Direct Entry Midwifery Research Articles

An audit review of midwifery qualifications and distribution in Zambia

Background In Zambia, the last decade has seen the development of multiple midwifery qualification, including direct-entry midwifery, an advanced diploma in nursing and midwifery, or a Bachelor of Science, Master of Science or Doctor of Philosophy in midwifery programme. Despite advancements in midwifery training, there is no research on different categories of midwifery qualifications in Zambia and their competencies. Therefore, there is a need to review midwifery qualifications and the distribution of midwives in Zambia. The aim of this audit review was to evaluate qualification categories of midwives currently registered with the General Nursing and Midwifery Council of Zambia and the distribution of midwives across Zambia. Methods An audit review of midwifery qualifications and their distribution across Zambia was undertaken using the General Nursing and Midwifery Council of Zambia's register of nurses and midwives 2020. Data were extracted from the report and presented as frequencies. Results A total of 6112 midwives were registered by the General Nursing and Midwifery Council of Zambia at the time of data collection, of which the majority (87.6%) were women and registered nurse midwives (52.7%). The most common place of practice was a hospital (41.5%) and the greatest proportion of midwives worked in Lusaka (24.6%). Conclusions This audit review provides insights into midwifery qualification categories in Zambia and their distribution, and indicates that levels of practice should be clearly defined in terms of their competencies. With advancements in midwifery training, the authors believe there will be an increase in midwives' autonomy and their involvement in decision making at all levels of care.

Self-perceived competency of midwives in Kenya: A descriptive cross-sectional study.

Midwifery competence is demonstrated in the context of midwifery education, regulation and practice to support the quality delivery of care to women. Midwives with appropriate competencies can deliver up to 80% of maternal health services. The pre-service education programmes in Kenya offers different midwifery competencies for the various programmes, influencing expected outcomes in practice. This study aimed to assess midwives' perceived level of competence based on the International Confederation of Midwives (ICM) standards in Kenya. The study was conducted in selected public health facilities in Kenya. An observational cross-sectional design was used. A multi-stage sampling technique was used to select the counties and health facilities and random sampling to determine 576 midwives. Data were collected using a self-administered assessment tool adopted from the ICM competency domains. A total of 495 (85.9%) midwife respondents participated in this study, of which 389 (78.6%) respondents in all training categories were highly competent in the four ICM domains. The midwives' qualifications and facility level were associated with their self-perceived competence during practice. Those trained in the direct-entry midwifery programme were more competent, p = 0.016 (Kruskal wallis H = 8.432). Midwives' competence was influenced by the level of education and facility where they practice. All pre-service midwifery programme graduates must meet the essential ICM competencies and need to enhance continuous professional development (CPD) programmes and facility-based mentorship for the midwives.Contribution: To optimise midwifery-led practice in primary health care, midwifery competence should be enhanced in pre-service and in-service education for improved health outcomes.

Diverse pre-service midwifery education pathways in Cambodia and Malawi: A qualitative study utilising a midwifery education pathway conceptual framework

