide how you are feeling, but in holism, it is unethical to do so. However, you certainly can’t “dump” on your client! A simple acknowledgment of your situation, without processing, will do the trick and put your visit on the right track, as long as you reassure her that you are glad to see her and are looking forward to your time together.
In my experience with international work, most midwives at this juncture are walking the line between humanism and holism; those caught up in humanism are more likely to burn out or cop out on their professional values and personal care, whereas those stepping into holism discover rewards of increased energy and resilience, greater self-determination and healthier relationships in general. In short, these are the midwives who stand to advocate autonomous midwifery practice, promote autonomy in their clients and ultimately seed sustainability for their work and those they serve.
As the adage tells us, “It’s never too late to have a happy childhood” and, likewise, it’s never too late to become the midwife you need to be so you can move forward in a healthier way, with energy for yourself, your family and, hopefully, to teach and prepare the next generation.
Bringing this back to the student perspective: How can you tell what model program you are enrolled in or might want to choose if you are still deciding? Here are a few questions to consider:
Does the curriculum have components that address not just my academic and clinical preparation, but also my personal growth and political astuteness? If not, can I safely communicate this?
Is my relationship with my instructor(s) egalitarian? Academically, clinically? As regards their emotional availability and transparency? If not, can I safely communicate this?
Can I safely confide the impact of personal crises on my educational process to my instructors or administration?
Is there a mechanism for feedback to each unit of work, regarding content, learning tools, learning experience, outcome in meeting the learning objectives and ideas for improvement? If not, can I safely communicate this?
If I am LGBTQ or in any way marginalized culturally (e.g., by religion, culture, race), is there voice for me in this program? If not, can I safely communicate my need for advocacy?
Does this program present opportunity for periodic assessment regarding my personal goals, and the evolution of these, in becoming a midwife? If not, can I safely communicate this?
Am I acquiring the skills to practice holistically, to the deepest extent of my understanding? If not, can I safely communicate this?
Quite honestly, making this list of questions has shown me, as an instructor, areas where I can improve. And that is the way it is meant to be. The deep and enduring beauty of midwifery is that, although the core of it is unchanging, our personal/cultural/political growth and learning continually upgrade our skills and the art of what we do.
How often, in times of great challenge at a birth, do we fall back on faith, the deeper understanding that the very physiology of birth has taken us to an altered state wherein information not personally known to us will come forward, into our heart and hands so that we can do what is necessary—sometimes to save life? Bottom line for students—does your educational program prepare you for this? Bottom line for educators—if you know this truth, why not speak it? And bottom line for all of us—if not now, when?
- Davis-Floyd, R. 2001. “The Technocratic, Humanistic, and Holistic Paradigms of Childbirth,” Int J Gynaecol Obstet 75(Suppl 1): S5–23.
- International Confederation of Midwives. 2010. “Essential Competencies for Basic Midwifery Practice.” Revised 2013. Accessed June 14, 2017. http://internationalmidwives.org/assets/uploads/documents/CoreDocuments/ICM%20Essential%20Competencies%20for%20Basic%20Midwifery%20Practice%202010,%20revised%202013.pdf.
- Harman, Toni. 2012 “Agnes Gereb and the Case for Human Rights in Childbirth.” The World Post. Accessed Jun 15, 2017. huffingtonpost.com/toni-harman/filming-agnes-gereb_b_1539595.html.