English for Specific Purpose (ESP)

1.    How to learn English for Specific Purpose (ESP) !

How is English for Specific Purposes (ESP) different from English as a Second Language (ESL), also known as general English?

The most important difference lies in the learners and their purposes for learning English. ESP students are usually adults who already have some acquaintance with English and are learning the language in order to communicate a set of professional skills and to perform particular job-related functions. An ESP program is therefore built on an assessment of purposes and needs and the functions for which English is required .

ESP concentrates more on language in context than on teaching grammar and language structures. It covers subjects varying from accounting or computer science to tourism and business management. The ESP focal point is that English is not taught as a subject separated from the students' real world (or wishes); instead, it is integrated into a subject matter area important to the learners.

However, ESL and ESP diverge not only in the nature of the learner, but also in the aim of instruction. In fact, as a general rule, while in ESL all four language skills; listening, reading, speaking, and writing, are stressed equally, in ESP it is a needs analysis that determines which language skills are most needed by the students, and the syllabus is designed accordingly. An ESP program, might, for example, emphasize the development of reading skills in students who are preparing for graduate work in business administration; or it might promote the development of spoken skills in students who are studying English in order to become tourist guides.

As a matter of fact, ESP combines subject matter and English language teaching. Such a combination is highly motivating because students are able to apply what they learn in their English classes to their main field of study, whether it be accounting, business management, economics, computer science or tourism. Being able to use the vocabulary and structures that they learn in a meaningful context reinforces what is taught and increases their motivation.

The students' abilities in their subject-matter fields, in turn, improve their ability to acquire English. Subject-matter knowledge gives them the context they need to understand the English of the classroom. In the ESP class, students are shown how the subject-matter content is expressed in English. The teacher can make the most of the students' knowledge of the subject matter, thus helping them learn English faster.

The term "specific" in ESP refers to the specific purpose for learning English. Students approach the study of English through a field that is already known and relevant to them. This means that they are able to use what they learn in the ESP classroom right away in their work and studies. The ESP approach enhances the relevance of what the students are learning and enables them to use the English they know to learn even more English, since their interest in their field will motivate them to interact with speakers and texts.

ESP assesses needs and integrates motivation, subject matter and content for the teaching of relevant skills.

    The responsibility of the teacher

A teacher that already has experience in teaching English as a Second Language (ESL), can exploit her background in language teaching. She should recognize the ways in which her teaching skills can be adapted for the teaching of English for Specific Purposes. Moreover, she will need to look for content specialists for help in designing appropriate lessons in the subject matter field she is teaching.

As an ESP teacher, you must play many roles. You may be asked to organize courses, to set learning objectives, to establish a positive learning environment in the classroom, and to evaluate student s progress.

    Organizing Courses

You have to set learning goals and then transform them into an instructional program with the timing of activities. One of your main tasks will be selecting, designing and organizing course materials, supporting the students in their efforts, and providing them with feedback on their progress.

    Setting Goals and Objectives

You arrange the conditions for learning in the classroom and set long-term goals and short-term objectives for students achievement. Your knowledge of students' potential is central in designing a syllabus with realistic goals that takes into account the students' concern in the learning situation.

    Creating a Learning Environment

Your skills for communication and mediation create the classroom atmosphere. Students acquire language when they have opportunities to use the language in interaction with other speakers. Being their teacher, you may be the only English speaking person available to students, and although your time with any of them is limited, you can structure effective communication skills in the classroom. In order to do so, in your interactions with students try to listen carefully to what they are saying and give your understanding or misunderstanding back at them through your replies. Good language learners are also great risk-takers , since they must make many errors in order to succeed: however, in ESP classes, they are handicapped because they are unable to use their native language competence to present themselves as well-informed adults. That s why the teacher should create an atmosphere in the language classroom which supports the students. Learners must be self-confident in order to communicate, and you have the responsibility to help build the learner's confidence.

    Evaluating Students

The teacher is a resource that helps students identify their language learning problems and find solutions to them, find out the skills they need to focus on, and take responsibility for making choices which determine what and how to learn. You will serve as a source of information to the students about how they are progressing in their language learning.

    The responsibility of the student

What is the role of the learner and what is the task he/she faces? The learners come to the ESP class with a specific interest for learning, subject matter knowledge, and well-built adult learning strategies. They are in charge of developing English language skills to reflect their native-language knowledge and skills.

