Call Us Midwives: Critical Comparison of What Is a Midwife and What Is Midwifery Elaine Jefford, Cristina Alonso, and Jennifer R

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Call Us Midwives: Critical Comparison of What Is a Midwife and What Is Midwifery Elaine Jefford, Cristina Alonso, and Jennifer R. Stevens

Research has identified midwifery as key to improving maternal and child health globally. Consequently, increasing the numbers, access, and quality of midwives is paramount as attention, funding, education, and support increases. Yet what a midwife and midwifery are is often misunderstood. The terms midwife and midwifery are often used interchangeably. Other cadres such as nurses, doulas, Skilled Birth Attendant, traditional birth attendant, and nurses with obstetric/perinatal experience are often referred to as midwives or providers of midwifery care. As health systems work to integrate midwives and midwifery, global clarity and understanding must exist on what midwives are and what they are not, and what midwifery is and is not. As the first step to establishing clarity; we undertook a critical comparison of existing different countries, ’not for profit and professional organizations’ definitions and interpretation of a midwife and midwifery philosophy. The International Confederation of Midwives’ definition of a midwife and midwifery philosophy, and their Global Standards for Midwifery Education acted as the baseline. A global consensus and commitment to educational systems and culture that teaches the midwifery model and the philosophy behind that care can positively impact and improve outcomes for women and babies. KEYWORDS: midwifery; midwife; philosophy; education; regulation

WHAT IS A MIDWIFE AND MIDWIFERY? (ICM, 2017). Using the theoretical and experiential knowledge from their formal education, the midwife Midwives developed the International Confederation draws on their formal education (ICM, 2018). Such skills of Midwives (ICM) definition of a midwife and mid- and knowledge are enacted via the midwifery philoso- wifery for midwives around the world (ICM, 2017). phy of a partnership relationship between the midwife The ICM has provided clarity in relation to the “noun” and woman where there is mutual respect and shared midwife and the “verb” midwifery. Despite many lan- decision-making (ICM, 2018; Miller & Bear, 2019). Con- guages, not having the strict noun and verb construct of sequently, the ICM provides direction that if a person English, its 132 Midwives Associations, recognize these is educated to the ICM Global Standards for Midwifery documents across 113 Countries, which represent Education (ICM, 2018) and practices to the ICM defini- approximately 500,000 midwives. The term “midwife” tion of a midwife (ICM, 2017). Regardless of their local generally refers to the individual and the training and title, this person is entitled to practice the art and science skills required to use the title of midwife. The term of midwifery and use the title of midwife. “midwifery” speaks more to how a midwife does what Despite this, some countries, not for profit and she/he does, as well as the philosophy behind the pro- professional organizations, and other groups have pub- fession. A midwife offers care across the childbearing lished their own definition or interpretation of what a continuum, which begins with reproductive and sex- midwife’s scope of practice is; what a midwifery philoso- ual health education through to the postpartum period phy should entail; and what a model of midwifery care is

