Profession: “A calling requiring specialized knowledge and often long and intensive academic preparation.” This definition is taken from Merriam Webster's Collegiate Dictionary, 10th edition.
Midwife: “A person who, having been regularly admitted to a midwifery educational programme, duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery.” This definition was adopted by the International Confederation of Midwives in October 1990.
Traditional Birth Attendant (TBA): “A person who assists the mother during childbirth and initially acquired her skills by delivering babies herself or through apprenticeship to other traditional birth attendants.” This definition was published by the World Health Organization in 1992 (1).
It is now critical that we in the United States start using the two international definitions and titles cited above and nothing else to define the profession of midwifery and to distinguish between the roles of the midwife and the TBA. If someone has appropriate academic preparation, is certified by a national organization, is licensed in the jurisdiction, and is accountable to the public, that person is a midwife; if not, that person is a traditional birth attendant.
Traditional birth attendants play a vital role throughout the developing world in areas where women have no access to professional midwives. They are usually mature women chosen by their community or extended family for their practical approach and experience. In those areas of the world where TBAs practice, they are trained and supervised by midwives whenever possible.
Here in the United States, access to midwifery care is still limited in some areas; and, because freedom of choice is one of the tenets of our democracy, some women may choose to risk birthing with someone who is not professionally trained. However, it must be recognized that maternity care provided only by TBAs is not the international goal. Additionally, midwives have a broader scope of practice, including provision of primary care and well-woman gynecology services, than do TBAs. If the United States were to recognize the distinction between midwives and TBAs, each state would need not only to legalize midwifery, but also to enact separate regulations for midwives and for TBAs.
If the United States follows the international standard. American citizens will no longer be confused by the names “nurse-midwives.” “lay midwives.” “empiric midwives,” “direct-entry midwives.” apprentice-trained midwives.” or “licensed midwives.” The name “midwife” will be reserved only for those who have proved their beginning competency by successfully completing an accredited academic program and passing an examination given by a national certifying organization.
It is not elitism to insist that midwives be professionally prepared—it is simply prudent public health policy. It is also not necessary that the process be simple or easy. Certification and/or licensure are the minimum standards for every other professional group in the United States—doctors, lawyers, teachers, nurses, accountants. Even beauticians are not allowed to cut a client's hair until they have finished cosmetology school and passed a state licensing exam. And yet, many certified nurse-midwives (CNMs) support the “right” of unlicensed individuals to be responsible for two lives as they attend women at birth.
The Board of Directors of the American College of Nurse-Midwives (ACNM) brought the ACNM definition of a “midwife” into compliance with the international definition in the Position Statement “Midwifery Education,” which was approved in June 1996 (see Appendix). In concordance with national standards for most other professions, the Statement specifies that midwifery education should either require or grant a baccalaureate degree upon completion.
Midwives, however, do not have to be nurses. The international definition does not require or even mention nursing as a prerequisite for the profession of midwifery. Many ACNM members would acknowledge the usefulness of nursing as a background for midwifery education; however, it is not nursing education that prepares midwives. It is midwifery education that will meld the academic knowledge and the intuitive skills, the science and the art of midwifery. One hopes that creative educational programs will be designed that build upon the skills, experience, and knowledge that adult learners bring to the program. ACNM must support efforts to make midwifery education more broadly available to all who wish to join our profession.
Until recently, the ACNM limited itself to certifying only midwifery candidates who were also nurses (2). The Midwives Alliance of North America (MANA) filled the void for those professionally trained midwives who were not nurses. The relationship between these sister organizations has sometimes been strained, and issues of disagreement remain. We hope that ACNM will continue the dialogue with MANA as we both endeavor to make high-quality midwifery care the standard in the United States.
As the ACNM enters the new millenium, we must consider with what name we want to enter the next century. In the 20th century, the venerable name of “midwife” was reviled, misunderstood, restricted, hyphenated, and debated. This author hopes that the 21st century finds us again proudly claiming our profession and our name—MIDWIFE.