    Interest for Learning

People learn languages when they have opportunities to understand and work with language in a context that they comprehend and find interesting. In this view, ESP is a powerful means for such opportunities. Students will acquire English as they work with materials which they find interesting and relevant and which they can use in their professional work or further studies. The more learners pay attention to the meaning of the language they hear or read, the more they are successful; the more they have to focus on the linguistic input or isolated language structures, the less they are motivated to attend their classes.

The ESP student is particularly well disposed to focus on meaning in the subject-matter field. In ESP, English should be presented not as a subject to be learned in isolation from real use, nor as a mechanical skill or habit to be developed. On the contrary, English should be presented in authentic contexts to make the learners acquainted with the particular ways in which the language is used in functions that they will need to perform in their fields of specialty or jobs.

    Subject-Content Knowledge

Learners in the ESP classes are generally aware of the purposes for which they will need to use English. Having already oriented their education toward a specific field, they see their English training as complementing this orientation. Knowledge of the subject area enables the students to identify a real context for the vocabulary and structures of the ESP classroom. In such way, the learners can take advantage of what they already know about the subject matter to learn English.

    Learning Strategies

Adults must work harder than children in order to learn a new language, but the learning skills they bring to the task permit them to learn faster and more efficiently. The skills they have already developed in using their native languages will make learning English easier. Although you will be working with students whose English will probably be quite limited, the language learning abilities of the adult in the ESP classroom are potentially immense. Educated adults are continually learning new language behaviour in their native languages, since language learning continues naturally throughout our lives. They are constantly expanding vocabulary, becoming more fluent in their fields, and adjusting their linguistic behaviour to new situations or new roles. ESP students can exploit these innate competencies in learning English.

2.    How to get self progress in English for Midwives !

    Rebirth of a career

When writing down their choices of vocation, few people today opt

 for midwifery, resulting in the fact that we now have a large number of uneducated and incompetent midwives.  Wikipedia

 defines midwifery as a healthcare profession, where experts provide prenatal café to expecting mothers attend to the birth of the infant, and provide postpartum care to the mother and her child.  Practitioners of this profession are known as midwives, a term used for both men and women.

Unfortunately, in Pakistan, midwives do not enjoy the same or even similar status that other professionals related to the field of healthcare do.

Midwifery as a profession is not understood in Pakistan.  A professional midwife is equated with a daai (the illiterate woman who delivers 80 per cent of babies in Pakistan).  And because of this ignorance, midwives in Pakistan do not enjoy the prestige awarded to them in the developed countries like Europe where 80 per cent of the babies are delivered by professional midwives.

    Required Qualification

In Pakistan those who want to pursuer a career in midwifery are required to complete their matriculation and should be under 35 years of age,

    The criterion of becoming a practitioner in midwifery

Those interested in the profession can apply to any of the 120 plus institutes offering midwifery training and which are both in the public and the private sector.  In fact, there are more schools of midwifery in Pakistan than schools of nursing

Besides this every school of nursing has a school of midwifery, and every female nursing has a school of midwifery, and every female nurse is required to complete additional one year midwifery training besides a three year nursing course.  This one-year training is compulsory, since without it, a nurse cannot get a promotion.

But very few nurse midwives practised midwifery once they enter the practical field.  In the end, midwifery is practised by those who are not nurses and some schools train only midwives who are not trained nurses.  There are three categories of non-nurse midwives; the lady health visitor, the pupil midwife and he community midwife. 

    Organization offered Training in Midwifery field

In Pakistan, major organizations that are providing proper midwifery training under the umbrella of nursing education are the Aga Khan University, Karachi; Dow Institute of Nursing Karachi, Pakistan Institute of Medical Sciences (PIMS), Islamabad,; Ziauddin University, Karachi;  the University of Health Sciences, Lahore;  Fauji Foundation, Rawalpindi, the National Institute of Child Health, Karachi and Liaquat National Hospital, Karachi. 

    Job opportunities

A midwife is not very popular due to the low status given to this profession, particularly by nurses.  In a country like Pakistan where birth rate is on the rise, one might think that a career in midwifery would be a profitable and this is true to some extent when it comes to setting up one’s own clinic.

