Midwifery: Introduction

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Pat Sonnenstuhl

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Feb 11, 1998, 3:00:00 AM2/11/98
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Archive-name: medicine/midwifery/intro
Posting-Frequency: monthly
Version: 0.02
Last Modified: 1996/6/8

The topics addressed in this document are:

1. WHAT IS MIDWIFERY?
2. WHAT DO MIDWIVES DO?
3. HOW DO I BECOME A MIDWIFE?
4. WHERE DO I FIND A MIDWIFE?
5. IS MIDWIFERY CARE SAFE?

1. WHAT IS MIDWIFERY?

The simplest definition of midwifery is "with woman", but truly,
midwifery means different things to different people. For many,
the Midwifery Model is an attitude about women and how pregnancy and
birth occur, and view that pregnancy and birth are normal events until
proven otherwise. It is an attitude of giving and sharing information,
of empowerment, and of respecting the right of a woman and her family to
determine their own care.

The attitude of midwifery, or the Midwifery Model can be contrasted with
the Medical Model. In general, the Medical Model is an attitude that
there is potential pathology in any given situation, and that medicine
can assist to improve the situation. Medicine is also about teaching,
informing, and prevention, but the power seems to be more with the
provider rather than with the woman.

Historically, midwives have always been around to help women give birth.
Before physicians, midwives were the primary healers in their
communities. They were the medicine women of their own cultures, and
assisted families and women throughout their lives. In the Old Testament
they were described as examples of the strength and faith in God.

Midwives were once the nutritionists, herbalists, doctors, ministers,
counselors all rolled into one 'profession'. Many feel they were the
first holistic practitioners. Midwives were always available to help
the poor, the women without medical care or the women who were the
outcasts of their culture. Today, midwives take care of anyone who
wishes to see them, but practice within the constraints of their medical
and legal systems.

Today midwives are as diverse as the populations they serve. Midwives
are willing to take care of anyone who wishes to see them. Over 70% of
births in the world are attended by midwives. In the Netherlands,
midwives deliver a majority of the babies. Other countries do not
utilize midwives to their fullest potential. Each country worldwide has
a slightly different view of midwifery, and of how midwives work within
their communities. In sci.med.midwifery, midwives will speak from these
various perspectives and cultures. Midwives are encouraged to share
their statistics and work situations within this newsgroup.

The World Health Organization (WHO) presents us with the following
definition of the midwife:

A midwife is 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 practice midwifery.
(WHO, FIGO, ICM Statement)

2. WHAT DO MIDWIVES DO?

Midwives teach, educate and empower women to take control of their own
health care. In most communities, they provide prenatal care, or
supervision of the pregnancy, and then assist the mother to give birth.
They manage the birth, and guard the woman and her newborn in the
postpartum period.

Most midwives encourage and monitor women throughout their labor with
techniques to improve the labor and birth. Reassurance, positive imaging
and suggestions to change positions and walk helps labors progress. Many
midwives provide family planning services and routine women's health
examinations such as pap smears and physical examinations.

They teach women about sexually transmitted infections, and focus on
prevention of the spread of infections. What specifically midwives do
will depend upon: her training, her licensure, and what is allowed in
the state, province, or country in which she practices.

For example, in the United States some midwives can prescribe
medications, provide women's health care throughout the menopause years.
Midwives worldwide attend births in the home, hospital or birthing
center, depending upon their education and licensure, and the rules
governing their practice.

Midwives believe it is especially important to provide time for
questions, teaching, and time to listen to the concerns and needs of the
women they care for.

The WHO definition of the midwife gives us the following guidelines
about what midwives do:

She must be able to give the necessary supervision, care and advice to
women during pregnancy, labour and the postpartum period, to conduct
deliveries on her own responsibility and to care for the newborn and the
infant. This care includes preventative measures, the detection of
abnormal conditions in mother and child, the procurement of medical
assistance and the execution of emergency measures in the absence of
medical help. She has an important task in health counseling and
education, not only for the woman, but also within the family and the
community. The work should involve antenatal education and preparation
for parenthood and extends to certain areas of gynecology, family
planning and child care. She may practice in hospitals, clinics, health
units, domiciliary conditions of in any other service.
(WHO, FIGO, ICM Statement).

3. HOW DO I BECOME A MIDWIFE?

There are many different paths to becoming a midwife.

