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Midwives are trained to provide care and support to women throughout pregnancy, delivery, and the post-partum period. Besides providing care during pregnancy, labor and delivery, and post-partum, midwives offer gynecological care and family planning to women all through their lives. The word "midwife" means "with woman" and the title is used to refer to both male and female practitioners. Certified nurse-midwives (CNM) and direct-entry midwives are trained to provide comfort and care throughout the labor and delivery process (American College of Nurse-Midwives, 2006).

 There are various categories of midwives that differ in education and licensing requirements.  In Australia, the two main types of midwives are certified nurse-midwives and direct-entry midwives. Both offer quality care to women and infants, but they differ in education and licensing requirements. Some women prefer lay midwives and in Queensland, there is a very active group of people running a training apprenticeship model of direct entry midwifery. To be registered by the state boards in Australia, midwives must have completed an approved course of study and most registered midwives have gained a general nursing qualification prior to a midwifery course. General Nursing was once a precondition for Midwifery in this country. In the past, all midwives had to first qualify as registered nurses before completing a midwifery certificate (or graduate diploma) to specialize in midwifery. (This is why they are commonly referred to as 'certified nurse-midwives' in the USA). In more recent years, 'direct entry' midwifery courses have evolved in Australia, meaning that midwifery education can now be acquired after a 3 or 4 year degree, without becoming a registered nurse first. The direct entry structure is rather new in Australia, but has been around for several years in New Zealand, the UK and parts of Europe. Currently, most midwives in Australia are also registered nurses (Annells, Averis, Brown, 2007).

This paper tries to give reasons why midwives should midwives should go through a nursing training first and at the same time tries to justify the argument that midwives should not be nurses first. The paper tries to derive the conclusion that indeed nursing is an indispensable element in midwifery but because of shortage of midwives in Australia especially in the rural areas and the fact that some people who have a passion for midwifery may not want to be trained as nurses; nursing should not be a prerequisite to midwifery here in Australia. This will ensure that people who prefer direct-entry midwifery are not locked out.


All midwives should be nurses first

In Australia General Nursing is offered as a three year university course Australia wide. It is a degree course and entails all aspects of Health and nursing. Therefore when midwives are trained as nurses first,   provides a strong basis for them to offer quality service when compared with midwives who have not undergone this training (Ashworth & Morrison, 2001).

Because most nurse- midwives attend births in hospitals, they become part of hospital culture, learning it from the inside. Thus they are often able to generate momentous cultural transformation. In hospitals across the country, the nursing experience enables them to introduce alternative policies and techniques such as allowing women to eat or drink during labor, to get up and walk, to labor in water, and to room in with their babies after birth. Obstetricians and nurses who observe the benefits of  nurse midwives care are often motivated to change both their attitudes toward birth and the way they treat birthing women ( Avery, 2008) . Most nurse -midwives because of the nursing experience find their work intrinsically pleasing: they are in a perfect position to thrive on the intimate connections they build up with their clients, often on the spot during labor or birth, on a client's positive response to their nurturing, empowering care, and on their ability to sometimes hold a holistic space in which a woman can freely birth the way she chooses, in spite of the medicalizing constraints of the hospital environment. Nurse-midwives have also been helpful in developing out-of-hospital freestanding birth centers where they can frequently offer holistic nursing and midwifery care (Barclay, 2007).

Nurse-midwives due to their wide knowledge (combination of both midwifery and nursing skills) have been recognized in Australia for their immense contributions in reducing infant and maternal mortality, premature births and low birth weight rates. Several studies have been carried out and reports released document the success of certified nurse-midwives in their quest to improve maternal-child health. The nursing experience has been found to be a key reason why nurse-midwives are more successful (Barclay, 2005).

By having midwives who are educated as nurses first will ensure that the midwives are equipped with necessary and wide knowledge on scientific advances in fighting infection through hygiene and drugs this will ensure that women and their babies are less likely to die under the care of midwives than under the care of doctors (Barclay, 2005).

Nurses who are trained as midwives, like doctors, may employ some medical interventions, for instance electronic fetal monitoring, labor-inducing drugs, pain medications, epidurals, and episiotomies, if the need arises. On the other hand, direct-entry midwife may not legally be permitted to make use of these techniques without a doctor's supervision. And birthing centers may or may not be operational for these procedures. This puts midwives who are trained as nurses first to offer a wide range of services to patients even are relevant even in cases of complications.

A midwife's education alone stresses that pregnancy and birth are normal and healthy events until established otherwise. Midwives view their role as supporting the pregnant woman while allowing nature takes its course which can be very risk at times. This risk is overcome if the midwives undergo training as nurses first (Barnes, 2009).