Besides setting up their own clinic midwives also have various opportunities to work in public as well as private hospitals.  Some of the many hospitals where Pakistani nurse midwives are employed in the maternity departments include the Aga Khan hospital, karachi Sobhraj Maternity home, karachi, the National Institute of Child Health karachi, Dr Ziauddin Ahmed hospital karachi Liaquat National hospital, karachi Shifa International hospital Islamabad;  Medicare Hospital and maternity home, Kohat and Fauji Foundation hospital, Rawalpindi.

Not only does a midwife has scope for progress, but if she is a nurse with midwifery training, then there are plenty of opportunities to move up the ladder.  Unfortunately, the quality of present training does not allow or prepare midwives to function independently even at the national level.  Let alone at the international level. And even though, the nurse midwives do get jobs in a few other countries, they do not function as midwives there.

There was a time when midwives had no voice and no platform of their own.  But today, they have a professional organization and hopefully it will improve the situation of midwifery education and practice.

The bottom line is that a lot needs to be done to create awareness about the role and functions of a midwife at very high levels.  Only then will the career prospects and reputation of this profession gain a respectable status in our society. 

3.    What obstacles appear in learning ESP !

English for Specific Purposes (ESP) is a young and developing branch of EFL in Russia. As T. Nazarova (1996) shows, for many years ESP instruction was limited to training special lexicon and translating numerous texts. Of course, such methods did not reflect students' interests and resulted in low learner motivation and poor participation. With the spread of the student-centered approach in Russia and the continued increase of international contacts in various spheres, much attention has been paid to the design of ESP courses that can prepare students for professional communication. However, developing new courses along such lines raises the issue of training teachers. Designing a course that can best serve learners' interests and needs is an obstacle for many instructors. How can teachers develop a new course? Where should they start? What can be done about students' poor motivation? How should teaching materials be selected? These are some of the questions that are often asked by many teachers. Therefore, the purpose of this paper is to suggest a framework for an ESP course-development process that will help teachers with some of the problems they may come across in designing a new ESP course.

    Students' Analysis

It is very important to start the course-developing process with an analysis of the target group of students: many problems in L2 classes are a result of teachers not paying attention to learners' interests and ignoring students as a source of essential information. With the spread of communicative language teaching (CLT), much emphasis in second language (L2) methodology has been paid to the learner-oriented instruction. As a result, needs analysis has been given considerable attention in making a particular course serve a particular group's interests (Graves K., 1996; Harrison R., 1996; Hutchison T. & A. Waters, 1987; Vorobieva N., 1996). However, students can provide much more valuable information for teachers than an expression of their needs (Sysoyev P., 1999). Therefore, a better term than needs analysis might be students analysis.

Students' analysis can give two kinds of information. The first reflects learners' "possession" - their current level in their L2-ESP, field knowledge in L1 and/or L2, motivation, methods of learning they have experienced, etc. The second represents what learners want to achieve - what traditionally has been called "ESP needs".

Two kinds of information consequently correspond to two levels of knowledge presented in S. Krashen's Input Hypothesis (1985), also known as i + 1 Hypothesis. According to the study, i represents students' current level of L2 competence, and + 1 is a level of ESP proficiency beyond their present level.

Similar to S. Krashen's theory is L. Vygotsky's (1978) concept of the Zone of Proximal Development (ZPD) in which there are two main stages of an individual's development. The first stage is what a child or learner can do by himself. The second stage is his potential, what he can accomplish with the help of another, more competent person. The distance between two stages is called the ZPD. Vygotsky also introduced a notion of a mediator - a person who helps students achieve what they cannot do by themselves. In the teaching of ESP, the role of mediator will be placed on the teacher, who will start from students' current stage and bring them to the second stage of their needs.

There may be different ways of finding information about students needs and previous experience. At the university and high school levels, it can be done through various questionnaires, surveys, group discussions, individual talks, etc. For example, Business English students may be asked to list areas in which everyone foresees using ESP (for instance, selling insurance, opening bank accounts, dealing with foreign customers in currency exchange offices, translating business documents from English into Russian, etc.).

