Developing nations are plagued by high maternal mortality rates, unwanted pregnancies, and family planning policies that aim to control population growth through sterilization and unsafe birth control drugs. In such harsh settings, traditional midwives are important and effective agents of women’s wellness and family planning policy. This essay will evaluate the community roles of professional versus traditional midwives in rural Asia, including discussion regarding the meager respect afforded traditional midwives by physicians and clinic staff without acknowledging the work they accomplish with such limited resources.
Analysis of the results of midwife training programs will compare government-sponsored programs’ curricula to outreach education by colleagues from the international community, showing that these professional midwives provide methods for integrating traditional midwives into professional (hospital) circles as well as offering more realistic approaches to midwives in indigenous communities in the face of Western biomedicine’s influx into government policy.
Data will also be presented that suggests that maternal mortality rates are reduced as a result of pre- and post-partum care from midwives, and that education and home visits by midwives helps advance women’s status by increasing their ability to regulate their fertility. Professional versus Traditional Midwives The international definition of midwife ratified by the World Health Organization (WHO) describes an individual who has completed a duly recognized program of study and is registered or legally licensed to practice midwifery in their country (WHO, 2000).
This differs from most cultural definitions of a midwife. More often, midwives are any woman experienced in birth and recognized by her community to be a midwife. WHO calls these women Traditional Birthing Assistants (TBAs), and considers them care providers who fall outside the formal sector of skilled birth attendants. However, these women are experienced in maternal care and offer expertise to their clients. They are also accepted by their communities as able midwives and habitually afforded more trust than professionals. Professional midwives in Northern nations receive eight or more years of education.
Their practice is usually categorized as an alternative form of healthcare. In fact, an estimated two-thirds of all babies born globally are delivered by midwives, most of whom are traditional (Rogers & Solomon, 1975). In developing nations, government programs have been implemented to train young women from urban settings in professional midwifery to ultimately work in rural communities. After completing the required two-year program, they are sent into cultures unlike their own to work in under-funded, ill-supplied clinics where medicines are sold out the back door to make up for the meager salaries earned.
These young urban women expect to be treated with respect and see themselves as superior to TBAs (Davis-Floyd, 2000). However, community midwives are trusted and respected elders with experience in birth assistance, and most have children of their own. While most traditional midwives receive no formal education, many feel a spiritual calling to the role, and still some take over the position after the death of a mother or grandmother (Rogers & Solomon, 1975).
While some undertake long apprenticeships, nearly all learn simply by attending many births (Davis-Floyd, 2000). Family Planning and Western Medicine In international discourse, the professional midwife community considers the current trend in family planning initiatives to have begun with United States Security Memorandum 200 (Lim & Zenack, 2000). When Henry Kissinger penned this bill in 1974, he produced a document of Malthusian alarmism, claiming that estimates on population increases would reach numbers beyond the capacity of the earth’s ability to produce food.
Like the extreme Malthusians known to advocate for cuts in famine relief to poor and overpopulated nations (Hartmann, 1995), this document called for drastic and ethnocentric population control measures, including falsifying food shortages to Southern countries and advocating the use of birth control drugs that would lead to sterility without knowledge or consent (Kissinger, 1974). Thus, the importance of traditional midwives educated in modern contraception methods is paramount. In this arena is where first world professional midwives play a crucial role.
It was Western civilization that ripped off the indigenous birth practices of the world. It is now up to the midwives of the West to promote the healing of birth globally,” said Cuban midwife Marina Alzugaray (Lim & Zenack, 2000, 1). Through outreach programs to reach midwives in rural Asia and elsewhere, these midwives of the West offer thorough education and training to TBAs about the birth control offered by their governments. They also provide training in non-artificial methods of contraception, which are not always available or affordable to women in rural Asia (Lim & Zenack, 2000).
Viable methods of fertility control, such as the Ovulation Method, are necessary to the health of women everywhere. The influx of Western medicine has greatly complicated the role of traditional midwives. Third world governments increasingly recognize only new biomedical practices as formal healthcare. As Western biomedical techniques are dependent upon diagnostic tests and expensive machinery, it is not realistic in rural areas. Here again, the structural violence of government systems orchestrated by structural adjustment programs and international policies takes its toll.
Clinics are shut down as financial aid is cut (Loder, 2003), and hospitals are inaccessible from communities with no means of transportation. Professional and community midwives are divided by a hierarchical, colonialist system in which development planners try to exterminate TBAs as the unskilled bottom level of the biomedical pyramid (Davis-Floyd, 2000). Traditional midwives are scapegoats for maternal mortality rates, as Western medicine sees their “unskilled” practice as the cause of fatal complications during birth – the leading cause of premature death among women in developing nations (Maine et. . , 1996).
Impact on Maternal Mortality and Women’s Health Indeed, research has shown that midwives greatly impact rates of maternal mortality in developing nations. Where traditional midwives are available, maternal mortality is decreased. This is proven, in one instance, by a study done in Bangladesh. Prior to intervention, which entailed posting TBAs with training by government health care workers from area hospitals, twenty maternal deaths with direct obstetric causes over eighteen months were observed in both the study and control communities.
After intervention, twenty were again observed over an eighteen month period in the control group, but just six in the intervention area (Maine et. al. , 1996). This seventy percent reduction in reproductive deaths was found to be directly attributable to the presence of midwives in the area, who knew when to refer couples to hospital or clinics, and in particular offered more intensive pre- and post-partum care than one would receive under a physician (Maine et. al. , 1996). The cooperation between hospital staff and TBAs must be acknowledged in this study.