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(American College of Nurse Midwifes [ACNM], 2018; WHY WORDS/DEFINITIONS MATTER: Australian College of Midwives [ACM], 2018; Renfew EDUCATION STANDARDS PROFESSIONAL et al., 2014; United National Population Fund [UNFPA], IDENTITY AND WHO WE ARE 2018; World Health Organization [WHO], 2018). Indi- vidual countries, global organizations, and international The midwife is a recognized autonomous professional non-governmental organizations (INGOs) also misuse who provides a range of sexual and reproductive health the terms. For example, in some locations skills taught services including care during pregnancy, birth, and are basic while in other places, such as Nepal, com- postnatal and obstetrical emergency stabilization, in plex skills such as a vacuum extraction (operative vagi- diverse contexts. Existing cultural, social, and physical nal birth) are taught (Puri, Tamang, Shrestha, & Joshi, inequities may influence professional midwives’ auton- 2014). This “add on” training for nurses or new emer- omy, agency, and ability to work to their full scope of gency obstetric care training for non-midwife providers practice. For example, lack of resources including sup- or health workers may be as short as 3 months. Yet upon plies, pay, and collaborative practice can vary from coun- completion, the person is often called a midwife and they try to country and even practice to practice (Vedam take on the role of working with childbearing women. et al., 2018). This results in what could be termed “boundary slippage” The ICM definitions of a midwife (ICM, 2017) of what a midwife is according to the ICM definition and midwifery philosophy enables midwives, irre- (ICM, 2017). The lines becomes blurred with those of a spective of geographical location, to advocate for nurse, Skilled Birth Attendant Traditional Midwife, com- themselves when exercising their legitimate authority munity health worker (CHW), and doula throughout the to speak about midwives and their work. (ICM 2014) maternal child health care context. (SBA; WHO, ICM, & Consequently, these definitions are fundamental when Federation of International Gynecologist and Obstetri- developing quality educational programs. Further, it cians [FIGO], 2004). All of these cadres have unique edu- enables appropriate regulation and thus accurate eval- cational pathways, some more clearly defined than oth- uatation of the impact and quality of care midwives ers, but none of them meet the requirements of a midwife provide. as defined by the ICM (2018). Midwifery holds two characteristics necessary to WHO, in a joint statement with the United Nations reach its full potential: the relationship between a woman Population Fund (UNFPA), United Nations Interna- and her midwife, and an integrated enabling environ- tional Children’s Emergency Fund (UNICEF), ICM, ment to support this. The former is the core of mid- International Council of Nurses (ICN), FIGO, and Inter- wifery care: the relationship between the midwife and national Pediatric Association (IPA), has attempted to the woman (Miller & Bear 2019, Guilliland & Pairman, clear this confusion with their recently publish definition 2010; Leap & Pairman, 2006; Pairman, 2010). of “skilled health personnel providing care during child- Midwifery needs to function autonomously and be birth” (WHO, UNFPA et al., 2018). The critical attention fully integrated into the healthcare system. This creates these global agencies place on women and their new- an environment whereby there is ease of consulting and borns is well founded. Their quest is to reduce mater- transferring care when care is identified as outside of nal and neonatal mortality globally by providing women the midwife’s scope of practice (ICM, 2017). When bar- with access to some form of obstetric emergency care riers prevent either the process of relationship or the (WHO, UNFPA, UNICEF, 2009). It is, therefore, imper- process of integration from being fully enabled, mid- ative to keep the needs of women and their newborns wifery cannot be expressed to its fullest potential. Conse- as well as those of midwives central to this discussion. quently, this causes a loss of benefits for the woman, the What appears to be lacking, however, are fundamental midwife and the healthcare system. When this relation- elements such as the level of education, philosophy of ship and philosophy is at the foundation of what a mid- training, and how these cadres are regulated (while still wife does, care moves beyond providing purely lifesav- often given the label midwife). Having a distinct defini- ing or technical skills. The midwife prioritizes the use of tion of what a midwife is, a midwifery model of care and respectful, compassionate, relationship driven care that philosophy is important for a profession, as these impact is negotiated in partnership with the woman (Miller & the unique education required to promote the profes- Bear 2019, Guilliland & Pairman, 2010; Pairman, 2010; sion. Further, it offers a framework for monitoring and Vedam et al., 2018). Yet if midwives feel undervalued evaluating quality midwifery care. and unsupported, socially and/or culturally, to enact

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and fully engage in the midwifery philosophy of care, for profit and professional organizations’ definitions ofa then the core of the midwifery model of care and the midwife and midwifery philosophy with the ICM defini- foundation of the midwifery profession are lost (Filby, tion (ICM, 2017) and philosophy (ICM, 2014). The guid- McConville, & Portela, 2016; WHO, ICM, & White ing questions for this critical comparison are: Ribbon Alliance [WRA], 2016). 1. What are the strengths and limitations of existing def- Historically there has always been contention initions of a midwife? between midwives and the medical profession (Willis, 2. What are the strengths and limitations of required 1983). It could be argued the tension is due to the dif- education standards? ferences between the philosophical stances of the two 3. What are the strengths and limitation of existing mid- professions, differences in models of care and the ill- wifery philosophies? ness and risk lens from which medicine views child- 4. How do the above aspects impact upon a midwife, a bearing. Further, culturally reinforced gender inequities midwifery model of care and the midwifery profes- are often played out in the attempt to keep midwifery sion? and women’s health within the dominant medical model (Betro, Mcclair, Currie, & Banjerie, 2018; Hartigan, 2001). As midwifery refuses to conform to the illness- STRENGTHS AND LIMITATIONS OF EXISTING medical dominated model in healthcare, this may has DEFINITIONS OF A MIDWIFE: CORE THEMES contributed to the slow promotion of the midwife as an IDENTIFIED IN CURRENT DEFINITIONS independent, autonomous practitioner. Further, it has contributed to the lack of priority for midwifery as a The ICM states that for a midwife to practice, a coun- unique model of care. Additionally, despite men becom- try must enable specialized education, regulation, and ing midwives, midwifery remains a woman-dominated autonomous practice (ICM, 2017, 2014). Standards for profession providing care to women, her partner and education must result in a cohesive profession that is reg- family however she defines it. While we acknowledge ulated, allows for quality planning, and accountability that both women and trans men and other non-binary (Castro Lopes et al., 2016). The education of a midwife identities may become pregnant and access midwifery must, therefore represent and be aligned with the philos- services, in this article we will refer to women/woman ophy of midwifery as defined by the ICM (2014). as anyone who is having a baby. Midwifery is and Although it may seem evident that professional should be in conflict with the medicalization of child- education must prepare competent professionals in a birth when that medicalization is applied unnecessarily. specific field, at a global level the education of a mid- Midwifery guidelines acknowledge that medical inter- wife often does not prepare autonomous professionals vention is warranted if a mother and/or baby are at risk who are skilled in the midwifery philosophy or model of when a deviation from the physiological process occurs care. This disconnect may emerge from midwives being during the perinatal period. Nevertheless, physiological ignored or suppressed as healthcare providers. This his- care becomes problematic when played out in the med- torical suppression stems from when midwifery was/is ical model, where healthy “patients” need support, edu- perceived as a subset of nursing and ultimately to be cation, and accompaniment rather than the escalating controlled by medicine (Coburn, 2006; Fahy, 2007; Filby interventions that increase the psychological, physical, et al., 2016). The midwifery profession rejects such per- and financial costs they often experience. Creating a path ceptions or limitations on a midwife’s right to be seen to professionalism, without losing the philosophy that is as an autonomous practitioner. This includes any cen- unique to the midwifery profession is paramount if this sorship on midwives to speak about midwives and their care model is to be maintained, grown and compliment work. the medical model rather than be seen as an alternative or in opposition to it. The challenge in the conflicting definitions of what a midwife is, what she/he does and the philosophy inder- STRENGTHS AND LIMITATIONS OF REQUIRED pinning that must go beyond what is the minimum years EDUCATION STANDARDS: ANALYSIS OF of education and demonstrable skills for midwives’ edu- EDUCATIONAL FRAMEWORKS cation, but the essence of what midwifery is as a profession. A critical comparison is therefore necessary to The ICM definition of the midwife ( 2017) and the ICM