Even though very important, students' data should not be overused. Finding out this information does not mean that teachers should teach only what their students want. Of course, teaching cannot take place in isolation. There are certain things, such as curriculum, institutional guidelines, and standardization, that cannot and may not be ignored. However, in developing a new course, students' analysis will help teachers bring together the required and desired in formulating goals and objectives, conceptualizing the content of the course, selecting teaching materials, and course assessment, as we are going to examine in this paper.

    Formulation of Goals and Objectives of the Course

Formulating goals and objectives for a particular course allows the teacher to create a clear picture of what the course is going to be about. As K. Graves (1996) explains, goals are general statements or the final destination, the level students will need to achieve. Objectives express certain ways of achieving the goals. In other words, objectives are teachable chunks, which in their accumulation form the essence of the course. Clear understanding of goals and objectives will help teachers to be sure what material to teach, and when and how it should be taught. In his book D. Nunan (1988) gives a clear description of how one should state objectives. Depending on what is desired, objectives may sound like the following:

   Students will learn that ...

   Students will be aware of ...

   Students will develop ...

It is also important to state realistic and achievable goals and objectives.

    Conceptualizing the Content

Several years ago, ESP teaching in Russia was characterized by the structural approach. From year to year, different students with the same or similar majors had to use exactly the same textbooks and syllabuses. But all students are different and with the rapid development of the world, changes in students needs and interests are inevitable. Therefore, ideally, in establishing a learner-centered approach there should be a shift in L2 pedagogy in the selection of the content of the course. This shift should serve the learners' interests and needs.

Conceptualizing the content is not a context-free process. When taking into account information about the students, goals, and objectives, teachers need to determine which aspects of ESP learning will be included, emphasized, integrated, and used as a core of the course to address students' needs and expectations. There may be different ways of conceptualizing the content. Teachers can focus on developing "basic skills", communicative competence, intercultural competence, vocabulary awareness, etc. For example, an English for Academic Purposes (EAP) course for Russian high school students who are going to participate in a foreign exchange program can be conceptualized around L2 culture.

One of the goals of this course, for instance, is to achieve intercultural communicative competence. Students are developing language skills, but it is accomplished through the integration of the sociocultural component into the teaching various elements of the language.

It should also become clear that even though separated in structural charts, all skills and aspects of the language are interwoven in the real communication. Therefore, they should be treated, taught, and tested as one inseparable unit.

    Selecting and Developing ESP Materials

For many teachers, selection of teaching materials is based on their availability. Furthermore, chosen materials determine the content of the course. Quite often it serves as a justification and explanation of the use of the same syllabus with different students. In student-centered instruction, the appropriateness of materials includes student comfort and familiarity with the material, language level, interest, and relevance.

However, in some situations teachers are dependent on the materials and are required to use the same textbook over and over again. Potentially there is nothing bad in using the same teaching materials, if everything is conceptualized through a learner-centered approach. The same article or audio story can be used for developing reading or listening comprehension skills, cultural awareness, expanding vocabulary, etc. Thus, as K. Graves points out, teaching materials are "tools that can be figuratively cut up into component pieces and then rearranged to suite the needs, abilities, and interests of the students in the course (Graves K., 1996: 27).

    Course Planning

After formulating major objectives and choosing teaching material, many teachers start planning a new course. There may be different ways of organizing activities. In CLT the following pattern is traditionally used: "pre-activity ? activity ? follow up". Teachers start with what students already know or with a fairly simple task, and then pass to more complex activities. Another approach to "recycling" materials has recently become quite popular. Students learn information about the L2 country and then recycle it in the activity about the L1 country. In this way, the "Dialogue of Cultures" principle is achieved. It is recommended that teachers be flexible in course planning, i.e. that they be ready adjust the syllabus and make slight changes in the course while teaching, so that they can best address students interests and needs.

    Evaluating the Course

Course evaluation is the last, but not the least, important stage. Teachers should evaluate their courses to improve and promote their effectiveness. Evaluation can be done in two different ways: implicitly and explicitly. Implicit evaluation takes place during the semester, when learners, by their grades, participation, and motivation, give clues to the teacher on how their learning is going on. Explicit evaluation may take place at the end of the course or after students have experienced it. Using questionnaires, surveys, talks, etc. teachers ask the students to express their attitude towards the subject matter, instructional methods, activities, teacher's role and so on. Evaluation of the course is a brave step for the teacher. He should be open-minded in hearing and implementing learners' comments.

