The following are a few of the frequently asked questions related to international midwifery and Safe Motherhood.
1. What do I need to do in order to work as a mid- wife in another country? Midwives desiring to practice midwifery in a country where they did not complete their basic education as a midwife need to investigate such issues as reciprocity of education, recognition of licensure or other regulatory condi- tions, and the ability to obtain a permit to work in that country. The U.S. system of basic or first-level midwifery education meeting criteria specified by the ACNM Division of Accreditation is very spe- cific to midwifery practice in the United States. In most countries, basic midwifery education and/or licensure is rarely transferable to another country without some type of negotiation with the regula- tory body in the new country. In some cases, pre- sentation of evidence of graduation from an ACNM accredited nurse-midwifery or midwifery education program, successful completion of the ACC Certification Examination, and a notarized copy of one’s license to practice midwifery in a given state will meet the regulatory requirements to be registered or licensed as a midwife in another country. In other cases, presentation of these docu- ments will obviate the need to take another exami- nation for entry into midwifery practice, though a period of observation by supervisor midwives may be required before a permit to practice is issued.
If you are thinking about practicing midwifery in another country, it is wise to learn as much as possible about the status of maternity care and women’s health, the scope of midwifery practice, and any particular regulatory and reimbursement patterns under which midwives work. Beginning your exploration of almost any country is made easy through the Internet. Finding out the details about the vital health indicators (e.g., maternal and infant mortality and morbidity rates and/or ratios) can often be done through the World Health Organization or other agencies of the United Nations in addition to the U.S. Centers for Disease Control and Prevention. Several Web sites are listed at the end of this chapter (Appendix B) to facilitate this investigation of health indicators.
Discovering the details about midwives and midwifery practice in a given country is often diffi- cult, especially in those developing countries where access to electronic media is still quite limited. The International Confederation of Midwives (ICM) is a good place to begin for contacts with individual member associations that might become your con- tact for a discussion of midwifery work in that country. However, not all countries of the world have midwifery associations, and there are some FIGURE 4-4 The white ribbon is a symbol dedicated to
the memory of women who have died during pregnancy or childbirth.
Source:White Ribbon Alliance for Safe Motherhood. Awareness, Mobilization, and Action for Safe Motherhood: A Field Guide.
Washington, DC: NGO Networks for Health, 2000.
midwifery associations that are not yet members of the ICM. In these cases, you might talk with indi- viduals or agencies that work in such countries, in- cluding staff of the ACNM Division of Global Outreach, Save the Children—Saving Newborn Lives, and Family Care International.
Obtaining a global perspective on midwifery education, regulation, and practice is essential for all midwives as women throughout the world need the services provided by well-prepared midwives, and global migration of health workers is a reality.
A note of caution is warranted: any new midwifery graduate often needs time to become confident with all the midwifery skills, management decisions, and adjustment to the autonomous role of the licensed midwife. It is often easier for new graduates to at- tain this level of confident practice in their own country before learning a new health system and pattern of midwifery practice in another country.
Take time to make good decisions about your ca- reer and how to advance it to include international midwifery service.
2. What do I need before applying for international consultation positions in midwifery? International midwifery experience is often a prerequisite to be- coming eligible for international consulting posi- tions in midwifery—whether short- or long-term. In many ways, it becomes a catch-22 situation: in order to be employed in international midwifery, you have to have had international midwifery expe- rience—and yet it is difficult to obtain international midwifery experience if you have never worked in another country. However, many midwives gain such international experience through volunteer- ing—either with a church-related organization, the Peace Corps, emergency relief agencies, or other volunteer agencies. Sometimes the international ex- perience required does not have to relate to mid- wifery; at other times international midwifery experience is vital.
Among the most important criteria for interna- tional consultation in midwifery is excellence in both practice and teaching. Be the best midwife you can be prior to thinking about sharing your experi- ence with others. Hone your teaching skills with in- dividuals and with groups. Remember, expertise takes time and is built upon one’s ongoing mid- wifery experience—it does not come quickly or without effort, including learning from your mis- takes. Effective consultation also requires expert communication skills, cultural sensitivity and com- petence, and insight into and awareness of the im-
pact of your values and value-biases on how you view the world—especially when that world is very different from your own. We all view the world through our own “value lens”—and must under- stand that though there are some universal values, such as respect for human dignity, there are many values that are not shared from one culture to an- other, from one country to another, or from one person to another in the same country. The person with unexamined values can be a menace to others, for lack of insight into oneself often means the un- conscious imposition of one’s personal values on others—often inappropriately.
It is important to have a working ability in at least one language other than English. The effort in- volved in learning another language (or more) is an important element of becoming culturally compe- tent. Multiple language ability is an extra bonus for those interested in international midwifery consul- tation. English, Spanish, and French are the major languages of the United Nations, the World Health Organization, the International Confederation of Midwives, and other international agencies. With these languages, a midwife can work successfully in almost all areas of the world. Taking time to learn the dominant language of the country where you plan to work is not only valuable for working with in-country colleagues, but also expresses your re- spect for their language. Consultants assigned on a short-term basis (working for a few days or weeks) often do not have the luxury of time to learn a local language, such as Chichewa, Urdu, Hindi, or Polish, and therefore need to know how to work through interpreters. Long-term consultants work- ing for several months or years will need to learn the local language and will need to have time pro- vided to study in the country if the language is not among those taught in colleges and universities in their home country. While working in the language of the host country is not always mandatory, having the ability to do this demonstrates exceptional com- mitment to the host colleagues and their culture.