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for the critical comparison of WHO (2018), UNFPA • National recognition of the profession of midwifery (2018), The Lancet (Renfew et al. 2014), ACNM (2018), • Midwifery educational process that is a unique pro- and ACM (2018) documents. Thematic analysis was cess with unique standards. (pre-service educational used to identity both explicit and implicit themes (Fahy, faculty and administrative standards) 2007; Richardson-Tench, Nicholson, Taylor, Kermode, & • Midwifery education that results in a quality assess- Roberts, 2018) around education. This involved a search ment offering validation, regulation, and accountabil- for key words within ICM definition of a midwife (ICM, ity 2017). To validate the key words, each author conducted • Midwifery quality of practice that is based on ongoing the analysis separately. Upon consensus, these were then competency (in-service education). placed under seven themes that create a strong, legitimate, autonomous professional. These themes included: Interestingly, only the country specific definitions from Australia (Puri et al., 2014) and the United States 1. A specific midwifery education program (ACM, 2018) referred or mentioned ICM definition 2. State/Country recognized (ICM, 2017) and competencies (ICM, 2019). Maintain- 3. Content is based on core competencies ing clarity is particularly important for education as it 4. Educational process is unique and has standards generally defines the core essence of the profession for 5. Education results in quality assessments that offer val- full expression of the professions’ philosophy. It also pro- idation, regulation, and accountability vides a framework for professional identity, curriculum 6. Education confirms the right to a unique title of Mid- development, and assessment. Midwives as part of their wife and responsibility education program acquire theoretical and clinical com- 7. Quality of practice is based on ongoing competency. petence. The primary focus is on childbearing being a natural physiological event, which requires the midwife As the terms midwife and midwifery are often used inter- to trust the woman’s body to birth. At times, deviations changeably, the next step of the analysis was to criti- from normal occur and the midwife must be compe- cally compare the ICM themes to other major organiza- tent to diagnose and immediately respond to and stabi- tions published definitions of a midwife and midwifery lize unexpected emergencies (Richardson-Tench et al., (ACNM, 2018; ACM, 2018; Puri et al., 2014; Renfew 2018). Midwifery education, however, must not be lim- et al., 2014; UNFPA, 2018). The aim was to note any ited to view childbearing through the medical lens of similarities, differences, and gaps. While it is acknowl- risk and intervention. Rather midwifery education must edged that several documents authored by these orga- prepare midwives to be autonomous providers of com- nizations might incorporate reference to midwifery prehensive women’s healthcare within the philosophy of philosophy and/or what a midwife is in some form, the midwifery. To be a midwife, one needs to embrace mid- focus of this article is specifically on the explicit docu- wifery and its philosophical stance, understand it, and ments termed (midwifery) philosophy or definition of strive to enact it daily. It is what makes the care a midwife a midwife/what is a midwife. The reason for this it that gives so unique. when a search is undertaken on these terms, the key Global variations, however, in the definition of a documents cited in this article are located. Additionally, midwife and midwifery has led to different countries and they are often referenced as stand-alone documents, and programs having separate understandings and diverse therefore should be judged as such. implementation of the professional identity and education of midwives. The ICM has attempted to mitigate variation in midwifery education (ICM, 2018) through IMPACT ON EDUCATION AND CARE its competencies (ICM 2019, 2018) and educational standards (ICM, 2018). However, lack of consensus on the Most of the definitions by other organizations offer min- part of WHO (2018), UNFPA (2018), and national asso- imal specific guidance on education (ACM, 2018; Puri ciations (ACM, 2018; Puri et al., 2014) on a unified defi- et al., 2014; Renfew et al., 2014; UNFPA, 2018). Four of nition and identity of midwifery leaves many wondering the seven themes identified within the ICM document what a midwife is, and how is she/he unique and differ- were lacking in most of the other organizations docu- ent from a nurse, doula, CHW, or SBA? ments including (ACM, 2018; Puri et al., 2014; Renfew In addition, the approach of treating midwifery et al., 2014; UNFPA, 2018): as less than a legitimate autonomous profession with a