    Round Up

As we can see, developing a new course is a difficult, but a very important, process. Before teaching, instructors will need to formulate the goals and objectives of the course, conceptualize the content, select teaching materials, plan the course, and be ready to evaluate it. In the center of the course developing process should a particular group of students the course is designed for.

    Course-development as an On-going Process

Developing a new course is not just planning a course. In teaching, instructors are constant learners. With professional experience, our views, teaching concepts, and methodological knowledge are continuously changing. From year to year, we have different students with different needs and background. That will inevitably make it necessary and important to modify every course and adjust it to a particular group of students. Furthermore, quite often in the classroom things take place in an unexpected or unplanned way. Flexible teachers are open to making necessary changes while teaching. They can see what can or should be modified, added, or changed to make the course reflect students' interests and needs. Therefore, course development can be seen as an on-going process.

4.    Midwife in America and Indonesia !

    Midwives in America

1.  MIDWIFERY IN THE UNITED STATES:

In the US there are three types of midwives. 

I. ERTIFIED NURSE MIDWIVES (CNMs) are trained through approved programs of the American College of Nurse Midwives (ACNM). CNMs are trained in the disciplines of nursing and midwifery, but their primary focus is the practice of midwifery. These programs are run by Nurse-Midwives, and usually affiliated with a University or medical school. Programs are either a one year Certificate Program or a two year Master's Program. Some Masters degrees are in Nursing, some in Public Health, and some in Midwifery.

Some states are requiring a Master's Degree for a CNM to practice (such as Washington and Oregon) for licensure. Some programs admit two year degree RNs, and some programs require a BS in Nursing for admission into the program.

There are several accelerated programs, such as the one at Yale that admits non-nurses with a 4 year degree and in three years the individual graduates with a Masters in Nursing and become eligible to take the boards to become both an RN and a CNM.

The Community Based Nurse Midwifery Education Program (CNEP) is an innovative distance learning program which allows a student to study at home and gain clinical experience locally.

Some midwifery programs for RNs seeking a CNM are developing innovative curriculums and channels to increase access to education. The list of schools for CNMs is long, and new programs are approved each year.

You can contact the American College of Nurse Midwives (ACNM) at <info@acnm.org> to determine where the schools are and what the requirements for admission are.

Subscribing to the Journal of Nurse Midwifery (the journal of the American College of Nurse Midwives) will provide you with updates about programs, and articles about CNMs and the issues facing them.

In the USA, Certified Nurse Midwives are growing and flourishing, numbering over 4000. They are making inroads in many ways, bringing midwifery care into the hospitals, providing care for low income families and becoming a respected provider and part of the team of providers in medical school programs, training residents in normal birthing.

Usually, CNMs work in a collaborative or co-management relationship with physicians. This implies teamwork and promotes continuity of care.

In some states CNMs also hold a separate title, and must use it with their legal signature. For example, in Washington state, I am an Advanced Registered Nurse Practitioner (ARNP) and Certified Nurse Midwife (CNM). I am licensed through the Board of Nursing as an ARNP because I am a licensed as a CNM.

This is important for our future viability, because nurse practitioners are uniting, and someday that might be the title across the nation. I am required to use the title ARNP, and choose to use CNM also. This is confusing sometimes to the public.

II. LICENSED OR CERTIFIED (direct entry) MIDWIVES practice in a home or birth center setting. They can receive their training through a combination of formal schooling, correspondence courses, self study and apprenticeship.

Although this is a non-nurse entry route for midwifery, nurses are not excluded. These midwives must show that they meet or exceed the minimum requirements for the practice of midwifery by documenting experience and passing both skills and didactic exams. In the United States, direct- entry midwifery is legally recognized in 29 states. Licensure, certification or registration is available in 17 states and Medicaid reimbursement is available 6 states.

Licensed or certified midwives usually have a working relationship with the State Health Departments, do sign birth certificates, have lab accounts and usually have doctor back-up and emergency procedures lined up. Licensed or certified midwives are reimbursed by many insurance companies for birth center and home births.

There is a movement in the United States towards Professional Midwifery: a process through which those aspiring to be midwives can proceed and at the end be called a CERTIFIED PROFESSIONAL MIDWIFE (CPM).