ObjectivesEducated and skilled midwives are required to improve maternal and newborn health and reduce stillbirths. There are three main approaches to the pre-service education of midwives: direct entry, post-nursing and integrated programmes combining nursing and midwifery. Within these, there can be multiple programmes of differing lengths and qualifications, with many countries offering numerous pathways. This study explores the history, rationale, benefits and disadvantages of multiple pre-service midwifery education in Malawi and Cambodia. The objectives are to investigate the differences in education, roles and deployment as well as how key informants perceive that the various pathways influence workforce, health care, and wider health systems outcomes in each country. DesignQualitative data were collected during semi-structured interviews and analysed using a pre-developed conceptual framework for understanding the development and outcomes of midwifery education programmes. The framework was created before data collection. SettingThe setting is one Asian and one African country: Cambodia and Malawi. ParticipantsTwenty-one key informants with knowledge of maternal health care at the national level from different Government and non-governmental backgrounds. ResultsApproaches to midwifery education have historical origins. Different pathways have developed iteratively and are influenced by a need to fill vacancies, raise standards and professionalise midwifery. Cambodia has mostly focused on direct-entry midwifery while Malawi has a strong emphasis on dual-qualified nurse-midwives. Informants reported that associate midwifery cadres were often trained in a more limited set of competencies, but in reality were often required to carry out similar roles to professional midwives, often without supervision. While some respondents welcomed the flexibility offered by multiple cadres, a lack of coordination and harmonisation was reported in both countries. Key conclusionsThe development of midwifery education in Cambodia and Malawi is complex and somewhat fragmented. While some midwifery cadres have been trained to fulfil a more limited role with fewer competencies, in practice they often have to perform a more comprehensive range of competencies. Implications for practiceEducation of midwives in the full range of globally established competencies, and leadership and coordination between Ministries of Health, midwife educators and professional bodies are all needed to ensure midwives can have the greatest impact on maternal and newborn health and wellbeing.

The three pathways to becoming a midwife: self-assessed confidence in selected competencies in intrapartum care from seven African countries

Background/Aims Globally, there are three pathways to become a midwife: midwifery post nursing, direct entry midwifery and integrated nursing and midwifery. There is limited knowledge on the effectiveness of pre-service midwifery education. The aim of this study was to describe and compare midwifery students' confidence in intrapartum skills and associated factors such as type and level of education. Methods A multi-country cross-sectional study was conducted, where midwifery students were approached in the final months of their education programme. Data were collected using a questionnaire, based on the basic skills by the International Confederation of Midwives. Intrapartum care comprised 40 skills. Results In total, 1407 midwifery students from seven sub-Saharan countries responded. The 40 skills were grouped into six domains; three related to care during the first and second stage of labour and three related to care during the third stage of labour. Sex and age were significantly associated with confidence, with female students and those 26–35 years old having higher levels of confidence. Students enrolled in a direct entry programme were more confident than other students in all three domains of care related to the first and second stage of labour. Conclusions Direct entry was found to result in higher confidence for midwifery students than post nursing programmes or integrated programmes. Further research is needed for evaluation of competence.

A Public Health Ethics Analysis of the Criminalization of Direct Entry Midwifery.

Multiple types of midwives practice in the United States, but regulation of midwifery practice varies by state. In some states, direct entry midwifery practice is unregulated or criminalized. Because regulations are the most burdensome of the public health interventions, they require the most stringent ethical critique. This article uses the most recent Public Health Code of Ethics to analyze the ethics of regulations that criminalize direct entry midwifery practice. The Code establishes 8 criteria for ethical actions: (1) permissibility, (2) respect, (3) reciprocity, (4) effectiveness, (5) responsible use of scarce resources, (6) proportionality, (7) accountability and transparency, and (8) public participation. Laws that criminalize direct entry midwifery practice violate all of these criteria and therefore cannot be considered an ethical approach to the state's duty to safeguard public health. The remedy for this problem is for all states to license and regulate all types of midwives that meet international standards of education and training.

Learning about midwifery in another country from a distance: Evaluation of a virtual classroom learning session