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TABLE 1. Analysis of Education in Midwife and Midwifery Definitions Education ICM- UNFPA- Lancet- WHO- ACM- ACNM- Themes Midwife What Midwives Midwifery Midwifery Australian (United States) Identified in (ICM, 2017) Do (ICM, 2017) (ICM, 2017) (ICM, 2017) Mid- Midwifery and ICM wifery Scope of Definitions and Phi- Practice (ICM, of Midwife losophy 2017) (ICM, 2017) Specific midwifery Specifies a “A well-trained “Skilled, Not mentioned “Informed by “Formal education, education “midwifery midwife” knowledgeable, scientific graduate degree” program education and evidence” program” compassionate care” State recognized “Recognized in Not mentioned Not mentioned Not mentioned Not “Education program the country” mentioned is accredited” but refers to ICM Content is based “Based on ICM Skills focused Core Not mentioned Evidence- “meet core on core competencies characteristics informed competencies for competencies for basic Basic Midwifery (pre-service midwifery Practice of the educational practice” ACNM” refers to objectives) ICM competencies Education process Using the Not mentioned Not mentioned Not mentioned Not Not mentioned is unique and “framework of mentioned has standards the ICM Global but refers (pre-service Standards for to ICM educational Midwifery faculty and Education” administrative standards) Education results Education results Not mentioned Not mentioned Not mentioned Not “Educational in quality in mentioned program is assessment that “qualifications but refers accredited” offers validation, to be registered to ICM regulation, and and/or legally accountability licensed” Education and Results in legal Not mentioned Not mentioned Not mentioned “Midwife is Not mentioned regulation status to authorized confirms the “practice to provide right to a unique midwifery and maternity title and use the title care on responsibility ‘midwife”’ their own responsibility” Quality of practice The midwife Not mentioned Not mentioned Not mentioned Not “Must be recertified is based on “demonstrates mentioned every 5 years . . . ongoing competency in but refers meet specific competency the practice of to ICM continuing (in-service midwifery” education education) requirements” (Continued)

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TABLE 1. Analysis of Education in Midwife and Midwifery Definitions (Continued) Education ICM- UNFPA- Lancet- WHO- ACM- ACNM- Themes Midwife What Midwives Midwifery Midwifery Australian (United States) Identified in (ICM, 2017) Do (ICM, 2017) (ICM, 2017) (ICM, 2017) Mid- Midwifery and ICM wifery Scope of Definitions and Phi- Practice (ICM, of Midwife losophy 2017) (ICM, 2017) Overall Comprehensive, No reference to No reference to No reference to Refers and NO reference to impression reference ICM. Focused on ICM. No specifics ICM. Very brief, links to ICM definition, definition skills a midwife on education. focused on scope ICM for focuses on scope, can provide. Focused on and skills. definition. and skills, Mentions scope, some Nothing on Midwife. accreditation and “people with philosophy and education or Philosophy discusses midwifery skills” consultation and philosophy is compre- relationship with referral hensive nursing. Refers to (see philos- ICM ophy chart) competencies

Note. ACM = Australian College of Midwives; ACNM = American College of Nurse Midwifes; ICM = International Confederation of Midwives; UNFPA = United National Population Fund; WHO = World Health Organization.

development and impact on a healthcare system. The midwifery education as a pathway to create unique pro- current overemphasize on skills needed to save lives, fessionals that practice within the framework of mid- without emphasizing the autonomy of the profession and wifery philosophy. Rather it could be postulated that its philosophy, demonstrates a lack of vision for qual- some organizations focus on training a provider with ity in women’s health and midwifery. It also reflects per- a specific set of clinical skills who may call themselves sistent tensions that place women within the contested midwives. The difference between the two approaches space of being viewed through the dominate medical- to midwifery education is important in a global con- illness model, rather than the woman-centered mid- text where national and international organizations are wifery model. It can be postulated, midwives who are working to improve women´s experience of care, clinical solely educated within a medical risk lens will not nec- outcomes, and the health of women and babies. essarily practice woman-centered care, rather, they will focus on identifying obstetric risk and managing obstetric emergencies. It could also be inferred that in coun- STRENGTHS AND LIMITATION OF EXISTING tries where midwives are limited to having a set of life- MIDWIFERY PHILOSOPHIES: UNDERSTANDING saving skills, medical interventions such as inductions, MIDWIFERY BEYOND SKILLS and cesarean sections will remain high. The impact of this maybe that women will feel undervalued in their To assess the framework available for midwifery and birthing experience (Leap & Pairman, 2006). Alterna- midwifery care philosophy, a thematic analysis was used tively, midwives who are educated within a specific to identify both explicit and implicit themes within the woman-centered philosophy and model that emphasizes ICM’s Philosophy and Model of Midwifery Care (ICM, values such as human rights, and informed consent, are 2017, 2014). Five themes were identified that form the healthcare providers who may contribute to social, cul- foundation of how midwifery care is to be provided. tural, and health justice in an integrated model. In countries where midwifery operates in an autonomous model, 1. Promotion of human rights through the provision of evidence demonstrates that interventions are low and shared care based on principles of justice, equity, and maternal satisfaction is high (UNFPA, 2018). Ultimately respect for human dignity the experience of care, outcomes, and cost-effectiveness 2. Attitude surrounding care provided is that pregnancy of midwifery will vary according to the educational is a normal physiological state. The goal is to opti- model under which midwives are trained. mize the process with a supportive, non-intervention It would appear from the thematic analysis under- approach, honoring its uniqueness for each woman