The North American Registry of Midwives (NARM) is the first certifying body to offer both a national examination and a national validation process for professional direct-entry midwives, and CNMs who assist with birth at home, who come to their practices through multiple educational routes. NARM has been offering a registry examination of entry-level midwifery knowledge since 1991. NARM has just completed a pilot project for a certification process which validates skills, knowledge and experience.

This certification is now being offered nationwide and the new credential is for Certified Professional Midwife. The CPM has successfully completed prescribed studies in midwifery accomplished through a variety of educational routes. The examination is based on Core Competencies established by the Midwives' Alliance of North America (MANA) <Manainfo@aol.com> the national organization representing midwives. The CPMs then practice in accord with the MANA Standards and Guidelines for the Art and Practice of Midwifery.

III. LAY or EMPIRICAL MIDWIVES, also referred to as direct entry midwives, obtain their training through a variety of routes. This category may also include very experienced and well trained midwives who practice in states where there is no reciprocity for the license they already have, such as Oregon, where certification is not required unless one wants to get medical funds for low income clients. This category does not exclude nurses from its ranks. (Sharon Hodges-Rust). These might also be midwives who have chosen not to become licensed or certified for a variety of reasons, ranging from the lack of experience necessary for licensure to not wanting to work under any type of mandated protocols or guidelines. Some are part of a religious group, and practice only within a specific community. In some areas they cannot charge for their services, and can be prosecuted for doing so.

Community-based midwives have been providing care for pregnant women across North America for many past years. Currently there are two to three thousand independent midwives in the US alone. There are many types of providers providing prenatal care and birthing assistance in the United States: Midwives with different sorts of titles and qualifications, Physician Assistants, Family Practice or General Practitioners, and Obstetricians. As you can imagine, the process and outcome of a birthwill be different, depending upon the provider chosen to assist thebirth.

2. WHAT CAN MIDWIVES DO?

This will depend on the type of licensure and the laws and restrictions within the local area.

CNMs can obtain hospital privileges, in some states can prescribe most medications needed by women, and can attend birth in the home, hospital or birth centers. They can provide family planning and women's health care in addition to the full scope of prenatal and birthing care. How they practice will depend upon their work setting.

Some CNMs practice in large, busy Level III hospitals. This is usually episodic care, and they might work shifts and specific clinics, and be able to work a limited 40 hour week. Some CNMs have a solo private practice and others work in group practices with other CNMs and/or physicians. Most CNMs provide total midwifery care, with a physician for consultation and co-management as needed. CNMs can earn a consistent income, and can also practice as an RN if she cannot work as a CNM. Sometimes CNMs work for a family planning agency such as Planned Parenthood or the Health Department providing family planning services and women's health care. Some CNMs practice midwifery internationally on special projects for the American College of Nurse Midwives. Present projects include work in Ghana, Egypt, Uganda, Indonesia, Morocco and Bolivia and include work with family planning agencies and the training of training of Traditional Birth Assistants and working towards improving the overall standard of living for women and their families.

Obtaining hospital privileges in the United States is a critical element in a midwife's ability to practice and use the resources found within the hospital, such as the lab, radiology and the emergency room. Hospital by-laws can be written to either include or exclude this non-physician provider. Some by-laws require physician supervision and sometimes their presence at the birth. Other by-laws are more liberal. CNMs have made many strides over the past few years, and many hospitals are receptive to midwives. Women are requesting the care of midwives, and hospitals choose to offer this option.

Non-physician providers in some institutions, can independently admit and discharge their clients, however cannot vote on any committees. CNMs attend the perinatal committee, which discusses the rules and regulation of the particular obstetrical unit, but they are not allowed to vote on rules which might affect them. CNMs attend these meetings, and their visible presence makes an impression at some level to their viability.

The by-laws limit who can practice. Each candidate is carefully screened for accuracy of licensure and educational program. Probationary periods exist for different practitioners, and requirements for non-physicians might differ somewhat from what is required for a physician. Hospital administrators are looking at different models of health care, and at countries where midwives provide most of the care.

