Perhaps it's time for the Knesset to strengthen midwifery as an autonomous profession.
By GOMER BEN-MOSHE, MICHELE KLEINpregnant 88(photo credit: )
'Yael' was healthy and her second pregnancy had progressed normally. She already had a little girl and wanted to give birth at home in her small house in the North. She contacted a midwife during her pregnancy and they planned a home delivery.
"I was called out in the middle of a summer night," recalls the midwife. "Candles were burning all around the house, giving an atmosphere of holiness. The little girl was fast asleep upstairs. In the middle of the room, the birthing woman shifted about in an inflated swimming pool, full of water, moaning in pain. Then suddenly she began to push and the baby slipped out naturally and simply into the water. With a little help, she lifted the baby above the water and put it to her breast. In echo to her intense cry at the moment of delivery, her husband and the second midwife helping called out joyously 'Mazel tov, Baruch Hashem!' It was an amazing experience, so different from a hospital birth!"
This midwife is one of 15 who currently assist home births in Israel, although about 700 of the country's 1,200 midwives work in hospital delivery rooms.
At the end of July, the Knesset Committee on the Status of Women held a discussion on childbirth and midwifery. The main issue of debate was the postnatal financial bonus that the National Insurance Institute (NII) gives a new mother - but only if she has given birth in hospital. A woman like Yael, who chooses to give birth at home, can only qualify for the bonus if she hospitalizes herself within 24 hours after her delivery. The women's lobby demanded that a home delivery not disqualify any new mother from the postnatal bonus.
Another issue discussed in the Knesset that day was the midwives' demand to keep their independent license, as stipulated in the Midwives Act of 1929, which demands that all midwives be trained and registered. New legislation pertaining to the nursing profession would have annulled the law, and midwives are concerned that this would lower the level of care for birthing women. Currently, Israel has a low maternal and infant mortality rate - comparable to that of Holland, Britain, Australia and New Zealand, where midwives are also licensed and are the main caregivers to pregnant women - even though Israel's birth rate is higher than most other industrialized countries. What are the local "wise women" doing to maintain the high level of care, both in and out of hospital delivery rooms?
The Hebrew word meyaledet goes back to the specialized birth helpers in the Bible. The Mishnaic word hachama ("wise woman") implies that the midwife had greater knowledge and skill than other women. Her authority was such that she could charge for her services and rabbis accepted her testimony in court. The medieval French term for the midwife sage femme also means "wise woman" - one whose role is to assist women through the entire birthing process and also pass on to the next generation her special wisdom about birthing, death, sexuality and health. The medieval English word midwife, derived from "with woman," has a second meaning; "to midwife" is to assist in bringing about a new result. Many Israeli midwives have done just that - teaching and counseling women, innovating change, and a few have built a constructive partnership with their Palestinian counterparts.
Most midwives in Israel assist women in the hospital delivery room, where they share the care of birthing women with obstetricians. But one can also find a midwife helping women in the postnatal, gynecological, preemie and neonatal wards, as well as in community health centers and in the private sector. And one can meet Israeli midwives at international conferences, where they share their wisdom and learn from others.
Israeli midwives are qualified nurses who have spent an extra year specializing in midwifery and passed a national licensing exam. They learn the profession in nursing school as well as through hands-on practice in the delivery room. Their apprenticeship takes place with the agreement of the birthing woman and under the supervision of an experienced midwifery teacher.
Badaya Mussa, a young woman with a Master's in nursing, earned her midwifery license a few months ago. She recalls one birth during her training: "The woman didn't want me to deliver her baby because I was still a student midwife. I respected her wish and stood by her head as she labored. I supported her, explained [things] to her, and guided her throughout the birth while a qualified midwife caught her baby, just as she had asked. I believe that labor takes place naturally, and most of the midwife's job is to give the woman emotional support and guidance. That's what I did."After the birth I went to visit her in the postnatal ward. She told me that, from her point of view, I was her midwife."
"My view of midwifery starts with a broad look at the whole field of women's health," says Dr. Pnina Mor, PhD, who has been a midwife for 32 years at Shaare Zedek Hospital and wrote her doctorate in nursing on her research on genetic predisposition to breast and ovarian cancers. Mor set up and runs a clinic for healthy women who carry the gene associated with breast cancer, in addition to her supervision of trainee midwives in her ward.
"Midwives shouldn't be confined to the delivery room. A midwife has to know all about female health and about care. I build a relationship with the women I work with; they trust me and open up in many different ways. They may tell me about problems in their family or health complications; the fact that I'm a midwife doesn't limit my job to delivering babies."