BackgroundStudying abroad promotes cultural awareness and understanding of different healthcare settings and practices but family or financial constraints prevent some students from taking advantage of these opportunities. We developed a virtual classroom learning session to give Danish and Irish midwifery students an opportunity to explore midwifery and maternity care in another country. ObjectivesTo evaluate the content of midwifery students' chat room discussions about the differences in maternity and midwifery care during an international online learning session, and their opinions of the session. Participants27 Danish and 37 Irish undergraduate direct entry midwifery students. MethodsContent analysis of students' chat room discussions and post-session survey. FindingsStudents engaged enthusiastically in the chat room discussions throughout the session. Almost all of the interactivity was between students themselves, and questions raised by students from one country were answered by students in the other country. Discussions centred on the lecture content, rates of interventions and birth outcomes, but developed into broader issues relating to one-to-one midwifery care during labour, factors that facilitate normal birth, national data availability, staffing levels, and financial and cultural aspects of having children at earlier or later ages.In the survey, students described the session as awakening curiosity and a fun way to learn. They found it ‘cool’ to talk with real students from another country, a memorable way of discussing differences between the two maternity care systems and expanding knowledge. Negative comments related to technological problems. ConclusionAn international virtual classroom learning session can give midwifery students insights into midwifery elsewhere, stimulate curiosity and be an engaging way to learn. Our students' experiences show that it can offer a real, engaging and positive learning experience and enrich students' knowledge of cultural differences.

Millennium development Goal 5: progress and challenges in reducing maternal deaths in Ghana.

BackgroundHigh maternal deaths in developing countries are recognised as a public health issue. To address this concern, targets were set as part of the Millennium Development Goals, launched in 2000 by the United Nations General Assembly. However, despite focused efforts, the maternal health targets in developing regions may not be achieved by 2015.DiscussionWe highlight progress and challenges in reducing maternal deaths, with a particular focus on Ghana. We discuss key issues like the free maternal healthcare package, transportation and referral concerns, human resources challenges, as well as the introduction of direct-entry midwifery training and the Community-based Health and Planning Services rolled out to specifically help curb poor maternal health outcomes.SummaryA key contribution to the country’s slow progress towards achieving Millennium Development Goal 5 is that policy choices have often been in response to emergency or advancing problems rather than the use of preventive measures. Ghana can benefit greatly from long-term preventive strategies, the development of human resources, infrastructure and community health education.

Midwifery education in Ireland – The quest for modernity

Midwifery education in Ireland has undergone significant changes in recent years including the introduction of direct entry midwifery programmes and a transfer of education to the university sector. While this has provided increased educational opportunities for midwives, the challenge for midwife educators is to prepare students for the increasing complexities of maternity care with a focus on obstetric risk and maternal morbidities with the need to educate midwifery students to support normality and provide woman centred care. The Nursing and Midwifery Board of Ireland has recently produced new Standards and Requirements for midwifery education and Practice Standards for midwives. This article provides information on midwifery education in Ireland and the documents that support the development of the profession.

Impact of perinatal mental health education on student midwives' knowledge, skills and attitudes: A pre/post evaluation of a module of study

Whilst midwives are well-placed to identify and address the mental health need of women in their care, many report lacking the ability to do so. Therefore, they ignore or brush aside women's mental health needs. To improve midwives' competency in this area, the first authors developed and delivered a module on perinatal mental health issues within their university. The module aimed to improve knowledge, skills, and attitudes in relation to working with women about mental health issues. In 2012, a post-survey evaluation of the module demonstrated positive findings; following a number of revisions to the module, this more robust pre/post evaluation was conducted. The objective of this study was to examine the impact of the perinatal mental health module on student midwives' knowledge, skills, and attitudes in addressing mental health issues with women. Design Pre-module and Post-module Surveys were Used. Participants were students undertaking a 4-year undergraduate direct entry midwifery degree programme in Ireland. The pre-survey had 28 participants, the post-survey had 26 participants, and there were 25 matched pairs. The data were analysed using SPSS Version 21.0. Descriptive, frequencies and paired sample t-tests were calculated. Qualitative data were analysed thematically. Comparison of the pre and post measures, based on paired samples t-tests, showed that the programme statistically increased participants' knowledge and skills. Whilst students' self-reported attitudes towards women and mental health issues were already quite positive, they reported even more positive attitudes following the course. Written feedback provided by students also supported these positive findings. This evaluation provides evidence that a module on perinatal mental health is effective at improving the self-reported knowledge, skills, and attitudes of student midwives towards women with mental health issues. It is recommended that educators consider the opportunity of including a similar module in their curriculum.