The issue of hospital privileges affects non-CNMs, if they were to want privileges, or even to use the services available at the hospital. The midwife without privileges would need to go through a physician or other provider to get an ultrasound ordered, and the results would go to the physician, not the midwife. Many midwives do not seek hospital privileges, but others want to be able to transition their clients into the hospital should the need arise, and be able to continue care within the hospital. Some DEMs also sit on various committees in their states and are able to promote change in obstetrical care, along with the consumers in the community.

Midwives without a formal license practice in a variety of ways and with a variety of tools. Some use homeopathic, herbal and other non-allopathic therapies within their practice, such as massage, accupressure and reflexology. They assist births in the home or within a birth center. Some midwives are considered to be practicing illegally in their state by some authorities. It is not illegal to have a home birth, but it might be illegal for a midwife to attend the birth without appropriate licensure. A good example is in Washington State, where there are CNMs, Licensed Midwives and non-licensed midwives. If the non-licensed midwife charges for her services, this is considered illegal by state law. Licensed midwives and CNMs can bill for their services through the state, and be reimbursed by insurance plans. Many midwives practice independent of any major medical community, consulting with a specific physician if necessary that is supportive of their cause, or having the client seek a consulting physician should problems arise.

In some situations, midwives contact whatever back-up is available, using the hospital's on-call physician should transfer be necessary. A hospital's reception of a midwife's transport may vary. Sometimes the midwife and parents face a physician or nurse who disapproves of the intended birth at home. However as midwives and out-of-hospital birthing have become more common, the hospital staff has become more likely to greet the transport with professional respect. Licensure or certification provides a minimum standard to which midwives adhere. The intention is to protect the consumer from harm by a practitioner without adequate training, but is no guarantee of competency.

Licensure and certification also imply a peer review process to help midwives feel accountable for their actions.

In the USA, CNMs usually work from standing protocols that they have developed themselves. These are reviewed by their consultant physicians, and guide care. Generally these are of a medical or allopathic orientation, however there are CNMs who use herbs and non-allopathic treatments within their practice. The ACOG (American College of Obstetrics and Gynecology) has well documented and clearly presented guidelines for practice, and most seem respectful of the diversity of practice within the USA. Following these guidelines are not required for practice, but are considered part of the "standards of care" within the community. Should legal action be taken against a physician or midwife, these guidelines will be reviewed, and used as a standard against which the outcome could be judged.

3. WHAT DO MIDWIVES DO? 

Midwives teach, educate and empower women to take control of their own healthcare. In most communities, they provide prenatal care, or supervision of the pregnancy, and then assist the mother to give birth. They manage the birth, and guard the woman and her newborn in the postpartum period. Most midwives encourage and monitor women throughout their labor with techniques to improve the labor and birth. Reassurance, positive imaging and suggestions to change positions and walk helps labors progress.

Many midwives provide family planning services and routine women's health examinations such as pap smears and physical examinations. They teach women about sexually transmitted infections, and focus on prevention of the spread of infections. What specifically midwives do will depend upon: her training, her licensure, and what is allowed in the state, province, or country in which she practices. Certified Nurse Midwives (CNMs) in most states within the USA can prescribe most medications, and in some areas also provide women's health care throughout  the menopause years. CNMs can attend birth in the hospital, birthing center, or home.

All midwives specialize in understanding normal aspects of the childbearing cycle. They are trained to recognize deviations from the normal, recommend holistic means for bringing the situation back into the realm of normal, or refer to another practitioner when necessary. Midwives believe it is important is to provide time for questions, teaching, and time to listen to the concerns and needs of the women they care for.

4. HOW DO I BECOME A MIDWIFE?   

There are many different paths to becoming a midwife. Which path you choose will depend on many factors: where you live, what the rules and regulations are in your state or country which govern midwives, your age and education, and what sorts of experiences you have had with birthing. The most important thing is that you need to look at your reasons for wanting to become a midwife are, both short term and long term. This will help you determine which path is best for you. The resource published by Midwifery Today, "Getting an Education: Paths to Becoming a Midwife" gives good guidance and information about the various paths to becoming a midwife.

Some women start as childbirth educators and/or doulas to see how it feels to them. I started as a childbirth educator, and offered to labor support births with my students. It reaffirmed my decision to become a midwife, and the fire within me became very strong. I lived in California at the time, and already had a 2 year degree in nursing, so decided upon sought a Certificate program, through the University of Mississippi, which was one year. I could have done things differently, but this path seemed the best one for me at the time. While teaching childbirth classes and gaining experiences with childbirth, I soon met midwives and others interested in birthing. I observed many different types of births and began develop a personal philosophy about birthing.