Which path you choose will depend on many factors: where you live, what
the rules and regulations are in your state or country which govern
midwives, your age and education, and what sorts of experiences you have
had with birthing. The most important thing is that you need to look at
your reasons for wanting to become a midwife are, both short term and
long term. This will help you determine which path is best for you. The
resource published by Midwifery Today Getting an Education: Paths to
Becoming a Midwife gives good guidance and information about the various
paths to becoming a midwife. In some areas women start as childbirth
educators and/or doulas to become exposed to birth and working with
pregnant women.

4. WHERE DO I FIND A MIDWIFE?

Seek midwives in your community, state and country of province. Speak
with local childbirth educators about midwives they know, and of course,
talk with your friends about their birth experiences and their
particular choice of provider. Watch for health fairs in your area,
check with herb and health food stores and ask questions of other types
of health providers such as massage therapists.

Sometimes a call to the local hospital or health center will give you
information about midwives, childbirth educators and doulas. Some
systems have referral systems for midwives in place, and you can easily
locate a midwife. In other areas you may need to ask lots of questions.
Locate your La Leche League or other groups that work with mothers and
infants, and ask for names of midwives they know. There might be a
listing within your phone book for midwives, but some midwives are not
listed there due to finances or legalities. For example, in the US,
sometimes only CNMs are found in the yellow pages and it might be more
difficult to find the names of midwives who attend homebirths.

Contact nurse practitioners in your area, your local Health Department
and Planned Parenthood. They will usually tell you their favorite
providers first.

5. IS MIDWIFERY CARE SAFE?

As mentioned before, midwifery is probably the oldest profession known
to humankind. Certain mammals (whales for example) have been seen
assisting their sisters births, and helping new whales reach the surface
of the water, and are called midwives. The more the scientific method is
used to analyze birth and the use of technology, the more the midwifery
model stands out at a model for normal pregnancy and birth. Two recently
published works support non-intervention and midwifery care as being
safe and cost effective.

"A Guide to Effective Care in Pregnancy and Childbirth" is a
collaborative effort to prepare, maintain and disseminate reviews of
randomized trials of health care using the Cochrane Database. This is an
international effort, and a very readable resource.

The Database is based on a decade-long study of controlled trials in
obstetric care concerning different aspects of care and treatment. It
also describes the approaches and decisions that have been demonstrated
effective and those for which the evidence in inconclusive or negative.

"As technical advances became more complex, care has come to be
increasingly controlled by, if not carried out by, specialist
obstetricians. The benefits of this trend can be seriously challenged.
Direct comparisons of care given by a qualified midwife with medical
backup with medical or shared care show that midwifery care was
associated with a reduction in a range of adverse psychosocial outcomes
in pregnancy, and with reductions in the use of acceleration of labor,
regional analgesia/anesthesia, operative vaginal delivery, and
episiotomy." (p 15)

BIRTH: Issues in Perinatal Care Vol:22, No 2: June 1995 summarizes this
resource.

A second excellent resource is "Obstetric Myths Versus Research
Realities". This lists many recent abstracts from medical research in an
organized and systematic fashion.

It would be impossible to quote them, and one needs to review this text
to appreciate its value.

Women seeking assistance for her pregnancy and birth will find providers
at all points along the spectrum: physicians that are highly
interventive, physicians that behave similarly to midwives that are non-
interventive, trusting herbs and other modalities, and midwives that
practice like physicians. The onus is on the woman and her family to
question the available providers and find the match that best suits her
individual needs.

Please also see the following additional documents
describing midwifery in specific areas:

BIBLIOGRAPHY OF BOOKS AND RESOURCES ABOUT THE PROFESSION OF MIDWIFERY
MIDWIFERY IN AUSTRALIA
MIDWIFERY IN CANADA
MIDWIFERY IN FLANDERS (in development)
MIDWIFERY IN THE UNITED KINGDOM (in development)
MIDWIFERY IN THE UNITED STATES

************************************************************

This FAQ was prepared by Pat Sonnenstuhl, ARNP, CNM, RH <cnm...@aol.com>
with the supportive assistance of the following contributors.

Suggestions for topics to add to the FAQ are always welcome.

