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An American look at midwifery in Iceland
ANAMERICANLOOKATMIDWIFERYINICELAND
Lisa L. Paine, CNM,
MS,
MPH, and Bjiirg P&lsd&tir, NM
ABSTRACT An American nurse-midwife recently visited several midwives at the University Hospital in Reykjavfi, Iceland, and a community hospital in Akranes, Iceland. Midwives were observed during their attendance at several births, as well as in all other areas of their practice. This paper includes a look at the Icelandic health system, the role of the midwife, midwifey education, and midwifey practices. The practice and education of midwives in Iceland is contrasted to that of nurse-midwives in the United States.
Iceland, Europe’s most westerly point, is located just beneath the Arctic Circle. A volcanic island country about the size of Kentucky, it is bathed by the Gulf Stream, giving it a climate relatively mild for its geographic position. Iceland supports a population of approximately 250,000 with nearly half living in the capital city of Reykjavik. Fishing, forestry, agriculture, and mining are its principle industries.’ In this beautiful Scandinavian country, where the summers are bright and the winters dark, midwife means “mother of light.”
THE HEALTH SYSTEM
There is a comprehensive, national system of social security in Iceland, which is true for much of Scandinavia. Contributions to the system are mandatory. A wide range of insurance benefits, including maternity grants, are offered. Thus, there is na-
Address correspondence to: Lisa L. Paine, CNM, 704 Glen Allen Dr., Baltimore, MD 21229.
Journal of Nurse-Midwifery
??
tionwide access to medical care, including prenatal care, for every woman.‘,* In 1975, there were 353 physicians and 118 professional midwives in Iceland. Only 43 of the professional midwives were nurse-midwives. By 1980, the number of physicians increased to 488, and by 1986 there were 430 active professional midwives, 155 of whom are nurse-midwives. In 1980, Iceland had 46 hospitals; and with one bed available for every 61 inhabitants, it maintained one of the highest bedto-inhabitant ratios in the world. L* Icelanders are proud of their obstetrical statistics. In 1983, there were 4371 live births. The birth rate was 18.4 per 1000, one of the highest in Europe. In 1985 infant mortality rate was the worlds lowest at 6 per 1000. At the University Hospital in Reykjavik, where more than half of the country’s births take place, the perinatal mortality rate was a remarkable 5.6 per 1000 in 1985. During the same year, the cesarean section rate at the University Hospital was 14%.1-4 In addition to the University Hospital, there is a free-standing birth
Vol. 32, No. 5, September/October
Copyright 0 1987 by the American College of Nurse-Midwives
1987
center in Reykjavik where a few deliveries occur. This facility closes during the summer months when most staff members are vacationing. The remainder of the approximately 2000 deliveries per year are done in fully equipped, but smaller community hospitals around the country. The services offered at the community hospitals are of excellent quality, but limited access to highly specialized equipment and personnel has led to transport of high risk mothers and babies to the University Hospital in Reykjavlk. In 1975, 98% of Iceland’s deliveries took place in-hospitah it is estimated that even fewer births occur outside the hospital today. Although 75-80% of all births are attended by midwives, domicillay midwifery is very rare. *s Iceland differs from some other European countries, such as the Netherlands, where the concept of home birth for normal deliveries is being preserved.6 ROLE OF THE MIDWIFE
Midwives attend nearly all births that do not require operative intervention by vacuum, forceps or cesarean sec319 0091/2182/87/$03.50
tion. This includes delivery of women with preeclampsia, diabetes, prematurity, twins, and stillbirths.4 The 125 bed University Hospital Maternity Department in Reykjavik is nearly totally staffed by midwives. In addition to attending the nursing and management aspects of labor and delivery, midwives provide all care offered in the antepartum unit, postpartum unit, gynecologic surgery, and the normal nursery. The midwife assists the obstetrician in the antepartum clinic, but does not independently provide prenatal care. In addition, midwives do a majority of the obstetrical ultrasounds and conduct all childbirth preparation classes. 4,7 Midwives play a minor role in gynecology and family planning. Contraceptive counseling is provided by midwives, but gynecology examinations and yearly PAP smears are conducted by physicians in specially designed PAP smear clinics.7
Iceland’s regional intensive care nursery is staffed by midwives and nurses with additional training in the care of high risk infants. This nursery, though located in the Maternity Department, is administered by the local Children’s Hospital. The midwives and nurses employed here are very involved in the national neonatal transport system and in the education of parents with high risk infants8 Very few nurses are employed in obstetrics and gynecology in Iceland. The role of the obstetrical nurse so familiar in the United States is nonexistent in the Icelandic system. Inorder to provide obstetrical nursing care, one must be a midwife or nurse-midwife. There are some registered nurses working in the gynecology/oncology units, the neonatal intensive care unit, and in surgey,4y7 but most care in these areas is provided by midwives. THE PROFESSION OF MIDWIFERY