The primary role of the consultant is to offer advice after learning about the country and back- ground on issues to be addressed during the consul- tation, sharing experiences from other areas of the world that might be useful in the given situation, or offering suggestions as to how these experiences might be adapted to the country or situation. Above all, a consultant is a guest in the country and needs to act in a way that preserves the integrity of the host country. A large measure of humility is vital to international consultants—for a consultant must al-
ways remember that the host country needs to make the final decisions on any advice or sugges- tions given. This is yet another example of the mid- wifery model of care that empowers others to care for/decide for themselves what is best for them.
It is a good idea and often fun to spend time talking with midwives who have spent a good por- tion of their career as international midwifery con- sultants. These are very wise and worldly individuals, and they can offer insight into what works and what does not work in the international arena relative to midwifery, women’s health, family planning, public health, or primary care—to name a few of the areas of consultation needed in the world. International midwifery consultants work with a variety of levels of health workers—from the revered Traditional Birth Attendant (TBA) to physi- cians needing midwifery skills. They may provide educational consultation at universities and colleges for preservice (basic) or postbasic (degree) mid- wifery education, hands-on training in Life-Saving Skills (LSS) or upgrading of general midwifery skills (on-going education). They may provide consulta- tion to governments, Ministries of Health, and pol- icymakers on the health needs of women and childbearing families. They may work with in-coun- try midwives to begin and/or strengthen local mid- wifery associations. They may also work with regulatory agencies, such as nurses’ and midwives’
councils, to provide for strong self-governance and regulation of midwifery practice in the country.
There is a great need for strengthening midwives and midwifery throughout the world, and ACC cer- tified nurse-midwives and midwives have a strong educational base on which to build the needed skills to become an effective international midwifery con- sultant. Clinical and teaching expertise, cultural competence, known personal values, and a mini- mum of a second language joined together with a passionate commitment to women’s health and quality midwifery care can result in an effective ca- reer as an international midwifery consultant.
3. Where can I find information on topics such as Safe Motherhood, violence against women, female genital cutting (mutilation), positive and negative traditions (practices) surrounding pregnancy and birth in a variety of cultures, and gender discrimina- tion? As more and more midwives are guided into international midwifery—whether by faculty when they are students or through personal interests—
searching for the best sources of information on se- lected international topics in women’s health
becomes very important. Every midwife should fully understand the global efforts to make childbearing safe for all women and should remember that preg- nancy is a condition that was never intended to re- sult in the death of the woman or infant. However, hundreds of thousands of women still die during childbearing, and many of their newborns also die.
As Rebecca Cook noted several years ago [2], the global tragedy of maternal death and disability is one of the most poignant reminders that women’s rights are being disregarded in many areas of the world. Human rights for girls and women are an- other key topic of interest among midwives, as the nature of midwifery is working with women—
wherever they are and in whatever condition mid- wives find them [28]. Violence against women, female genital cutting, the continued low status of women, and other forms of gender discrimination are all evidence of the persistent denial of the basic human rights of young girls and women throughout the world. Key sources of information on human rights and the status of women can be located in the Web sites of the World Health Organization, and UN agencies such as the United Nations Fund for Women (UNIFEM), UNICEF, and UNFPA.
Some of the most interesting topics surround- ing pregnancy, birth, and the immediate postnatal periods involve cultural rituals and taboos for the woman. These range from what can be eaten or not eaten, to what the woman can see or do. Selecting an area of the world to read about, explore, and discuss with members of that society can be a mind- expanding activity for the midwifery student or new graduate. As you will discover when working in the international arena, the goal of midwifery care is to support those cultural traditions that pro- mote the health and well-being of women or are harmless, and to work to eliminate those rituals and taboos that are harmful to women and infants.
Books on these topics abound, beginning with some of the early writings of Margaret Mead and other cultural anthropologists. A literature search will re- sult in some very interesting reading, and will help you to understand the culture of birth, including the culture in the United States, more fully.
4. What are the various educational pathways to midwifery practice throughout the world? There are a variety of educational pathways to becoming a professional midwife throughout the world in keeping with the ICM/WHO/FIGO International Definition of the Midwife. These can be captured in two main categories: (1) midwifery education built
upon or within nursing, and (2) midwifery educa- tion entered directly without a health background.
In each of these two pathways, there are a variety of educational levels that are prerequisite to entering midwifery education. Within developed nations, the majority of midwifery education is built upon a minimum of a high school education, although the actual midwifery education may or may not lead to a college degree. In developing nations, midwifery education is generally built upon a minimum of a tenth grade secondary education.
It is estimated that approximately one-half of the world’s professional midwives are also nurses, constituting dual professional qualification. Many nations require dual qualification in nursing and midwifery to meet the growing need for profes- sional health workers working in community-based primary care facilities. In other areas of the world, direct-entry midwifery is encouraged to meet the demand for childbearing services of high quality.
And in several nations, both types of professional midwives are prepared. Whatever the pathway to midwifery education, it is the competencies of the individual midwife that are most important.
5. How can I become active in the International Confederation of Midwives? Any individual mid- wife who is a member of a midwifery association that is a member of the International Confederation of Midwives (ICM) is considered an active member of the ICM. As noted earlier in this chapter, ICM depends on the volunteer efforts of midwives throughout the world to carry out its mission, vi- sion, and global strategy. Midwifery students, new graduates, and experienced midwives are encour- aged to take an active role within the ICM. This role may be working with officers of the Confederation on individual projects, such as the evolving international midwifery competencies and standards of practice, the development of the ICM Web site, or on mid-triennium conferences and Triennial Congresses held in their area of the world.
Anyone interested in becoming active in the ICM should contact the Secretary General at ICM head- quarters to volunteer their time and talents.