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Midwifery Education
This interview is with a health professional who has worked in several countries, including Cambodia, Indonesia, and Somalia as a midwifery educator. She trained professional midwives in Cambodia and Indonesia, and traditional birth attendants in Somalia and Cambodia. She also worked on primary health care and community development projects in Somalia and Cambodia. Her first international experience was in Somalia, training traditional birth attendants and working in community health development.
This experience really framed a lot of my perspective. I saw people really struggling to get by.
Professional Midwives and Traditional Birth Attendants: What is the difference?
Women have a long tradition of helping other women give birth. In most countries in the world, midwives and traditional birth attendants rather than doctors attend the birth. A distinction is made between professional midwives and traditional birth attendants. Professional midwives are trained health professionals, and meet professional standards determined by the country. While they sometimes attend births in women's homes, they often practice in hospitals and birthing centers, where they have greater access to lifesaving medicines and supplies and are trained in lifesaving skills. Traditional birth attendants often have little or no formal education and have learned what they know about birth either from other traditional birth attendants and/or by attending the births of their friends, neighbors, and relatives. They attend births in women's homes, and often do not have the knowledge, skills, or supplies necessary in some births.
Women become traditional birth attendants in a variety of ways:
A lot of cultures have a tradition of traditional midwives. They have a calling to be a midwife because someone in their family was a traditional midwife. They are told in dreams that they are supposed to be midwives. Or some of them are just caught in a situation where they have to do a delivery because no one else is there. They later continue to attend births after that one experience.
Traditional birth attendants often come from the same cultural group as the women who need their care. They often speak the same language, understand the culture, live close enough to be available at any time, and can provide emotional and physical support for pregnant women. However, most traditional birth attendants do not have the knowledge or technical skills to help women with some of the complications of pregnancy, such as hyptertensive disorders of pregnancy, hemorrhage, infection, obstructed labor, and complications of miscarriage or abortion.
Traditional birth attendants would need extensive training and equipment to be able to help women with complications of pregnancy.
Hear how traditional midwives are limited in helping women with pregnancy complications.
The World Health Organization (WHO) recognizes that professional midwives can safely handle most pregnancies and have the skills to refer complex complications to a doctor. Well-trained professional midwives should continue to handle the majority of births.
However in much of the world, women do not have access to better trained or professional birth attendants. In Cambodia, literacy rates for the population are very low, especially among women. Few women have opportunities for the formal education that is required for further education as a health professional, such as a doctor or a professional midwife. For those that do become health professionals, there are a variety of cultural factors that make it difficult for educated women to live in or relocate to rural areas where traditional birth attendants do the majority of the births. Some countries have phased out traditional birth attendants, but only after spending decades raising the basic status and education level of women in the country.
Integrating midwifery and medical knowledge:
Traditional Birth Attendants in Cambodia
Midwifery educators work with both traditional birth attendants and professional midwives. In countries like Cambodia where traditional birth attendants continue to attend deliveries, midwifery educators train traditional birth attendants how to recognize and refer complicated pregnancies to a trained professional.
Despite their lack of formal training, traditional midwives are very knowledgeable about the normal birth process.
Traditional birth attendants have incredible knowledge about birthing. They don't have a lot of knowledge about some things we consider important, but they have a large understanding of the way normal birthing works.
Despite their knowledge about normal birthing, traditional birth attendants usually do not have the medical knowledge and skills to help women with life-threatening complications of pregnancy. To help them learn how to refer complicated pregnancies, it is especially important to begin with what they know about the birthing process and ground the material in their views of culture.
An understanding of cultural beliefs is essential for midwifery educators. For example, Cambodian birth attendants believed that all the "bad blood" had to come out after a pregnancy. Although some bleeding is normal after birth, too much blood can indicate hemorrhage. In trying to teach traditional birth attendants about the danger of hemorrhage, midwifery educators had to differentiate between the bad blood that had to come out, and the amount of blood that would be too much. If midwifery educators had been unaware or had ignored the traditional beliefs about bleeding after birth, serious miscommunication could have occurred.
In another example, Cambodian traditional birth attendants saw that women swelled before birth, and called it "swelling of the baby." Although some swelling can be normal, swelling can be a sign of danger in women who also have high blood pressure
Listen for how health professionals distinguished between swelling of the baby and problematic swelling.
By making these distinctions, health professionals honored the knowledge and cultural understanding of traditional birth attendants, while helping them gain new skills and knowledge about life-threatening complications of pregnancy.
Applying midwifery training in practice:
Professional midwives in Indonesia and Cambodia
Professional midwives have had formalized training, but much is in the form of memorization rather than application. Professional midwives may have memorized facts, but need more training to learn how to apply these facts in specific clinical situations.
A lot of the materials already developed were very didactic materials. They were taught by repetition. There was very little integration of what they may know now about birthing and how to apply that to a situation. We focused on taking what they knew about women's birth, and really mentored them and helped them apply what they knew. If we gave them a situation, we would ask: What does that mean? What could cause that? What would you do?
Putting new knowledge in clinical context helped midwives be able to use this new information. By integrating new knowledge with their current knowledge, health professionals were most effective in teaching new skills to midwives.
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Dawn Haney, January 2001
Last Modified: 02/03/2001
Contact: Dawn Haney
haneydaw@arches.uga.edu