Lisa L. Paine, CNM, MS, MPH, is a nursemidwife at the Johns Hopkins Hospital and an Assistant, Department of GYhV OB, at the Johns Hopkins School of Medicine, Baltimore, Ma y/and. She received her MS and nurse-midwifery education at the Uniuersity of Utah in 1982 and her MPH at the Johns Hopkins Uniuersity School of Hygiene and Public Health in 1987. She is currently a DrPH candidate at the Johns Hopkins University School of Hygiene and Public Health, Baltimore, Ma y/and. Bjtirg PBlsdWr, NM, is a nurse-midwife at the Uniuersity Hospital, Reykjauik, Iceland. She gmduated from the Nursing School of Iceland in 1981 and the Midwifey School of Iceland in 1984. She has done international relief work sponsored by the Icelandic Church Aid including the practice of midwifey and nursing in Wollo Prouince in Northern Ethiopia in 1985. She a/so serves as president of the Division of NurseMidwives within the Icelandic Nurse’s Society. Bjorg attended the 1986 Conuention of the American College of Nurse-Midwiues in Portland, Oregon.
320
Midwifery has been a recognized profession in Iceland since 1761. Since that time, midwifery has evolved to its present practice based upon British and Scandinavian standards5 The most recent changes in midwifery have surrounded the issue of admission requirements to the midwifery school. Prior to 1982, students were admitted to midwifery training without a nursing background. These graduates were then licensed by the State as professional midwives. However, since 1982, a requirement for admission is that the applicant be a registered nurse. Graduates since this admission requirement took effect have been licensed as nurse-midwives. This change has been seen as an important one, which will prepare Icelandic nurse-midwives to handle a broader variety of health-related issues.4,g Another change has recently taken place in nursing education. The baccalaureate degree is now the entry level credential for the practice of Journal of Nurse-Midwifery
??
nursing in Iceland. In the near future, the graduates of the midwifery school will all be baccalaureate prepared nurses. This change is causing the midwives and nurse-midwives to review their goals and priorities. Already, the midwives without nursing backgrounds have perceived that the nurse-midwives have a greater emphasis on education, research, and administration and have a lesser commitment to care at the bedside.4*7TgThese concerns are familiar to nurse-midwifery educators, clinicians, and researchers in the United States. Midwives are licensed in Iceland upon the successful completion of their midwifery education. Currently, there are no continuing education requirements; but this matter is under consideration by several midwives. s7 The Icelandic Midwives Society was founded in 1919.5 This professional organization represents Icelandic midwives on educational and employment-related issues such as salary and working conditions. The Society has published the Midwioes Journal since 1922.5 Currently, the journal is published three times yearly and includes professional articles written by midwives and announcements of interest to the society’s membership.rO There are two other professional groups to which many Icelandic nurse-midwives belong. They are the Icelandic Nurse’s Society and the nurse-midwives division of the Icelandic Nurse’s Society. All the groups serve a purpose in the professional development of midwives, especially during this time of vast changes in the profession. MIDWIFERY EDUCATION The Icelandic School of Midwifery occupies one floor of the University Hospital Maternity Department. Approximately 10 students per year are admitted to the 2 year program. To date, no males have graduated from the program, but applications from Vol. 32, No. 5, September/October
1987
males receive the same review as do applications from females. Students are selected by the Headmaster of the School (a university professor and obstetrician) and the Head Midwife of the Maternity Department. The Director of the Midwifery School has some input, but does not render the final decision.g The Director serves in more of a guidance capacity than in an actual educational administrative role compared to American midwifery program directors. The Head Midwife, whose function is comparable to our Director of Nurses, assumes more of the educational administration and clinical supervision of midwifery students4yg Staff midwives and shift supervisors on the various units are generally responsible for clinical teaching and evaluation of both midwifery and medical students. Didactic exams are constructed and administered by the midwife and physician lecturers. During the author’s visit, the midwives involved in clinical teaching expressed interest in upgrading the evaluation methods used for both didactic and clinical evaluation of their students.4p7,g Several evaluation methods used in United States midwifery programs were shared with these midwives; the exchange was interesting and helpful for all involved. The midwifery school houses a beautiful obstetrical library that is available to all students and midwives. Many contemporary European and American obstetrical books and journals are found here, as well as up-to-date audiovisual equipment. The library was established by the late Professor Sigurdur S. Magnusson, the Midwifery School Headmaster until his death in 1985.