While traditional midwives are often dismissively treated by healthcare “professionals,” they are reluctant to refer at-risk clients to go and be subjected to such disrespect. This instance of mutual accommodation is unfortunately not the norm and may be called a “partnership paradigm” (Davis-Floyd, 2000). Facilitating such partnerships and fostering recognition and respect for the TBA’s skills and care would greatly improve the health of mother and child as well as the relationship between rural Asia and professional health facilities. Another successful partnership paradigm exists in rural Thailand.
The National Family Planning Program of Thailand decided to train TBAs in post-partum sterilization to meet the demands of women in rural areas who may not be able to get to a hospital or choose to birth at home (Kanchanasinith et. al. , 1990). Physicians trained midwives in performing tubal ligation immediately after giving birth. The study done by Kanchanasinith and colleagues found that “there were no statistically significant differences between the two groups (physicians and midwives) in the number and type of complications that occurred during the surgery and immediately afterwards” (1990, 56).
The study did find, however, that midwives better communicated with the client, explaining the procedure and providing counseling and instructions more thoroughly than physicians (Kanchanasinith et. al. , 1990). A dark mark on the record of TBAs is their role in female genital mutilation. While not as common a practice in Asia as in Africa, female circumcision is a conflict between human rights and cultural beliefs. Unfortunately, practitioners of female genital mutilation are generally traditional birth attendants or even professional midwives.
The procedure is a highly-valued service offering substantial financial rewards, and a practitioner’s status in the community and income can be directly linked with performance of the operation (UNICEF, 2004). Traditional midwives in these areas are targeted for outreach education on the actual effects of the procedure, in the hope that increasing their awareness may decrease the epidemic. While the status of the midwife may increase from performing such a sacred task, female genital mutilation is a gender-based violation of the rights of the women victimized by the practice (UNICEF, 2004).
A contemporary addition to the role of midwives is their part in HIV/AIDS education and prevention. As the virus that causes AIDS proliferates all populations, rural Asia has not escaped infection. Midwives may be the only source of information some women ever get on the subjects of safer sex practices, sexually transmitted infections (STIs), and how to protect themselves and their children. Globally, more than 700,000 children under age fifteen are infected with HIV each year, and almost all occurs through transmission of the virus from mother to child during pregnancy, delivery or breast feeding.
As the epidemic spreads in Asia and the Pacific, the number of children infected is rising (UNICEF, 2004). Free and confidential testing and counseling is critical to slowing the spread of HIV, and traditional midwives worldwide are receiving training to make the service more readily available. Pregnant women who find they are infected with HIV may choose to terminate the pregnancy, mainly as a result media focus on them for some of the most deep-seated value judgments in the whole AIDS arena, portraying “guilty” infected mothers passing the virus to their “innocent” infants (Mcrory, 1995).
In fact, research suggests that eighty seven percent of babies delivered to HIV infected mothers test negative for the virus, and with counseling from midwives about alternatives to breast feeding, those children remain healthy (Mcrory, 1995). How Midwives Increase the Status of Women Overall, midwives transcend gender inequalities that subordinate women in society. Traditional midwives are well respected in their communities as wise elders with expertise in their profession, spirituality, and special skills (Rogers & Solomon, 1975).
But midwives can also improve the status of all women in their community. The low status of women in rural Asia is detrimental to maternal and child health, as is the case in Bangladesh. Another study done there observed the effects of outreach programs done by midwives, in which the women conducted home visits and “doorstep delivery” of contraceptives (Phillips & Hossain, 2003). In doing so, midwives were able to educate rural women who may otherwise have not been allowed to travel outside the home, were without transportation to local clinics, or who lacked contact with persons outside their family.
The program was proven to help reduce the proportion of contraceptive users who ultimately opted for irreversible female sterilization, as was the agenda of the government’s family planning program (Phillips & Hossain, 2003). Additionally, on the basis of twenty three status indicators used by the experimenters, it was observed that the more visits a woman received from a midwife, the more likely she was to experience an increase in status (Phillips & Hossain, 2003).
The interaction between midwives and rural women in this experiment cannot be discounted as attributing to education that increased women’s status. However, it was found that this positive change was accredited mainly to the effect of fertility regulation rather than the social interaction during the visits (Phillips & Hossain, 2003). The impact of midwives on women’s status in this instance was derived from their impact on fertility regulation, or a reduction in unwanted fertility. Overcoming this gender inequality is important in increasing the status and health of women.
Unwanted pregnancy is one of three main factors contributing to violence against pregnant women, which greatly increases instances of fetal or infant death (Nasir & Hyder, 2003) harming women’s overall well-being and keeping her subordinate in status. Simply by fulfilling their role, traditional midwives increase the status of women. In the case of Bangladesh, the midwives gained mobility and prestige from their work. The deployment of female workers changed community perceptions about women’s roles.
Without depending on male partners, these women were employable, reliable, mobile and autonomous in their work, and thus the program was characterized as having a “beyond supply” social effect that enhanced women’s status (Phillips & Hossain, 2003). Midwives are educated and educators, providing training in contraception and reproduction. They provide public service to women in rural Asia, as well as viable birth control. These are three of the four needs of women to overcome poverty, and the contribution by traditional midwives cannot be overlooked.