Midwives see pregnancy, labor and delivery as part of one process. They can help expecting parents prepare for childbirth through classes or meetings. They stress the benefits of early communication between a pregnant woman and the medical team that oversees this process. Such preparatory work helps birthing women make informed choices about where to give birth, pain relief, and medical interventions. Some encourage natural methods of relaxation, such as the mother immersing in water, mobility and positioning, and a few have extra training in non-pharmaceutical relaxation techniques like shiatsu massage or reflexology.
Midwives teach childbirth education classes at clinics run by the country's four health funds, women's health centers, and privately. Ziva Garciani, who works in the delivery room at Nahariya Government Hospital, opened an enrichment center with another colleague. In addition to her course on childbirth education for pregnant couples, she also conceived and teaches a first aid course for new parents. This way, she has more contact with women in her community while supporting and empowering them.
"It's easy and tempting to go to work and come back and rest, but I always need more than just my formal work. Some years back I studied after work, now I teach. I gain a lot from this. Not financially, but in other ways," Garciani says.
Leslie Wolff, who worked for many years in the delivery room of Bnai Zion Rothschild hospital in Haifa and helped introduce a natural birthing facility there, now works in the same hospital as a breast-feeding adviser, teaching nurses and new mothers about this natural but sometimes difficult task. She is also striving to introduce "kangaroo care," skin-to-skin contact in the first two hours after delivery, an infant care project that encourages mother-baby bonding.
Midwives enjoy the special blessing of hearing the first cry of a healthy newborn and sharing the new parents' thankfulness and relief that their baby has arrived safely.
But occasionally, there's also tragedy and sadness in the delivery room. Midwife Gomer Ben-Moshe has a friend whose first pregnancy, some 40 years ago, ended in a stillbirth. The woman never saw the baby boy and still cries when she thinks of him. After hearing of a multi-disciplinary advisory committee at Soroka Hospital in Beersheba designed to help people in such situations, Ben-Moshe introduced a similar system at Nahariya Hospital. "Because the bereaved couple is in terrible shock at first, we invite them to return to our clinic several weeks after the tragedy to listen to them and try to answer their questions about what happened. The doctors, midwife, public health nurse and social worker all work together to help the couple through their difficult emotions. It's wrong to think that if we don't talk about it, the emotions will disappear. Pregnancy loss is a terrible blow and we have to make time in our work to assist with this difficulty."
Two of Israel's hospitals (Sheba Medical Center at Tel Hashomer and Laniado Hospital in Netanya) have midwifery-run birthing centers that allow natural birth for healthy, low-risk women who have already discussed this option with midwives. Up North near Tiberias, in the vicinity of Poriya Hospital, two enterprising midwives, Ruthy Tzur and Rosi Arazi, run their own home-like, private birth clinic. Naomi Noeh, an experienced midwife who is also qualified in shiatsu massage, offers a quiet and natural birthing environment in Kabri, not far from Nahariya Hospital. These women, and a dozen other midwives who work outside the hospital, maintain a good relationship with the closest hospital delivery room for the rare emergency cases.
For the 500 women a year who choose home birth, the Knesset committee's conclusion that the NII birth bonus should no longer depend on location, came as happy news. This promotes freedom of choice for birthing women. While many midwives have extended their work in imaginative and fulfilling ways beyond the delivery room, the majority of midwives are working hospital shifts. Perhaps it is time for the Knesset to strengthen midwifery as an autonomous profession, and support the ability of these "wise women" to take care of all healthy pregnant women throughout the birth process and afterward. For many expecting couples, this is the correct, safest and most cost effective choice - for their babies as well as for the state.
Between her shifts as a midwife at Nahariya Hospital, Ben-Moshe helped to build a Web site for the Israel Midwives Association. As most of the midwifery literature available is in English and few midwives have time to access professional journals, Ben-Moshe and her team have translated key articles and built an online Hebrew resource. "In our profession, it's vital to keep up-to-date," she says. "We translated many important articles and we also let midwives ask for what they wanted to read on the Web site and added all that, too. It was fascinating. It put me in touch with people all over the world."
Gomer Ben-Moshe is a licensed independent midwife with a Master's degree in Women's Studies. Dr. Michele Klein is the author of A Time to Be Born: Customs and Folklore of Jewish Birth.
if(catID != 151){
var cont = `Take Israel home with the new Jerusalem Post Store