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3. The foundation of all care is the relationship with taught and provided. They highlight human rights, how a woman. This requires respectful, personalized to support physiological birth, and the goal of the part- partnership throughout care with the goal of self- nership with a woman as a woman’s self-determination determination for the woman in her own care. These themes, not explicit in any def- 4. The midwife is an autonomous professional, respon- inition other than ICM’s, (2017, 2014), form the foun- sible for self and professional development includ- dation of the unique nature of the midwifery model of ing collaboration and consultation relationships with care (ACNM 2018; ACM, 2018; Puri et al., 2014; Renfew other professionals, with the goal to serve women and et al., 2014, UNFPA, 2018; Miller & Bear, 2019). their communities The relationship between a woman and midwife 5. Midwifery care is evidence-informed, competent, and is explicitly acknowledged as core to midwifery in all ethical. but two of the definitions (Renfew et al., 2014; UNFPA, The next stage of the critical comparison was to see 2018). Although UNFPA (2018) and WHO (2018) do not if these ICM identified themes were within the mid- mention the relationship between a woman and midwife, wifery philosophy documents authored by WHO (2018), on their websites, they do consistently refer to ICM’s UNFPA (2018), The Lancet (Renfew et al., 2014), ACNM definition (ICM, 2017), which does mention the rela- (2018), and ACM (2018). The Table 2 offers a summary tionship. This relationship, however, is more than a of the critical comparison. pleasant experience that midwives value. Rather, the focus of a non-authoritative, respectful partnership, is more about the quality of the relationship and its goal of IMPACT ON A MIDWIFE, THE MIDWIFERY a woman’s self-determination over her body and the care MODEL OF CARE, AND THE MIDWIFERY she/he receives. The partnership is the practical imple- PROFESSION mentation of midwifery’s human rights-based approach to care. This relationship requires time and continuity so Definitions by other international and professional orga- the woman and midwife can get to know and trust each nizations offer a range of guidance on the midwifery other. Further it requires the midwife to be flexible and philosophy and model of care and reinforce the lack of humble, acknowledging that although she/he may be an clarity over the unique model of midwifery. (ACNM, expert in midwifery care, she/he is not an expert in the 2018; ACM, 2018; Puri et al., 2014; Renfew et al., 2014; woman’s experience or her values (Kuo, Wu, & Mu, 2010; UNFPA, 2018). Two of the five themes stated above were Thorstensson, Nilsson, Olsson, Wahn, & Ekström, 2015; absent by all but one other organization namely : Tinkler & Quinney, 1998). This relationship is the one of the greatest strengths of midwifery. It could potentially • The midwife is an autonomous professional, respon- inform the medical model if the revolution of woman- sible for self and professional development includ- centerd care is allowed to transform mainstream care. ing collaboration and consultation relationships with Ultimately healthcare should be driven by the unique other professionals with the goal to serve women and person receiving that care rather than the authority of the their communities provider. • Midwifery care is evidence-informed, competent, and ethical (Renfew et al., 2014).

Midwives and advocates of midwifery argue both DISCUSSION these themes (professional autonomy and evidence- informeded care) are necessary for legitimizing the Using the ICM definitions of midwife (2017) and profession. Neglecting these two themes within the defi- midwifery (2014) as a baseline, this article compares nition of a midwife and midwifery care has the potential definitions of a midwife and midwifery from around the to undermine any authority midwifery may have by sug- world. This was done deliberately as these documents gesting it is not a “real” or independent profession. The provide midwives legitimate authority to practise the recognition of the autonomy of the profession stands at art and science of midwifery, as well as to use the title the heart of midwifery policy and has deep implications Midwife. Further, these documents provide a frame- in practice and outcomes. work that promotes confidence for midwives to speak The three other themes noted in Table 1 provide about midwives and their work. It could be suggested,