MIDWIFERY PRACTICES One striking feature of childbirth in the busy labor and delivery unit at the University Hospital is the intense calm surrounding each labor and Journal of Nurse-Midwifery
??
birth. Sometimes as many as five to six deliveries occur per shift but the bustle and clamor so often witnessed in United States university hospitals was joyfully absent. Four to five midwives staff the unit on each &hour shift, with one midwife assigned to each laboring woman. Because the clinics and inpatient units each have separate midwifery staffs, often the midwives in the labor area have not met the women prior to labor. The Icelandic midwives handle this situation well, but they frequently use this example when discussing concerns over providing continuity of care.2,7 The midwife provides complete care for the woman during her labor and is responsible for the conduct of the delivery. As the time of birth approaches, the midwife summons the assistance of another midwife and a house doctor. This doctor attends the birth to administer the oxytocic drugs and examine the baby after birth, but the management of the delivery is clearly the province of the midwife. An obstetrician is available in house at all times, but generally attends only complicated births. There are five birth rooms equipped with labor/delivery/recovey beds that are used to accommodate the preferred semi-sitting position for birth. Heparin locks are routinely started for the administration of drugs, but the use of continuous IV fluids is rare. External fetal monitoring is routine; the practice seems well received by both the midwives and the laboring women. The midwives interpret the fetal heart rate tracings cautiously, and readily seek an obstetric consultation if any tracing is questionable. Icelandic midwives tend to use more obstetrical anesthesia and analgesia than midwives in the United States. Many women are medicated during labor with Petidin, a synthetic narcotic. Women also self-administer nitrous oxide by mask during active labor and second stage, and epidural anesthesia is common. Considering
Vol. 32, No. 5, September/October 1987
the amount and type of medication used, babies are surprisingly vigorous at birth. An obstetrical lubricating cream, Hibitane, is used for vaginal exams and perineal massage. Though delivery over an intact perineum is usually attempted, mediolateral episiotomies are used when indicated. Intravenous Methergine is routinely given to reduce postpartum bleeding. Mucus traps, rather than bulb syringes, are used for infant suctioning. As is common in many Scandinavian countries, the baby is held up by the ankles immediately after birth. It is believed that this practice is necessay for proper drainage of mucus and initiation of breathing. As soon as breathing is established and the baby is examined, the infant returns to the mother for the remainder of her immediate post-delivery recovery; in most cases, at least 2 hours. Fathers and other support people are encouraged to remain with the mother throughout the labor and birth, and are frequently called upon to help with positioning and early breast feeding. If forceps or vacuum extraction is required, the obstetrician performs the delivery in the birth room and the midwife resumes primary care immediately after the birth. Cesarean births are performed in the surgical suite adjacent to the labor and delivery area. Epidural anesthesia is used most often for cesareans and is administered by an anesthesiologist. An observer of a cesarean birth in Iceland would be extremely impressed with the quiet, respectful nature of the surgery. The moment of evey birth is surrounded by impressive dignity. Respect for each woman is shown by both the physicians and the midwives. The postpartum stay ranges from 4 days to 1 week, and is characterized by modified rooming-in and liberal family and sibling visitation. Most infants are breast fed. The long postpartum stay seems well received by the staff and families, who view it 321
as a well-deserved respite from the demands of parenthood. The paperwork surrounding each birth is quickly accomplished by the midwife. Because Icelanders do not believe in excess or waste of materials, organized and concise obstetrical records are kept. This surely would be welcomed by most American midwives. And finally, the midwife’s responsibilities include cleaning and sterilizing instruments, restocking the birthroom, and making up the fresh birthing bed.
landic midwife’s look of concentration turns to joy after each and every birth.
4. Tomasdottir, K. Personal communication with the Head Midwife at the University Hospital Labor Unit. July 19, 1986, Reykjavik, Iceland.
