CHAPTER 17 The emergence of midwifery as a distinct discipline
Literally, the word ‘midwife’ means ‘with woman’. The profession of midwifery is one of the oldest known. However, in Australia it has faced many challenges, especially over recent years. In 2005, the number of births registered in Australia totalled 259 800. This was an increase of 2.2% (Australian Bureau of Statistics [ABS] 2006g). In a significant majority of these cases, midwives would have provided care at least for part of the birth process, if not total care.
Midwifery is a truly international profession practised across all continents and in all types of communities. Midwifery is regarded as ‘both an art and a science’ (Pairman et al 2007: viii). The scope of midwifery practice is guided largely by local conditions and cultural traditions. However, there is also international understanding of midwifery roles and functions. In 2005 the guiding body for midwifery around the world, the International Confederation of Midwives (ICM), revised its ‘Definition of the Midwife’, which provides a foundation for the profession on an international scale.
Midwives are highly skilled health professionals who work with women throughout pregnancy, labour, birth and the puerperium. While equipped to handle variations from normal deliveries and emergencies, midwives are experts in normal childbearing. Care during pregnancy entails monitoring mother and baby, providing support and education, with referral if complications arise. During labour, midwives provide physical and psychological support, continually observe progress and assess maternal and fetal wellbeing, and work with the woman during birth. Following birth, midwifery care for the woman and her baby includes education, monitoring of mother and baby, and guidance with parenting and breastfeeding.
preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.
Finally, midwives provide health counselling and education at individual, family and community level on issues such as ‘antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care’. (ICM 2005a: 1).
Underpinning midwifery practice is a philosophy of woman-centred care. This approach to care requires responsiveness to the needs of women and their families, rather than that of the organisation or other influences (McCourt, Stevens, Sandall et al 2006) and empowering women to be involved in decisions about their care. Through the provision of women-centred care, midwives work in partnership with women in a way that seeks to build trust, understanding and confidence (Leap & Pairman 2006).
A number of standards guide the professional practice of midwives in Australia. The Australian Nursing and Midwifery Council (ANMC) have recently developed National Competency Standards for the Midwife. Within these guidelines, key competencies are incorporated into four broad domains: legal and professional practice, midwifery as primary health care, midwifery knowledge and practice, and reflective and ethical practice (ANMC 2006b). In addition, codes of ethics and professional conduct for Australian midwives are currently being developed to further guide professional practice, when national registration for midwives commences in the near future.
While midwives and obstetricians have worked closely alongside each other for many decades, these relationships have not been without friction. Prior to the 20th century, birth was viewed as a normal process and women in Australia gave birth at home. These births were attended by midwives who traditionally learnt their profession by working as apprentices to other experienced midwives. Arguing a lack of formal education and working class status, midwives in the 20th century were discredited by medical practitioners as being unsafe to deliver maternity care (Fahy 2007). The resulting medicalisation of childbirth produced a shift towards all births occurring in hospital settings under the control of doctors. Over time, further medicalisation with increased rates of interventions, such as caesarean sections, has occurred (Laws & Sullivan 2005). Today, while relationships are often harmonious, some traditional tensions persist as midwives advocate for women to have choice and control over their birth experiences, as well as seeking to keep childbirth as normal as possible.
Midwifery and nursing are distinct and different disciplines. However, in Australia, midwifery has an historical relationship that has seen it intimately linked with nursing and viewed as a specialty of nursing, rather than a discipline in its own right. In fact, prior to 2002, to become a midwife an individual had to be a registered nurse to undertake midwifery studies. This has resulted in the two professions being seen as the same despite their philosophical differences, with a lack of visibility of the very distinct nature of midwifery practice.