Indiana's Midwifery Statute and the Legal Barriers That Will Render It Unworkable

INTRODUCTION The State of Indiana recently legalized certified direct entry midwifery. Surely the new law, championed as a “huge step forward for families in Indiana” and the product of decades of lobbying efforts, would not merely maintain the status quo. Surely the new law, aimed to bring together two historically disparate groups, would not promote a greater resentment of one another. Surely the new law would not deprive Hoosier women of their United States Constitutional right to privacy or to the free exercise of their religion. Yet, the language of the new midwifery statute produces these results that surely no law should produce. Behind the portrayal of this law as a giant leap for midwife accessibility in Indiana, however, is the strong likelihood that very few aspiring midwives will be able to comply with the requirements needed to practice legally in the State of Indiana. Two provisions, in particular, will produce an unworkable statute: the

Introducing an obstetric emergency training strategy into a simulated environment

Midwifery educators are challenged to produce registrants who are fit for practice at the point of registration with competence at the heart of this expectation. In addition to achieving expertise in normal pregnancy, it is recognised that students need to have the skills of critical decision making where normal processes become adversely affected. An evaluation was undertaken with final year direct entry midwifery students using questionnaires and focus group interviews to determine whether simulated learning, such as the Practical Obstetric Multi-Professional Training (PROMPT) package, for emergency obstetric training would enhance self-efficacy and confidence levels in preparation for post-registration practice. The main themes that emerged from the study indicate that this style of learning increased midwifery students’ feelings of self-efficacy; highlighted the importance of a safe learning environment; reduced their anxiety regarding their ability to make decisions in clinical practice and reinforced confidence in their level of knowledge.

Marketplace Insertion and Professional Practice of Direct-Entry Midwives in Brazil: A Descriptive Study

Background: One of the strategies that need to be adopted in Brazil is to train and insert a large number of qualified midwives into the job market in order to promote improvements in indicators related to maternal and perinatal health and the model of care. Considering the recent training of midwives and the lack of studies on their absorption into the healthcare system, this study had the objective of verifying the socioeconomic and demographic characteristics of midwives that graduated in 2008 and 2009 from the Direct-Entry Midwifery Program of the University of São Paulo, characterizing and analyzing their academic and professional trajectory, insertion into the job market, and professional practice in midwifery. Method: From November 2012 to March 2013, a descriptive and quantitative investigation was carried out with a population composed of 82 midwives, 41 of them who graduated in 2008 and 41 in 2009. Data were obtained by means of an on-line questionnaire applied electronically and composed of open-ended and closed-ended questions relative to the socioeconomic and demographic identification of the midwives, their academic and professional trajectory, their insertion into the job market, and professional practice in midwifery. Results: Of the total number of former students, 70.7% agreed to participate in the study and answered the questionnaire. Of this sample, 58.6% fit into the age bracket of 23 to 27 years, 70.7% were single, 96.6% were female, 63.8% lived in the city of São Paulo, 65.5% participated in extracurricular activities during their training, 43.1% participated in specialization or refresher courses after graduating, 51.7% participated in scientific events, 22.4% produced scientific studies, and 19% published in scientific journals. Only 34.5% indicated working or having worked as a midwife. Conclusions: The results allow the conclusion that, despite the effort to improve their academic and professional trajectory, the first midwives, who graduated in 2008 and 2009, faced great difficulties in getting into a healthcare market which needs skilled human resources and is resistant to the incorporation of new professionals and models of care.

What is the Academic Consortium for Complementary and Alternative Health Care (ACCAHC)?