The authors wish to express their gratitude to the Icelandic midwives who were so willing to share their time and experiences toward the composition of this article, and to N. Katherine Brown for her editorial assistance, “HGfundar vilja lata i lj6s thakklaeti sitt vid thaer islensku lj&maedur, sem voru svo vingjamlegar ad gera thessa grein m6gulega med thvi ad deila med okkur tima sir-rum og reynslu.”
5. Einarsdottir, ES: Midwifery Education in Iceland: Yesterday and today. J NURS-MIDWIF 28(6):31-32, 1983.
REFERENCES SUMMARY
A visit to Iceland, where midwifery is supported and respected, and where malpractice issues are unheard of, would surely delight any American midwife. Though in some ways, our practices are as different as our languages, the spirit of international midwifery is manifest when the Ice-
322
1. The Europa Yearbook 1986: A WORLD SURVEY. London, Europa Publications Limited, 1986. 2. Maternity Care in the World, 2nd Ed. International Survey of Medical Practice and Training. Britain, Joint study group of IFGO and ICM, 1976. 3. Magnusson, SA: Iceland-Country and people. Reykjavik, Iceland, Iceland Review, 1978.
Journal of Nurse-Midwifery
6. Limburg, A: Obstetrical care in the Netherlands. J NURS-MIDWIF 29(3):215-216, 1984. 7. Eggertsdottir G, Haraldsdottir KR, Hauksdottir A, Matthiasdottir R, Nielsen H, Wlsdottir B, Saemundsdottir M. Personal communication. August 17, 1986, Reykjavik, Iceland. 8. Sigurdardottir, R. Personal communication with the Head Midwife of the University Hospital Neonatal Unit. July 18, 1986, Reykjavik, Iceland. 9. Einarsdottir, ES. Personal communication with the Director of the School of Midwifery. July 18, 1986, Reykjavik, Iceland. 10. Nielsen, H. Personal communication with the Editor of the MIDWIVES JOURNAL. August 17, 1986, Reykjavik, Iceland.
??Vol.
32, No. 5, September/October
1987
Lisa L. Paine, CNM,
MS,
MPH, and Bjiirg P&lsd&tir, NM
ABSTRACT An American nurse-midwife recently visited several midwives at the University Hospital in Reykjavfi, Iceland, and a community hospital in Akranes, Iceland. Midwives were observed during their attendance at several births, as well as in all other areas of their practice. This paper includes a look at the Icelandic health system, the role of the midwife, midwifey education, and midwifey practices. The practice and education of midwives in Iceland is contrasted to that of nurse-midwives in the United States.
Iceland, Europe’s most westerly point, is located just beneath the Arctic Circle. A volcanic island country about the size of Kentucky, it is bathed by the Gulf Stream, giving it a climate relatively mild for its geographic position. Iceland supports a population of approximately 250,000 with nearly half living in the capital city of Reykjavik. Fishing, forestry, agriculture, and mining are its principle industries.’ In this beautiful Scandinavian country, where the summers are bright and the winters dark, midwife means “mother of light.”
THE HEALTH SYSTEM
There is a comprehensive, national system of social security in Iceland, which is true for much of Scandinavia. Contributions to the system are mandatory. A wide range of insurance benefits, including maternity grants, are offered. Thus, there is na-
Address correspondence to: Lisa L. Paine, CNM, 704 Glen Allen Dr., Baltimore, MD 21229.
Journal of Nurse-Midwifery
??
