Tuesday, January 30, 2007

Nurse midwives and direct entry midwives

Continuing in the same vein as the discussion of "medwives" vs. midwives, I note that the January issue of the Journal of Midwifery and Women's Health has a review of Robbie Davis-Floyd's new book, Mainstreaming Midwives: The Politics of Change (Robbie Davis-Floyd, Christine Barbara Johnson, Routledge, New York, 2006). The book examines the growth of direct entry midwifery in the US. The review is written by a CNM who feels that the book stereotypes nurse midwives:
The stereotype of the CNM/CM as a medicalized, technology-dependent midwife is reinforced by statements such as the following:

“[MANA members] affirm that an attitude of trust on the part of the midwife fosters and facilitates the mother’s ability to trust and believe in herself, noting that many hospital-trained midwives prefer to rely on the information generated by the electronic fetal monitor and the sense of security that if a crisis arises, full-scale assistance is right around the corner.”

... Although the old adage states you can’t judge a book by the cover, Mainstreaming Midwives seems to belie the fact. The cover illustration shows a pregnant woman flanked by a midwife on either side. One midwife wears a white lab coat, a stethoscope around her neck, and carries a patient file in her hand, while the other wears a casual flowing dress, sandals, and carries a birth bag... Rather than motivating midwives to unify against the marginalization of their profession, the book further polarizes their positions.

...Direct-entry midwives (DEMs) are portrayed as social activists and CNMs/CMs as health professionals ... Styles attributed to CNM/CM health professionals include conducting professional meetings, strict adherence to charting and documentation, small earrings that attract no attention, fluorescent lights, fake flowers, machines that go beep, and language that is reserved and unimaginative. Contrasted with this are DEM birth activists who enjoy goddess gatherings, newsletters bearing poetry, vegetarian diets, recycling at all gatherings, dangling earrings and Birkenstocks, candles and real flowers, and sensational, catchy language... [C]omparisons such as these serve to widen, rather than bridge, the schism between CNMs/CMs and DEMs.

... Rising out of these struggles is the controversy over educational preparation for competent midwifery practice... Portraying ACNM as valuing midwifery education only when it is obtained at the university level, one interviewee quoted lauds the apprenticeship model of midwifery education as “building an inherent knowledge and intuition base so that the midwife learns to trust that whatever she needs at that time is available to her.” ... The authors acknowledge, however, that apprentice-trained midwives may practice for years before they “encounter enough complications and dangers to begin to take more seriously their responsibility to acknowledge and deal with risk.”
The reviewer suggests an interesting compromise:
...Perhaps the answer lies in the way our Canadian sister midwives solved their disagreement over midwifery education and practice. The direct-entry midwives agreed to university education at the baccalaureate rather than graduate level, and the nurse-midwives agreed to preserve a modified apprenticeship model of education. Canadian midwives educated since the new legislation attend births in all settings during their training. Following licensure, they are supported by law and reimbursed for attending births in any setting. The ability of the Canadian midwives to unify in designing this practical model has significantly contributed to the mainstreaming of midwifery in Canada. If we consider their example, US midwives may be able to break the current impasse by melding idealism and pragmatism for the greater good.


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