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TABLE 2. Analysis of the Philosophy of Midwifery in Midwife and Midwifery Definitions Care Philosophy ICM- UNFPA— Lancet— WHO— ACM— ACNM— Themes Philosophy What Midwives Midwifery Midwifery Australian (United States) Identified in and Model of Do (ICM, 2017) (ICM, 2017) (ICM, 2017) MW and Midwifery and ICM Midwifery Philosophy Scope of Definitions Care (ICM, (ICM, 2017) Practice (ICM, of Midwife 2017) 2017) and Midwifery Promotion of “Promotes, “Advance women’s “Respect for Human Rights not “Founded on ”. . . right to human rights protects, and and girls’ rights,” women’s mentioned respect for equitable, through the supports “prevent FGM individual women . . . ethical, provision of SRH women’s . . . offer support circumstances value of accessible quality care based on human, and assistance to and views” women’s healthcare . . . principles of reproductive, survivors of Human Rights work, . . . that respects justice, equity, and sexual gender-based not mentioned protects and human dignity, and respect for health and violence . . .” enhances the individuality, and human dignity rights” ”Based health and diversity among on the ethical social status groups.” principles of of women justice, equity, . . .” Human and respect for Rights not human dignity” mentioned Attitude “Pregnancy and Childbirth as “Optimizing “Measures aimed “. . . childbirth “. . . honor the surrounding care childbearing physiological and normal at preventing . . . to be normalcy of provided is that are usually how to promote biological, health problems undertaking women’s pregnancy is a normal is not mentioned psychological, in pregnancy, healthy lifecycle events normal physiological social, and the detection of processes . . .” . . . watchful physiological processes” cultural abnormal How to waiting and state. The goal is “Optimize[s] processes of conditions” promote a non-intervention to optimize the the normal, reproduction Childbirth as physiological in normal process with a biological, and early life” physiological process is not processes. . . supportive, psychological, and how to mentioned appropriate use non-intervention social, and promote is not of interventions approach, cultural mentioned and technology honoring its processes of . . .” uniqueness for childbirth” each woman. “Promote and advocate for non- intervention” The foundation of Midwifery care Foundation of “Working in Foundation of “Woman- “. . . a continuous all care is the takes place in relationship with partnership with relationship centered . . . and relationship with partnership woman and goal women to with woman founded on compassionate a woman. This with women, of self- strengthen and goal of self- the partnership” requires recognizing the determination women’s own determination relationship ”Involves respectful, right to self- not mentioned capabilities to not mentioned between a therapeutic use of personalized determination, care for woman and human presence partnership and is themselves and her midwife” and skillful throughout care respectful, their families” “Encompasses communication” with the goal of personalized, the needs as “Self- self- continuous and identified and determination determination non- negotiated by and active for the woman authoritarian the woman participation in herself . . . as healthcare defined by the decisions” woman herself” (Continued)

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TABLE 2. Analysis of the Philosophy of Midwifery in Midwife and Midwifery Definitions (Continued) Care Philosophy ICM- UNFPA— Lancet— WHO— ACM— ACNM— Themes Philosophy What Midwives Midwifery Midwifery Australian (United States) Identified in and Model of Do (ICM, 2017) (ICM, 2017) (ICM, 2017) MW and Midwifery and ICM Midwifery Philosophy Scope of Definitions Care (ICM, (ICM, 2017) Practice (ICM, of Midwife 2017) 2017) and Midwifery The midwife is an “. . . individually “The main “Consultation with “The procurement Midwifery “Consultation autonomous and collectively caregivers for and referral to of medical includes collaboration and professional, responsible women and their other services” assistance when collaboration referral with other responsible for for the newborns during No mention of necessary, the with and members of the self and development of pregnancy, labor, individual execution of consultation healthcare team professional midwifery care, childbirth, and in responsibility, emergency between as needed to development educating the the post-delivery professional measures in the health provide optimal including new generation period” No development absence of professionals. healthcare” collaboration of midwives” mention of medical help” No mention “formal and consultation . .. “concept of individual No mention of of individual education, relationships lifelong responsibility, individual responsibility, lifelong with other learning” . . . professional responsibility, professional individual professionals “practice in development, or professional development learning” with the goal to collaboration relationship with development serve women . . . with other other healthcare and their health professionals communities professional” “. . . to serve the needs of the woman . . . and community” Midwifery care is “Ethical and “Provide family “Timely No mention of Midwifery is “Includes evidence-based, competent planning prevention and care as informed by individualized competent, and midwifery care counseling and management of evidence-based, scientific methods of care ethical is informed and services . . . complications” competent, and evidence, by and healing guided by perform breast No mention of ethical collective and guided by the formal and and cervical care as individual best evidence continuous cancer screenings evidence-based, experience, available.” “. . . education, . . . perform basic competent, and and by the development scientific emergency ethical intuition No and application research, and obstetric care, mention of of research to application of and in care as guide ethical and evidence” humanitarian competent competent “Midwives crises . . . and ethical midwifery maintain their implement the practice” competence Minimum Initial and ensure Services Package” their practice is No mention of evidence- care as based” evidence-based, competent and ethical Note.ACM = Australian College of Midwives; ACNM = American College of Nurse Midwifes; FGM = female genital mutilation; ICM = International Con- federation of Midwives; UNFPA = United National Population Fund; WHO = World Health Organization.

globally accepted definitions for two potential reasons: definition of a midwife (ICM, 2017) and thus separate (a) they do not perceive or frame midwives as from nursing or (b) they mis-interpret the philosophy autonomous practitioners as defined by the ICM and scope of practice of midwifery as defined by the