It is in the philosophical approaches of both professions that the differences between nursing and midwifery become more evident. Nursing focuses largely on the prevention, care and management of illness. It incorporates the care of individuals across the lifespan, of all people and in a multitude of practice settings. Childbearing, however, is considered a normal physiological process, not an illness. Therefore, underpinning midwifery is a wellness perspective taking a ‘with-woman’ focus, specifically women’s childbearing health. Midwives often work autonomously in providing care. However, while midwives seek to promote normal birthing, they are equipped and able to identify and care for women experiencing variations from normal, in collaboration with other health professionals.
Recent years have seen immense changes to the educational preparation of midwives in Australia. Due to the historic development of midwifery, to become a midwife an individual was required to first become a registered nurse. This required completion of a 3-year undergraduate nursing program, practising as a registered nurse for at least 1 year, and then completing postgraduate studies in midwifery which could take another 1 or 2 years. While the traditional model still exists it is now possible to become a midwife without being a nurse first. In 2002, the first Bachelor of Midwifery programs became available in Victoria and South Australia, with programs now available in other Australian states. Some universities offer double degree courses in midwifery and nursing, while postgraduate options continue to be offered for nurses wishing to become midwives.
Following successful completion of an approved educational program, graduates can apply to the registering authority for registration to practise as a midwife. Currently, midwives must register with state nursing boards following graduation as there is no separate midwifery equivalent as yet. Table 17.1 presents the state and territory registering bodies and legislation guiding midwifery practice. Mutual recognition allows for midwives registered in one state or territory to apply for registration in another jurisdiction.
|Australian Capital Territory||ACT Nursing and Midwifery Board||Health Professional Act 2004|
|New South Wales||Nurses and Midwives Board, New South Wales||Nurses and Midwives Act 1991|
|Northern Territory||Nursing and Midwifery Board of the Northern Territory||Health Practitioners Act 2007|
|Queensland||Queensland Nursing Council||Nursing Act 1992|
|South Australia||Nurses Board of South Australia||Nurses Act 1999|
|Tasmania||Nursing Board of Tasmania||Nursing Act 1995|
|Victoria||Nurses Board of Victoria||Health Professions Registration Act 2005|
|Western Australia||Nurses Board of Western Australia||Nurses and Midwives Act 2006|
Three national bodies also influence midwifery practice in Australia. The Australian Nursing and Midwifery Council (ANMC) is a national body constituted to coordinate a national approach to regulation of midwifery and nursing. In doing so, it works closely with the state and territory registration authorities. The professional union representing midwives is the Australian Nursing Federation (ANF), although many nurses in NSW are covered under the New South Wales Nurses’ Association (NSWNA). The Australian College of Midwives (ACM) is the peak professional body that represents, and advocates on behalf of, midwives but does not provide union-style support.
Australian midwives practise in a variety of settings, providing primary level care. However, in 2002, 99.3% of Australian births occurred in hospital or birth centre settings (Laws & Sullivan 2005). Understandably then, midwives work predominantly in hospital maternity units, although a small number work in independent midwifery practice conducting home births.
Many midwives seek to work in specialised practice areas. With additional education, many become endorsed as lactation consultants able to provide specialised care for women experiencing difficulties with breastfeeding and lactation. Other midwives choose to work in specialised areas such as antenatal education, care of sick or premature neonates, fetal monitoring or family planning. Advanced practice roles are also under development with potential opportunities for midwives to develop midwife practitioner roles that will offer expanded scope of practice that may, for example, include limited medication prescribing rights.
Domiciliary midwives usually work out of public hospitals, providing support and monitoring through home visits to women and their babies, particularly if they have been discharged early from hospital, or have specific ongoing monitoring requirements. Access to domiciliary care does vary. In Victoria, for example, all women being discharged from public hospitals are offered one home visit. In other areas, domiciliary services vary according to individual hospital criteria. However, for women in rural areas less domiciliary support services may be available than in metropolitan areas.
Hospital-based maternity care is offered through both the public and private sectors. These services are funded by Medicare, either fully or partially. Different models exist within hospitals for the provision of such care, and can take different forms, such as those described below.