The Academic Consortium for Complementary and Alternative Health Care (ACCAHC) is a multidisciplinary, collaborative not-for-profit charitable organization created to improve patient care. This mission is accomplished through fostering mutual respect and understanding between various disciplines and emerging fields, mainly through interprofessional education, engagement in key policy initiatives, and the promotion of whole-person research. There are five core disciplines involved in ACCAHC (acupuncture and Oriental medicine, chiropractic, direct-entry midwifery, naturopathic medicine, and massage therapy), and three emerging fields (Ayurveda, homeopathy, and Yoga therapy). Membership seats are held by the council of colleges, plus the accrediting and certifying agencies of these disciplines. Other members are emerging CAM professions who are striving to meet regulatory standards in the United States. Why Is ACCAHC Necessary? The structure of health care in the United States is changing. Based on recent statistics, four out of ten Americans utilized some form of complementary and alternative medicine (CAM) within the past 12 months(1). According to the Bravewell Collaborative(2), “Over the past two decades, there has been documented growth in the number of clinical centers providing integrative medicine, the number of medical schools teaching integrative strategies, the number of researchers studying integrative interventions, and the number of patients seeking integrative care.” With such extensive growth, integration of CAM and conventional health care is imperative. ACCAHC is an organization dedicated to the optimal integration of CAM practitioners and professions into mainstream medicine. Such collaboration among the CAM disciplines and emerging fields strengthens and unifies this effort.

Midwifery students' perceived independence within the core competencies expected of the midwifery community upon graduation: an Italian study

The general aim of this article is to describe the independence perceived by midwifery students who are due to qualify with regard to core competencies that are considered essential by the community of professional midwives working in Italian healthcare hospitals. A multi-method research project was undertaken. One hundred sixty-seven midwives working in 11 regional facilities were approached with the aim of selecting the core competencies expected by graduands. In the same region, all graduands (24) educated at two universities were involved in the study aiming to discover the level of the independence (from 0 none to 10 maximum) perceived in each core competence selected by the midwives. The average score obtained by graduands in the questionnaire containing 102 core competencies was 717.4 (standard deviation 130.3, median 743). The minimum score was 363 and the highest was 916. Assuming the minimum cut-off at 612 points, five students (20.8%) had a perceived level of independence below sufficiency. Italian midwifery education has been reformed five times since 1940. The reduction in the length of the direct entry midwifery programme as introduced in the latest Italian national reform, and the higher standard of education requested also by European Directives, cause an increasing number of students to prefer to extend their course duration and postpone graduation until they feel independent. Any change in curriculum should consider the impact in the short, medium and long terms. For this reason, each new policy should consider carefully the point of view of experts in the disciplines, such as midwifery, with the objective of protecting and developing their competence in taking care of women, newborns and their families.

Great expectations: Legitimacy and emotions among out of hospital midwives

In this article we examine the process by which a group of marginal health-care professionals portray the legitimacy of their skills and services to potential clients. While extensive attention has been devoted to this construal of legitimacy through such affinitive alignments, much less attention has been given to elucidating the factors shaping how marginal social groups construct alternative professional legitimacy frameworks with which to contest dominant competitors. Drawing on qualitative content analysis of direct entry midwives’ (DEMs) online descriptions of their practices and in-depth interviews, we explain how DEMs construe professional legitimacy through alternative cultural understandings of maternity care and experience. Our study highlights three key components of DEMs’ professional legitimation: midwives’ alignment with professional associations and scientific research, the creation of new understandings of care relationships and space, and the role of emotions in defining the optimal birth experience. We argue that the positive emotions associated with direct entry midwifery care become critical mechanisms for redefining both professionalism and the experience of birth within the boundaries of alternative practice.