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ICM (2017; 2014). Midwifery autonomy is further hin- CONCLUSION dered when other cadres who have not been educated, and are not ”midwifery” providers, hijack or misuse Midwifery’s strength and uniqueness is how it provides the noun ’midwife’ and verb ’midwifery’. It could be the human rights-based midwifery model of care. Mid- argued that, as many languages do not have the same wifery’s opposition to the medical lens applied to what noun and verb midwife/midwifery construct as the is a natural physiological event (until it is not) causes English language this leads and compounds the confu- a healthy tension, yet the current situation of a global sion around our profession. The result of which fuels lack of consensus on the definition of the midwife the debate of the terms used across regions applied to and/or midwifery may undermine the development of a professional midwife as defined by the ICM (2014, this autonomous profession and unique philosophy that 2017, 2018). What is clear, regardless of where in the could compliment the medical model and strengthen world one is, use of the title Midwife should only healthcare systems. This article calls for all parties be sanctioned if a person has been educated to the involved in providing care to childbearing women to minimum level, in accordance with the ICM Global open discussions and strive for consensus to ensure that Standards for Midwifery Education (ICM, 2018) and the global push to increase access to midwives and mid- philosophy (ICM 2014). wifery care occurs under a common understanding of While diversity in practice may and should reflect what a midwife and midwifery care is. It is therefore cultural and social nuances, the concern discussed in this important to work collaboratively in order to keep criti- article is that the perception and understanding of the cal attention on the plight of women and their newborns. role of a midwife, the philosophy and function of the model varies and is contradicted among international and national agencies as noted in Tables 1 and 2. This critical comparison reveals that most organizations agree REFERENCES midwives provide women-centered care, which aligns with the advancement of human rights. Organizations differ and are vague on the specifics of how to imple- American College of Nurse Midwifes. (2018). Definition of midwifery and scope of practice of certified nurse- ment this. In addition, many of these documents neglect midwives and certified midwives.. Retrieved from http:// to mention a consistent approach to sexual health which www.midwife.org/ACNM/files/ACNMLibraryData/UP raises issues around policy and regulation of women’s LOADFILENAME/000000000266/Definition%20of%20 health and rights. Only the ICM (2017) and UNFPA Midwifery%20and%20Scope%20of%20Practice%20of% (2018) make explicit mention of midwifery as protector 20CNMs%20and%20 CMs%20Dec%202011.pdf of “rights.” While there is no mention womens’ or girls’ Australian College of Midwives. (2018). Midwifery rights protection as a value or practice in midwifery by philosophy and values. Retrieved from https: the ACNM (2018) and the ACM (2018). Such a lack of //www.midwives.org.au/midwifery-philosophy-values consensus among key health provider agencies, partic- Betro, L., Mcclair, T. L., Currie, S., & Banjerie, J. (2018). ularly at the level of WHO (2018), UNFPA (2018), and Expanding the agenda for addressing mistreatment in ICM (2017) limits a global approach around women’s maternity care: A mapping review and gender analysis. health and quality of care. Reproductive Health, 15, 143. doi:10.1186/s12978-018- It is important to acknowledge many countries 0584-6 lack a professional group bearing the title, education, or Castro Lopes, S., Nove, A., Hoope-Bendre, P., de Bernis, L., scope of practice of the midwife. This means childbear- Bokosi, M., Moyo, N. T., & Homer, C. S. E. (2016). ing women are cared for by many cadres of workers with A descriptive analysis of midwifery education, regula- varied levels of skills and philosophies. In a global con- tion and association in 73 countries: The baseline for a text, WHO (2018) and UNFPA (2018) and others are post-2015 pathway. Human Research for Health, 14, 37. funding and leading midwifery education and regulation doi:10.1186/s12960-016-0134-7 programs with the aim to reduce maternal and neonatal Coburn, D. (2006). Medical dominance then and now: Crit- mortality globally. It is imperative to provide some level ical reflections. Health Sociology Review, 15, 432–433. of training and care to avoid no care at all. This should doi:10.5172/hesr.2006.15.5.432 only occur, however, until appropriately qualified and Fahy, K. (2007). An Australian history of the subordina- skilled midwives can be educated in accordance to the tion of midwifery. Women and Birth, 20(1), 25–29.

ICMPdf_Folio:48 competencies (WHO, 2018). doi:10.1016/j.wombi.2006.08.003 Critical Comparison of What Is a Midwife and What Is Midwifery Jefford et al. 49