Ms. Sabrina Cuddy <swn...@fensende.com>:
Childbirth educator, Nursing Mother's Council volunteer, USA

Ms. Elizabeth Couch <kindre...@shop.medchem.purdue.edu>:
DEM, USA.

Ms. Marjorie A. Dacko <da...@accessnv.com>:
Home birth and birthing clinic practice. President of the Nevada
Midwives Association.

Ms. Sharon K. Evans <Birt...@aol.com>:
Writer and and licensed DEM, birth center practice. Co-chair for the
NARM Qualified Evalator Committee.

Ms. Cheri Van Hoover <Che...@aol.com>:
CNM, hospital practice, USA.

Mr. Patrick Hublou <phu...@innet.be>:
Midwife, Flanders, Belgium

Ms. Deirdre E.E.A. Joukes <065...@pc-lab.fbk.eur.nl>:
Consumers-viewpoint, The Netherlands

Ms. Debbie Pulley <Man...@aol.com>:
MANA Legislative Chair CPM, homebirth practice, USA

Pat Sonnenstuhl, ARNP,CNM, RH <cnm...@aol.com> has been an RN since
1965, and CNM since 1981. She became interested in midwifery in the
1970's when it began to flourish again in California and has practiced
midwifery in the home, birth centers and hospitals.
She is the the Internet spokesperson for a combination CNM-Licensed
Midwife group in Washington State called the Midwives Association of
Washington State (MAWS).
She supports safe birthing with qualified practitioners and encourages
empowerment and self-knowledge for women.
She recently completed the intermediate level of training to became a
registered hypnotherpaist and uses hypnosis in a variety of ways in her
practice of midwifery.

This FAQ may be reproduced freely for non-commercial purposes as long as
the author also received a copy of the posting and the reactions to the
posting that the distribution may cause.

This FAQ may be distributed for financial gain only with the expressed
permission from the author.


Pat Sonnenstuhl

unread,
Feb 11, 1998, 3:00:00 AM2/11/98
to

Archive-name: medicine/midwifery/united-states
Posting-Frequency: monthly
Version: 0.02
Last-Modified: 1996/6/8

Please also refer to the sci.med.midwifery Introductory FAQ for more
general information about midwifery worldwide.

The topics addressed in this document are:

1. MIDWIFERY IN THE UNITED STATES

I. CERTIFIED NURSE MIDWIVES

II. LICENSED OR CERTIFIED MIDWIVES

III. EMPIRICAL MIDWIVES

2. WHAT CAN MIDWIVES DO?
3. WHAT DO MIDWIVES DO ?
4. HOW DO I BECOME A MIDWIFE?
5. WHERE DO I FIND A MIDWIFE?
6. HISTORY OF MIDWIFERY IN THE UNITED STATES (in development)


1. MIDWIFERY IN THE UNITED STATES:

In the US there are three types of midwives.


I. CERTIFIED NURSE MIDWIVES (CNMs) are trained through approved programs
of the American College of Nurse Midwives (ACNM).

CNMs are trained in the disciplines of nursing and midwifery, but their
primary focus is the practice of midwifery. These programs are run by
Nurse-Midwives, and usually affiliated with a University or medical
school. Programs are either a one year Certificate Program or a two year
Master's Program. Some Masters degrees are in Nursing, some in Public
Health, and some in Midwifery.

Some states are requiring a Master's Degree for a CNM to practice (such
as Washington and Oregon) for licensure. Some programs admit two year
degree RNs, and some programs require a BS in Nursing for admission into
the program.

There are several accelerated programs, such as the one at Yale that
admits non-nurses with a 4 year degree and in three years the individual
graduates with a Masters in Nursing and become eligible to take the
boards to become both an RN and a CNM.

The Community Based Nurse Midwifery Education Program (CNEP) is an
innovative distance learning program which allows a student to study at
home and gain clinical experience locally.

Some midwifery programs for RNs seeking a CNM are developing innovative
curriculums and channels to increase access to education. The list of
schools for CNMs is long, and new programs are approved each year.

You can contact the American College of Nurse Midwives (ACNM) at
<in...@acnm.org> to determine where the schools are and what the
requirements for admission are.

Subscribing to the Journal of Nurse Midwifery (the journal of the
American College of Nurse Midwives) will provide you with updates about
programs, and articles about CNMs and the issues facing them.