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Midwifery without nursing background is not desirable for women with higher-risk pregnancies. Those expecting twins or multiples and those with previous pregnancy complications, gestational diabetes, high-blood pressure, or chronic health problems of any kind before pregnancy should discuss their options with their primary health care provider or an obstetrician. Certified nurse-midwives who practice in major medical centers and work very closely with obstetricians and perinatologists (specialists in high-risk pregnancy) may handle patients with risk factors. But midwives in lone practice or who practice in limited medical facilities generally do not. This means that nurses who are first trained as nurses will be more exposed handle complex situations during delivery (Flint, 2007).

Certified-Nurse Midwives are, as the name implies, are health practitioners (not always a woman) who has completed nursing school with a Midwifery component. They are registered by the State and can be found involved in a hospital or Midwifery Practice setting. Many consider certified nurse midwives to be the best of both worlds. This is because they are able to ensure a balance between the skill and apparent safety the medical establishment has to offer and the age-old practice of traditional Midwifery (Guilliland, 2009).

Nurse midwife needs to get a nursing degree as a registered nurse prior to entry in any program. Job experience as a registered nurse is also necessary before the rigors of nurse-midwifery education begins. This makes them highly qualified professionals with broad experience. Nurse-midwives are more likely to deliver babies in hospitals although some have free-standing birth centers and do attend homebirths. They also are more likely to have formalized physician backup though this varies a lot with each practice (NSW Health, 2000).  

Midwives previously trained as nurses are able to offer excellent Personal Care. The weight of evidence indicates that, within their areas of competence nurse-midwives provide care whose quality is equivalent to that of care offered by physicians. Furthermore, nurse-midwives are more skillful than physicians at providing services that depend on communication with patients and preventive actions. Patients are normally satisfied with the quality of care provided by nurse-midwives, particularly with the interpersonal aspects of care (Siddiqui, 2009).

The evidence to date, confirms the cost-effectiveness of these providers (nurse midwives), given the diversity of the populations they serve in Australia, often as substitutes for physicians; the fact that their care results in at least equivalent and sometimes better out comes, perhaps more quickly, given their patients' enhanced adherence to care regimes; the substantially lower cost of their training; and the collateral benefits of increased consumer choice and satisfaction (Woodward,  2006).

Because of their wide knowledge in both nursing and midwifery, they are in a better position to lower c-section deliveries. Nurse-midwifery has been described as "gentling the art of obstetrics" and "an enormous advantage to patients who expect normal vaginal delivery births which are low-risk this has also resulted to reduced number of C-section deliveries in Australia mainly because of hands-on approach of nurse-midwives in lowering the rate of c-section. Nonrandomized studies that were carried out in the United States suggested that mothers cared for by nurse- midwives are less likely to have a cesarean birth or to have labor induced than mothers cared for by physicians. Further studies indicate that that mothers cared for by certified nurse midwives have fewer complications than mothers cared by obstetricians, a fact that has been greatly attributed to their wide knowledge in both nursing and midwifery.

 Midwives who are also trained as nurses are health care practitioners educated in the two disciplines of nursing and midwifery. Because of this, they are more skillfully equipped to provide high quality health care to women as well as: preconception counseling, care during pregnancy and childbirth, normal gynecological services, support with family planning decisions, health maintenance and disease prevention and care of the menopausal woman (Woodward, 2006).

Within the parameters of nurse-midwifery, midwives previously trained as nurses have plentiful opportunities to learn new skills. For instance, in order to give their clients more continuity of care, many nurse midwives are learning and performing diagnostic ultrasound, and some are training to first-assist when their clients undergo Cesarean sections. Also because of nursing background, they are able to incorporate alternative and complementary methods such as herbal, nutritional, or homeopathic therapies.  Nurse- midwives can advance professionally into directorships of programs, education or research positions, or can move into the growing field of public health. This makes them one the most encompassing professionals in health care (Walker, 2006).

A certified nurse midwife has attended nursing school to become an RN (registered nurse) and then acquired even more training about birth. Most nurse midwives have the philosophy that they are there to help you deliver your baby. Their experience in both nursing and midwifery enables to always work in conjunction with a doctor. They are usually available to answer questions more readily than a doctor (Walker, 2006).

The nurse-midwife is educated and trained to offer a wide range of health care services for women and newborns. Their skills in both nursing and midwifery help them to perfectly execute their roles in taking care of mothers and newborns.  Nurse Midwives' functions include diagnosis (taking a medical history, doing a physical assessment, ordering laboratory tests and procedures), managing therapy (outlining care, providing prescriptions, coordinating consultations and referrals), and activities that promote women's health and reduce health risks.