Filby, A., McConville, F., & Portela, A. (2016). What pre- evidence-informed framework for maternal and new- vents quality midwifery care? A systematic mapping born care. Lancet, 384, 1129–1145. doi:10.1016/S0140- of barriers in low and middle income countries from 6736(14)60789-3 the provider perspective. PLOS ONE, 11(5), e0153391. Richardson-Tench, M., Nicholson, P., Taylor, B., Kermode, S., doi:10.1371/journal.pone.0153391 & Roberts, K. (2018). Research in nursing and midwifery Guilliland, K., & Pairman, S. (2010). The midwifery partnership: and allied health (6th ed.). Melbourne, Australia: Cen- A model for practice. Christchurch: New Zealand College gage Learning Australia PTY Limited. of Midwives. Thorstensson, S., Nilsson, M., Olsson, L., Wahn, E. H.,& Hartigan, P. (2001). The importance of gender in defin- Ekström, A. (2015). Women’s experiences of midwifery ing and improving quality of care: Some conceptual support during pregnancy a step in the validation of the issues. Health Policy and Planning, 16(Suppl. 1), 7– scale: “The mother perceived support from profession- 12. doi:10.1093/heapol/16.suppl_1.7International Con- als.” Journal of Nursing Care, 4(2), 1–6. federation of Midwives Tinkler, A., & Quinney, D. (1998). Team midwifery: The influ- International Confederation of Midwives. (2014). ICM ence of the midwife-woman relationship on women’s definitions. Retrieved from https://www.international experiences and perceptions of maternity care. Journal midwives.org/assets/files/definitions-files/2018/06/eng- of Advanced Nursing, 28(1), 30–35. doi:10.1046/j.1365- philosophy-and-model-of-midwifery-care.pdf 2648.1998.00769.x International Confederation of Midwives. (2017). Interna- United National Population Fund. (2018). Midwifery. tional Definition of the Midwife.. Retrieved from https:// Retrieved from https://www.unfpa.org/midwifery www.internationalmidwives.org/assets/files/definitions- Vedam, S., Stoll, K., MacDorman, M., Declercq, E., Cramer, files/2018/06/eng-definition_of_the_midwife- 2017.pdf R., Chenyney, M., . . . Kennedy, H. (2018). Mapping International Confederation of Midwives. (2019). Essen- integration of midwives across the United States: Impact tial competencies for midwifery practice 2018 update, on access, equity, and outcomes. PLOS ONE, 13(2), final version published January 2019. Retrieved e0192523. doi:10.1371/journal.pone.0192523 from https://www.internationalmidwives.org/assets/ Willis, E. (1983). Medical dominance: The division of labour in files/general-files/2019/02/icm-competencies_english_ Australian health care. Sydney, Australia: George Allen final_jan-2019-update_final-web_v1.0.pdf and Unwin. Kuo, S. C., Wu, C. J., & Mu, P. F. (2010). Taiwanese women’s World Health Organization. (2018). Midwifery. Retrieved from experiences of hospital midwifery care: A phe- https://www.who.int/topics/midwifery/en/ nomenological study. Midwifery, 26(4), 450–456. doi:10.1016/j.midw.2008.09.002 World Health Organization, International Confederation of Midwives, & Federation of International Gyne- Leap, N., & Pairman, S. (2006). Working in partnership. In S. cologist and Obstetricians. (2004). Retrieved from Pairman, J. Pincombe, C. Thorogood, & S. Tracy (Eds.), https://apps.who.int/iris/bitstream/handle/10665/42955/ Midwifery: Preparation for practice (pp. 258–270). Aus- 9241591692.pdf;jsessionid=E4939937D119E0C64394D tralia: Elsevier. 6EE0AB9115A?sequence=1 Miller, S., & Bear, R. J. (2019). Midwifery partnership. In S. World Health Organization, International Confederation Pairman, S. Tracy, H. Dahlen, & L. Dixon (Eds.), Mid- of Midwives, & White Ribbon Alliance. (2016). Mid- wifery: Preparation for practice (4th ed., Vol. 1, chap. 15, wives’ voices, midwives’ realities. Retrieved from http:// pp. 299–333). Chatswood, Australia: Elsevier. www.who.int/maternal_child_adolescent/documents/ Pairman, S. (2010). Midwifery partnership: A professionaliz- midwives-voices-realities/en/ ing strategy for midwives. In M. Kirkham (Ed.), The World Health Organization, United Nations Popula- midwife-mother relationship (pp. 208–231). New York, tion Fund, United Nations International Children’s NY: Palgrave Macmillan. Emergency Fund, International Confederation of Puri, M., Tamang, A., Shrestha, P., & Joshi, D. (2014). The Midwives, International Confederation of Nurses, role of auxiliary nurse-midwives and community health Federation of International Gynaecologists and Obste- volunteers in expanding access to medical abortion in tricians, & International Pediatrics Association. rural Nepal. Reproductive Health Matters, 22(44), 94– (2018). Definition of skilled health personnel provid- 103. doi:10.1016/S0968-8080(14)43784-4 ing care during childbirth. Retrieved from http://www. Renfew, M., McFadden, A., Bastos, M. H., Campbell, J., who.int/reproductivehealth/publications/statement- Channon, N. F., Cheung, N. F., . . . Declercg, E. competent-mnh-professionals/en/ (2014). Midwifery and quality care: Findings from a new

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World Health Organization, United Nations Population Correspondence regarding this article should be directed to Fund, & United Nations International Children’s Dr Elaine Jefford, PhD, MSc, Grad Dip Teaching & Learning, Emergency Fund. (2009). Averting Maternal Death BSc (Hons) Midwifery, Midwifery Academic & Researcher, and Disability (AMDD). Monitoring emergency obstet- Southern Cross University, Coffs Harbour, NSW 2450, ric care, World Health Organization. Retrieved from Australia. E-mail: [email protected] http://www.uonn.org/wp-content/uploads/2018/09/09- WHO-Handbook-for-Monitoring-EmOC.pdf

Disclosure. The authors have no relevant financial inter- est or affiliations with any commercial interests related to the subjects discussed within this article.

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