In the USA, Certified Nurse Midwives are growing and flourishing, numbering
over 4000. They are making inroads in many ways, bringing midwifery care
into the hospitals, providing care for low income families and becoming
a respected provider and part of the team of providers in medical school
programs, training residents in normal birthing.

Usually, CNMs work in a collaborative or co-management relationship with
physicians. This implies teamwork and promotes continuity of care.

In some states CNMs also hold a separate title, and must use it with
their legal signature. For example, in Washington state, I am an
Advanced Registered Nurse Practitioner (ARNP) and Certified Nurse
Midwife (CNM). I am licensed through the Board of Nursing as an ARNP
because I am a licensed as a CNM.

This is important for our future viability, because nurse practitioners
are uniting, and someday that might be the title across the nation. I am
required to use the title ARNP, and choose to use CNM also. This is
confusing sometimes to the public.

II. LICENSED OR CERTIFIED (direct entry) MIDWIVES practice in a home or
birth center setting. They can receive their training through a
combination of formal schooling, correspondence courses, self study and
apprenticeship.

Although this is a non-nurse entry route for midwifery, nurses are not
excluded. These midwives must show that they meet or exceed the minimum
requirements for the practice of midwifery by documenting experience and
passing both skills and didactic exams. In the United States, direct-
entry midwifery is legally recognized in 29 states. Licensure,
certification or registration is available in 17 states and Medicaid
reimbursement is available 6 states.

Licensed or certified midwives usually have a working relationship with
the State Health Departments, do sign birth certificates, have lab
accounts and usually have doctor back-up and emergency procedures lined
up. Licensed or certified midwives are reimbursed by many insurance
companies for birth center and home births.

There is a movement in the United States towards Professional Midwifery: a
process through which those aspiring to be midwives can proceed and at the
end be called a CERTIFIED PROFESSIONAL MIDWIFE (CPM).

The North American Registry of Midwives (NARM) is the first certifying
body to offer both a national examination and a national validation
process for professional direct-entry midwives, and CNMs who assist with
birth at home, who come to their practices through multiple educational
routes. NARM has been offering a registry examination of entry-level
midwifery knowledge since 1991. NARM has just completed a pilot project
for a certification process which validates skills, knowledge and
experience.

This certification is now being offered nationwide and the new
credential is for Certified Professional Midwife. The CPM has
successfully completed prescribed studies in midwifery accomplished
through a variety of educational routes. The examination is based on
Core Competencies established by the Midwives' Alliance of North America
(MANA) <Mana...@aol.com> the national organization representing
midwives. The CPMs then practice in accord with the MANA Standards and
Guidelines for the Art and Practice of Midwifery.


III. LAY or EMPIRICAL MIDWIVES, also referred to as direct entry midwives,
obtain their training through a variety of routes. This category may also
include very experienced and well trained midwives who practice in
states where there is no reciprocity for the license they already have,
such as Oregon, where certification is not required unless one wants to
get medical funds for low income clients. This category does not exclude
nurses from its ranks. (Sharon Hodges-Rust). These might also be
midwives who have chosen not to become licensed or certified for a
variety of reasons, ranging from the lack of experience necessary for
licensure to not wanting to work under any type of mandated protocols or
guidelines. Some are part of a religious group, and practice only within
a specific community. In some areas they cannot charge for their
services, and can be prosecuted for doing so.

Community-based midwives have been providing care for pregnant women across
North America for many past years. Currently there are two to three
thousand independent midwives in the US alone. There are many types of
providers providing prenatal care and birthing assistance in the United
States: Midwives with different sorts of titles and qualifications,
Physician Assistants, Family Practice or General Practitioners, and
Obstetricians. As you can imagine, the process and outcome of a birth
will be different, depending upon the provider chosen to assist the
birth.

2. WHAT CAN MIDWIVES DO?

This will depend on the type of licensure and the laws and restrictions
within the local area.

CNMs can obtain hospital privileges, in some states can prescribe most
medications needed by women, and can attend birth in the home, hospital or
birth centers. They can provide family planning and women's health care
in addition to the full scope of prenatal and birthing care. How they
practice will depend upon their work setting.