Numerous studies over the past 20 - 30 years have indicated that nurse-midwives can Handle most perinatal (including prenatal, delivery, and postpartum) care, and most of the family planning and gynecological needs of women of all ages. Although most of the nurse midwives practice focuses on childbearing, family planning, and gynecological care for well women, because of the nursing knowledge they have acquired, they may also check and manage common illnesses in adults. All services are completed together with the patient. Midwives who are also trained as nurses enter the workforce with both midwifery and nursing skills and knowledge allowing him/her to work across a broad range of practice areas in a variety of settings and within different models of care (Walker, 2006).

Why not all midwives should be nurses

Direct-entry Midwives include a diverse group of midwives that have entered the profession directly through midwifery education and training, and not through a pre-requisite program such as nursing. Persons who look for direct entry midwifery care represent varied demographic groups. Many parents are well educated individuals choosing direct entry midwife assisted home birth for philosophic reasons. They want more control over their birth experience than they might have in a traditional hospital. They want to reduce their chances of having interventions, such as drugs and surgery. Most direct entry midwives offer sliding fee scales and assist with births for free for the truly indigent. Another client groups are the women who are geographically separated from hospitals that provide maternity care. Another group who seek direct entry midwifery care may be the low income families who have no insurance (Walker, 2006).

Philosophically, direct entry midwives have a fundamentally different orientation to childbearing than the medical community. According to direct entry midwives, they offer care that supports the woman and her family, is culturally sensitive, and reduces unnecessary interventions and reliance on technology.

Direct entry midwives are rewarded for their dedication by the excellent outcomes and untrammeled beauty of the out-of-hospital births they attend, by the empowerment their clients experience through having given birth on their own, and by the strengthening of the family that often results when birth takes place at home. Other rewards include the awareness that their work is helping to preserve home birth as a viable option for Australian women and that they are keeping holistic, independent midwifery alive and are furthering the preservation and development of its unique body of knowledge- a knowledge based on the wide variations in truly normal birth, which can only take place outside of the artificial constraints of the hospital environment (Walker, 2006).

In Australia a three- year course in midwifery (bachelor of midwifery) has been introduced in which nursing is not a prerequisite. Education issues in this midwifery course differ from those facing nursing education because of differences in the relevant literature, the required outcomes for employers, policy directions, and the need to respond to changes in the delivery of maternity care. Additionally, in Australia, as elsewhere, midwives are licensed so they must be prepared at a level that enables them to function as practitioners in their own right, without having to undertake further education or training. This means that graduates of midwifery education programs should be capable of taking responsibility for the total care of a woman (and her baby) throughout the woman's pregnancy, labor and birth, and the early postnatal period, referring to other health professionals only when complications arise. The introduction of the Bachelor of Midwifery programs in Australia may provide the potential for midwifery to gain control of all processes associated with designing its own education, practice and regulation in the interest of improvements in maternity services (Woodward, 2006).

 Although Midwives who are also trained as nurses are able to prescribe medications and order pertinent laboratory tests that may not be available to direct entry midwives or lay midwives. But if a lay midwife has good backup arrangement the proper tests can be arranged with no difficulty. Unlike direct entry midwives, nurse-midwives are more probable to be bound by arrangements with the physician and the protocol of that particular office. This may decrease flexibility and increase likely interventions depending on how much independence the midwife has (Woodward, 2006).

Shortages of midwives are mainly acute in rural and remote areas of Australia and this places pressure on the sustained provision of maternity care and obstetric services in these areas. This requires many midwives to be trained. Setting a nursing course as prerequisite for midwifery training will lock out people who may want to train directly as midwives consequently aggravating the situation (Woodward, 2006).

Incorporation of nursing into midwifery forms an indispensable element among midwives. This is because midwives trained in both nursing and midwifery are in a perfect position to offer quality and encompassing services to mothers and newborns. Nurse-midwives have also helped reduce infant and maternal mortality, premature births and low birth weight rates a fact that has been attributed to their knowledge and skills in both nursing and midwifery. Also midwives with nursing experience have played a critical role in handling women who might develop complications during pregnancy or those with previous pregnancy complications. Because of the shortage of mid wives in rural areas in Australia and poor income, nursing should not be a prerequisite for midwifery. This will encourage many who might not want to go through nursing training to join midwifery thus helping to offset this shortage in rural area and at the same time making sure that midwifery services are available where health centers are not easily accessible.

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