I also became good friends with a midwife, and she mentored me to help me gain experience. She was an unlicensed midwife who became an RN at 35 and then a CNM. She has practiced in every type of setting as a midwife, including a private home birth practice and large Health Maintenance Organization (HMO) practice.

5.  WHERE DO I FIND A MIDWIFE?

Seek midwives in your community, state and country of province. Speak with local childbirth educators about midwives they know, and of course, talk with your friends about their birth experiences and their particular choice of provider. Watch for health fairs in your area, check with herb and health food stores and ask questions of other types of health providers such as massage therapists and doulas.

Call the local hospitals and ask about midwives, childbirth educators and doulas. Some systems have referral systems for midwives well thought out, and you can easily locate a midwife. In other areas you may need to ask lots of questions. Ask La Leche League leaders for names of midwives they know, as would any other groups that work with mothers and infants. There might be a listing within your phone book for midwives, but some midwives are not listed there due to finances or legalities. In Georgia, in the US, only CNMs are found in the yellow pages and none of them attend homebirths. Contact nurse practitioners in your area, and also your local Health Department and Planned Parenthood. They will usually tell you their favorite providers first.

    Midwives in Indonesia

During World Breastfeeding Week, 1-7 August 2008, UNICEF and other advocacy groups are promoting exclusive breastfeeding for the first six months of life, which experts believe could save 1.3 million infant lives every year.

LOMBOK, Indonesia, 29 July 2008 – It’s early morning as Dwinta Dyah Larasanti, a midwife, sets off to the local health clinic prepared to fight poor infant feeding. Dwinta’s weapon in this battle is simple: accurate information.

Dwinta is one of many new midwives trained with support from UNICEF in proper infant feeding practices. Now she is passing on her expertise to mothers in the community. At the clinic, she uses simple tools like flip charts and illustrated guides to explain the importance of proper breastfeeding.

“You should give your babies only breast milk from birth up to the age of six months. No formula, no solid food. Nothing but mother’s milk,” Ms. Larasanti tells her class. “Even when you start to wean your child, mother’s milk can be given up to two years and beyond.”

Developing countries suffer

The World Alliance for Breastfeeding Action advocates the ‘gold standard’ of breastfeeding – which includes immediate breastfeeding within one hour of birth and exclusive breastfeeding for the first six months of life, with continued breastfeeding for up to two years.

In Indonesia, most mothers do not exclusively breastfeed their babies for the first six months of life. This trend can be seen in many developing countries, and it leads to deadly consequences.

“Breast milk is the first vaccine of life. It can protect babies from diarrhoea, malnutrition and a host of other ailments that can kill,” said UNICEF Indonesia’s Chief of Health and Nutrition, Dr. Anne Vincent. “UNICEF is working in key areas to raise awareness among midwives and mothers alike. This programme is needed now more than ever.”

Effects of poor feeding

At Praya Hospital here on Lombok island, the effects of poor infant feeding can be seen on the faces of many suffering children.

Arya is nearly three years old and, weighing in at less than 6.5 kg, is acutely malnourished. His older brother died when he was about the same age. His mother Samsuarah admits she didn’t breastfeed properly and fed her young babies sugar water and rice.

This is a rare case for the award-winning hospital, which doesn't often see such acute cases. But it does reflect the need for ongoing support for all mothers and midwives.

Community support

To face these challenges and to ensure that proper breastfeeding information gets to as many mothers as possible, village-level support groups have been set up on the island. Nur Hasamin is a volunteer who attended breastfeeding classes at the local health clinic. She is also pregnant, and eager to spread her knowledge about proper feeding practices to her neighbours.

“Many mothers wean too early or think that bottle feeding is best,” said midwife Imansuri Hartini, who also noted that some manufacturers of formula and artificial foods provide cash incentives to midwives to promote their products.

“I know how important breastfeeding is, so I don’t want to do that,” she added. “I didn’t breastfeed my first child properly. But now I know what to do. I want to make sure that my new baby and all the babies in my village are healthy and protected.”