Some CNMs practice in large, busy Level III hospitals. This is usually
episodic care, and they might work shifts and specific clinics, and be
able to work a limited 40 hour week. Some CNMs have a solo private
practice and others work in group practices with other CNMs and/or
physicians. Most CNMs provide total midwifery care, with a physician for
consultation and co-management as needed. CNMs can earn a consistent
income, and can also practice as an RN if she cannot work as a CNM.
Sometimes CNMs work for a family planning agency such as Planned
Parenthood or the Health Department providing family planning services
and women's health care. Some CNMs practice midwifery internationally on
special projects for the American College of Nurse Midwives. Present
projects include work in Ghana, Egypt, Uganda, Indonesia, Morocco and
Bolivia and include work with family planning agencies and the training
of training of Traditional Birth Assistants and working towards
improving the overall standard of living for women and their families.

Obtaining hospital privileges in the United States is a critical element in
a midwife's ability to practice and use the resources found within the
hospital, such as the lab, radiology and the emergency room. Hospital by-
laws can be written to either include or exclude this non-physician
provider. Some by-laws require physician supervision and sometimes their
presence at the birth. Other by-laws are more liberal. CNMs have made
many strides over the past few years, and many hospitals are receptive
to midwives. Women are requesting the care of midwives, and hospitals
choose to offer this option.

Non-physician providers in some institutions, can independently admit and
discharge their clients, however cannot vote on any committees. CNMs attend
the perinatal committee, which discusses the rules and regulation of the
particular obstetrical unit, but they are not allowed to vote on rules
which might affect them. CNMs attend these meetings, and their visible
presence makes an impression at some level to their viability.

The by-laws limit who can practice. Each candidate is carefully
screened for accuracy of licensure and educational program. Probationary
periods exist for different practitioners, and requirements for non-
physicians might differ somewhat from what is required for a physician.
Hospital administrators are looking at different models of health care,
and at countries where midwives provide most of the care.

The issue of hospital privileges affects non-CNMs, if they were to want
privileges, or even to use the services available at the hospital. The
midwife without privileges would need to go through a physician or other
provider to get an ultrasound ordered, and the results would go to the
physician, not the midwife. Many midwives do not seek hospital
privileges, but others want to be able to transition their clients into
the hospital should the need arise, and be able to continue care within
the hospital. Some DEMs also sit on various committees in their states
and are able to promote change in obstetrical care, along with the
consumers in the community.

Midwives without a formal license practice in a variety of ways and with a
variety of tools. Some use homeopathic, herbal and other non-allopathic
therapies within their practice, such as massage, accupressure and
reflexology. They assist births in the home or within a birth center.
Some midwives are considered to be practicing illegally in their state
by some authorities. It is not illegal to have a home birth, but it
might be illegal for a midwife to attend the birth without appropriate
licensure. A good example is in Washington State, where there are CNMs,
Licensed Midwives and non-licensed midwives. If the non-licensed midwife
charges for her services, this is considered illegal by state law.
Licensed midwives and CNMs can bill for their services through the
state, and be reimbursed by insurance plans. Many midwives practice
independent of any major medical community, consulting with a specific
physician if necessary that is supportive of their cause, or having the
client seek a consulting physician should problems arise.

In some situations, midwives contact whatever back-up is available, using
the hospital's on-call physician should transfer be necessary. A
hospital's reception of a midwife's transport may vary. Sometimes the
midwife and parents face a physician or nurse who disapproves of the
intended birth at home. However as midwives and out-of-hospital birthing
have become more common, the hospital staff has become more likely to
greet the transport with professional respect. Licensure or
certification provides a minimum standard to which midwives adhere. The
intention is to protect the consumer from harm by a practitioner without
adequate training, but is no guarantee of competency.

Licensure and certification also imply a peer review process to help
midwives feel accountable for their actions.

In the USA, CNMs usually work from standing protocols that they have
developed themselves. These are reviewed by their consultant physicians,
and guide care. Generally these are of a medical or allopathic
orientation, however there are CNMs who use herbs and non-allopathic
treatments within their practice. The ACOG (American College of
Obstetrics and Gynecology) has well documented and clearly presented
guidelines for practice, and most seem respectful of the diversity of
practice within the USA. Following these guidelines are not required for
practice, but are considered part of the "standards of care" within the
community. Should legal action be taken against a physician or midwife,
these guidelines will be reviewed, and used as a standard against which
the outcome could be judged.