Reclaiming direct-entry midwifery training in Brazil: context, challenges and perspectives

Reclaiming direct-entry midwifery training in Brazil: context, challenges and perspectives Nadia Zanon Narchi, PhD in Nursing (Midwife, Professor), Lucia Cristina Florentino Pereira da Silva, PhD (Midwife, Professor), Dulce Maria Rosa Gualda, PhD (Midwife, Professor), Maria Helena Bastos, MSc, PhD (Visiting Research Associate) a School of Arts, Sciences and Humanities, University of S ~ ao Paulo (EACH-USP), Av. Arlindo Bettio, 1000—Ermelino Matarazzo, 03828-000 S ~ ao Paulo, S ~ ao Paulo, Brazil b Nursing School of University of S ~ ao Paulo, Av. Dr. Eneas de Carvalho Aguiar, 419—Cerqueira Cesar, 054470-300, S ~ ao Paulo, S ~ ao Paulo, Brazil c Florence Nightingale School of Nursing and Midwifery, King’s College London, 57 Waterloo Road, London SE1 8WA, UK

Informing Evidence: Claimsmaking in Midwives’ and Clients’ Talk About Interventions

Communication for informed choice is particularly challenging in clinical settings such as direct-entry midwifery, where the care model embraces diverse therapies and forms of knowledge. We identified three discursive moves (explanation, invocation, and evaluation) that Ontario midwives and clients used in making claims about proposed interventions. The analysis was informed by an understanding of communication as an interactionally situated and socially constructed interpretive practice. Both midwives and women called on the authority of biomedical discourse, but they also turned to sources such as women's wisdom to support their cases. The flexible use of these moves afforded participants considerable latitude in accepting or rejecting forms of evidence as authoritative. However, strategies designed to empower clients in making choices could unintentionally serve to enhance the authority of the care provider. Talk about interventions brings into view both the knowledge systems and the broader relations within which regulated midwifery practice operates.

Mainstreaming Midwives: The Politics of Change (review)

Reviewed by: Mainstreaming Midwives: The Politics of Change Susan L. Smith Robbie Davis-Floyd and Christine Barbara Johnson, eds. Mainstreaming Midwives: The Politics of Change. New York: Routledge, 2006. x + 557 pp. Ill. $85.00, £70.00 (cloth, ISBN-10: 0-415-93150-9; ISBN-13: 978-0-415-93150-2); $31.95, £15.99 (paperbound: ISBN-10: 0-415-93151-7; ISBN-13: 978-0-415-93151-9). In Mainstreaming Midwives, anthropologist Robbie Davis-Floyd and sociologist Christine Barbara Johnson document the developments in midwifery in the United States from the 1970s to the present. The book covers the struggles and successes of lay midwives who sought to create an independent profession of midwifery, known since the 1990s as "direct-entry midwifery." Historians of twentieth-century midwifery often end their investigations at mid-century, when midwifery declined among such groups as Japanese Americans and African Americans. In this exhaustive collection of case studies and recent histories, the authors present the latest phase in the long history of American midwifery, this time among predominantly middle-class, white women. The collection is strongly influenced by the birth activism and scholarship of Davis-Floyd, a medical anthropologist at the University of Texas, Austin: not only did she write or cowrite six of the thirteen chapters, but the other contributors make references to her encouragement and insights. The authors, mostly midwives and/or social scientists, frequently refer to the political motivations for their research, identifying their approach by such terms as "activist anthropology" (p. 314). These ethnographic studies of grassroots midwifery are built on dozens, even hundreds, of interviews with the various players. [End Page 234] The book's overall argument is that the efforts to legalize and professionalize midwifery through political activism, litigation, and legislation came at a price. The midwifery renaissance, the authors convincingly demonstrate, entailed competing cultures of midwifery. In particular, competition between nurse-midwives and lay midwives grew, and disagreements erupted among members within each group. Distinctions and power inequalities between nurse-midwives and lay midwives have a long history, as Laura Ettinger showed in Nurse-Midwifery: The Birth of a New American Profession (2006). The goal of the editors, therefore, is to provide a better understanding of the different perspectives and to urge collaboration and unity in the interest of midwife survival. The book is divided into three parts that fit together nicely to reveal the hotly contested, multiple meanings of midwifery. Part 1 provides discussion of the two major national midwife organizations, the American College of Nurse-Midwives and the Midwives' Alliance of North America, and their creation of direct-entry midwife options. Nurse-midwives, who increasingly sought independence from nursing, nonetheless were dismayed by lay midwives' disregard for formal midwifery educational requirements and hospital training. Lay midwives, who struggled to retain the home as the site for birth and apprenticeship as a method of midwife training, were offended by efforts to turn midwives into university-trained practitioners. Part 2 details midwife activism and the legislative battles with state medical organizations and nursing organizations in Florida, Minnesota, Colorado, Virginia, Iowa, and Massachusetts. Part 3 explores key issues in moving midwifery into the mainstream, including the presence of "renegade midwives." Overall, this is a fascinating book, although I take issue with a few assertions. First, Davis-Floyd labels this latest population of birth attendants "postmodern midwives" in order to highlight their differences from previous midwives who served various ethnic communities. She argues that postmodern midwives are "educated, articulate, organized, political, and highly conscious of their cultural uniqueness and importance" (p. 4)—yet, many of the Japanese American midwives who practiced along the American west coast and in Hawaii in the first half of the twentieth century also fit this description. Second, drawing on the case of Ontario, Davis-Floyd asserts that American midwives should follow the Canadian model of unified midwifery in which "all midwives can practice at home or in hospital and can offer the full range from low- to high-tech birth" (p. 65)—but this is simply not an accurate description of the situation for midwives in many Canadian provinces, including my own. Still, this book is a significant resource for scholars interested in American...

‘Inductions of labour’: on becoming an experienced midwifery practitioner in Aotearoa/New Zealand

This paper analyzes and explores varying discourses within the talk of new practitioner direct entry (DE) midwives in Aotearoa/New Zealand. In Aotearoa/New Zealand, midwifery is theorized as a feminist profession undertaken in partnership with women. Direct entry midwifery education is similarly based on partnerships between educators and students in the form of liberatory pedagogies. The context for the analysis is a large ethnographic study undertaken with a variety of differently positioned midwives based mainly in one city in New Zealand. I interviewed and observed over 40 midwives in their different practice settings in 2003. Complex and contesting forms of knowledge production are analyzed in this paper drawing on methodological insights from Foucauldian discourse analysis. New practitioners engage in techniques of self-monitoring and surveillance as they move towards becoming established practitioners. New midwifery subjectivities and forms of knowledge production which contest authoritative forms of knowledge are produced. Midwives in New Zealand are seen to inhabit a complex and liminal space of midwifery praxis. Paradoxically, they are exhorted to remain the 'guardians of normal birth' in a time of increasing interventions into birth both locally and internationally. Paradoxes encountered by new midwifery practitioners in New Zealand as they struggle to maintain ideals of 'normal' birth may be paralleled by the constraints inadvertently produced through governing discourses of emancipatory or liberatory pedagogies. The relevance of this is also highly critical for midwifery and birth practices internationally.

‘With woman’ philosophy: examining the evidence, answering the questions

'With woman', 'woman centred' and 'in partnership with women' are new terms associated with midwifery care in Australia, and the underlying philosophy has emerged both as an antidote to the medicalisation of pregnancy and in a bid to reacquaint women with their natural capacity to give birth successfully and without intervention. A reorientation of midwifery services in the 1990s, a shift towards midwifery-led care (MLC) and the subsequent introduction of direct entry midwifery programs all contributed to this new direction. Central concepts are a focus on the childbearing woman and a valuing of women's experiences. While this philosophical re-alignment has been applauded by many midwives in terms of maternal empowerment and improved autonomy for midwives, there are nonetheless some concerns that, with its emphasis on normality, midwifery-led care is in danger of becoming an exclusionary model. Particular concerns include meeting the needs of a growing cohort of women, those with 'high risk' pregnancies, and the educational adequacy of direct entry midwifery programs. To date, there has been no thorough evaluation of this emerging midwifery philosophy in Australia. In order to open the debate, this paper aims to initiate a discussion of 'with woman' midwifery care as it applies to Australian practice.