3. WHAT DO MIDWIVES DO?



Midwives teach, educate and empower women to take control of their own health
care. In most communities, they provide prenatal care, or supervision of the
pregnancy, and then assist the mother to give birth. They manage the
birth, and guard the woman and her newborn in the postpartum period.
Most midwives encourage and monitor women throughout their labor with
techniques to improve the labor and birth. Reassurance, positive imaging
and suggestions to change positions and walk helps labors progress.

Many midwives provide family planning services and routine women's
health examinations such as pap smears and physical examinations. They
teach women about sexually transmitted infections, and focus on
prevention of the spread of infections. What specifically midwives do
will depend upon: her training, her licensure, and what is allowed in

the state, province, or country in which she practices. Certified Nurse
Midwives (CNMs) in most states within the USA can prescribe most
medications, and in some areas also provide women's health care
throughout the menopause years. CNMs can attend birth in the hospital,
birthing center, or home.

All midwives specialize in understanding normal aspects of the childbearing
cycle. They are trained to recognize deviations from the normal, recommend
holistic means for bringing the situation back into the realm of normal,
or refer to another practitioner when necessary. Midwives believe it is
important is to provide time for questions, teaching, and time to listen


to the concerns and needs of the women they care for.


4. HOW DO I BECOME A MIDWIFE?

There are many different paths to becoming a midwife. Which path you choose
will depend on many factors: where you live, what the rules and regulations
are in your state or country which govern midwives, your age and
education, and what sorts of experiences you have had with birthing. The
most important thing is that you need to look at your reasons for
wanting to become a midwife are, both short term and long term.
This will help you determine which path is best for you. The resource

published by Midwifery Today, "Getting an Education: Paths to Becoming a


Midwife" gives good guidance and information about the various paths to
becoming a midwife.

Some women start as childbirth educators and/or doulas to see how it
feels to them. I started as a childbirth educator, and offered to labor
support births with my students. It reaffirmed my decision to become a
midwife, and the fire within me became very strong. I lived in
California at the time, and already had a 2 year degree in nursing, so
decided upon sought a Certificate program, through the University of
Mississippi, which was one year. I could have done things differently,
but this path seemed the best one for me at the time. While teaching
childbirth classes and gaining experiences with childbirth, I soon met
midwives and others interested in birthing. I observed many different
types of births and began develop a personal philosophy about birthing.

I also became good friends with a midwife, and she mentored me to help
me gain experience. She was an unlicensed midwife who became an RN at 35
and then a CNM. She has practiced in every type of setting as a midwife,
including a private home birth practice and large Health Maintenance
Organization (HMO) practice.


5. WHERE DO I FIND A MIDWIFE?

Seek midwives in your community, state and country of province. Speak
with local childbirth educators about midwives they know, and of course,
talk with your friends about their birth experiences and their
particular choice of provider. Watch for health fairs in your area,
check with herb and health food stores and ask questions of other types

of health providers such as massage therapists and doulas.

Call the local hospitals and ask about midwives, childbirth educators and
doulas. Some systems have referral systems for midwives well thought out,


and you can easily locate a midwife. In other areas you may need to ask

lots of questions. Ask La Leche League leaders for names of midwives
they know, as would any other groups that work with mothers and infants.


There might be a listing within your phone book for midwives, but some

midwives are not listed there due to finances or legalities. In Georgia,
in the US, only CNMs are found in the yellow pages and none of them
attend homebirths. Contact nurse practitioners in your area, and also


your local Health Department and Planned Parenthood. They will usually
tell you their favorite providers first.

Contact the
American College of Nurse Midwives <in...@acnm.org> or their web page:
<http://www.acnm.org>
Phone: (202) 728-9860)
for information about schools and practices within your area or
The Midwives Alliance of North America
<Mana...@aol.com>
Phone: (316) 283-4543

6. HISTORY OF MIDWIFERY IN THE UNITED STATES (in development)

Additional Documents about Midwifery include:

BIBLIOGRAPHY OF BOOKS AND RESOURCES ABOUT THE PROFESSION OF MIDWIFERY

INTRODUCTION TO MIDWIFERY
MIDWIFERY IN AUSTRALIA
MIDWIFERY IN CANADA (in development)


MIDWIFERY IN FLANDERS (in development)
MIDWIFERY IN THE UNITED KINGDOM (in development)

***********************************************************

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