tionwide access to medical care, including prenatal care, for every woman.‘,* In 1975, there were 353 physicians and 118 professional midwives in Iceland. Only 43 of the professional midwives were nurse-midwives. By 1980, the number of physicians increased to 488, and by 1986 there were 430 active professional midwives, 155 of whom are nurse-midwives. In 1980, Iceland had 46 hospitals; and with one bed available for every 61 inhabitants, it maintained one of the highest bedto-inhabitant ratios in the world. L* Icelanders are proud of their obstetrical statistics. In 1983, there were 4371 live births. The birth rate was 18.4 per 1000, one of the highest in Europe. In 1985 infant mortality rate was the worlds lowest at 6 per 1000. At the University Hospital in Reykjavik, where more than half of the country’s births take place, the perinatal mortality rate was a remarkable 5.6 per 1000 in 1985. During the same year, the cesarean section rate at the University Hospital was 14%.1-4 In addition to the University Hospital, there is a free-standing birth
Vol. 32, No. 5, September/October
Copyright 0 1987 by the American College of Nurse-Midwives
1987
center in Reykjavik where a few deliveries occur. This facility closes during the summer months when most staff members are vacationing. The remainder of the approximately 2000 deliveries per year are done in fully equipped, but smaller community hospitals around the country. The services offered at the community hospitals are of excellent quality, but limited access to highly specialized equipment and personnel has led to transport of high risk mothers and babies to the University Hospital in Reykjavlk. In 1975, 98% of Iceland’s deliveries took place in-hospitah it is estimated that even fewer births occur outside the hospital today. Although 75-80% of all births are attended by midwives, domicillay midwifery is very rare. *s Iceland differs from some other European countries, such as the Netherlands, where the concept of home birth for normal deliveries is being preserved.6 ROLE OF THE MIDWIFE
Midwives attend nearly all births that do not require operative intervention by vacuum, forceps or cesarean sec319 0091/2182/87/$03.50
tion. This includes delivery of women with preeclampsia, diabetes, prematurity, twins, and stillbirths.4 The 125 bed University Hospital Maternity Department in Reykjavik is nearly totally staffed by midwives. In addition to attending the nursing and management aspects of labor and delivery, midwives provide all care offered in the antepartum unit, postpartum unit, gynecologic surgery, and the normal nursery. The midwife assists the obstetrician in the antepartum clinic, but does not independently provide prenatal care. In addition, midwives do a majority of the obstetrical ultrasounds and conduct all childbirth preparation classes. 4,7 Midwives play a minor role in gynecology and family planning. Contraceptive counseling is provided by midwives, but gynecology examinations and yearly PAP smears are conducted by physicians in specially designed PAP smear clinics.7
Iceland’s regional intensive care nursery is staffed by midwives and nurses with additional training in the care of high risk infants. This nursery, though located in the Maternity Department, is administered by the local Children’s Hospital. The midwives and nurses employed here are very involved in the national neonatal transport system and in the education of parents with high risk infants8 Very few nurses are employed in obstetrics and gynecology in Iceland. The role of the obstetrical nurse so familiar in the United States is nonexistent in the Icelandic system. Inorder to provide obstetrical nursing care, one must be a midwife or nurse-midwife. There are some registered nurses working in the gynecology/oncology units, the neonatal intensive care unit, and in surgey,4y7 but most care in these areas is provided by midwives. THE PROFESSION OF MIDWIFERY
Lisa L. Paine, CNM, MS, MPH, is a nursemidwife at the Johns Hopkins Hospital and an Assistant, Department of GYhV OB, at the Johns Hopkins School of Medicine, Baltimore, Ma y/and. She received her MS and nurse-midwifery education at the Uniuersity of Utah in 1982 and her MPH at the Johns Hopkins Uniuersity School of Hygiene and Public Health in 1987. She is currently a DrPH candidate at the Johns Hopkins University School of Hygiene and Public Health, Baltimore, Ma y/and. Bjtirg PBlsdWr, NM, is a nurse-midwife at the Uniuersity Hospital, Reykjauik, Iceland. She gmduated from the Nursing School of Iceland in 1981 and the Midwifey School of Iceland in 1984. She has done international relief work sponsored by the Icelandic Church Aid including the practice of midwifey and nursing in Wollo Prouince in Northern Ethiopia in 1985. She a/so serves as president of the Division of NurseMidwives within the Icelandic Nurse’s Society. Bjorg attended the 1986 Conuention of the American College of Nurse-Midwiues in Portland, Oregon.
320
Midwifery has been a recognized profession in Iceland since 1761. Since that time, midwifery has evolved to its present practice based upon British and Scandinavian standards5 The most recent changes in midwifery have surrounded the issue of admission requirements to the midwifery school. Prior to 1982, students were admitted to midwifery training without a nursing background. These graduates were then licensed by the State as professional midwives. However, since 1982, a requirement for admission is that the applicant be a registered nurse. Graduates since this admission requirement took effect have been licensed as nurse-midwives. This change has been seen as an important one, which will prepare Icelandic nurse-midwives to handle a broader variety of health-related issues.4,g Another change has recently taken place in nursing education. The baccalaureate degree is now the entry level credential for the practice of Journal of Nurse-Midwifery
??
nursing in Iceland. In the near future, the graduates of the midwifery school will all be baccalaureate prepared nurses. This change is causing the midwives and nurse-midwives to review their goals and priorities. Already, the midwives without nursing backgrounds have perceived that the nurse-midwives have a greater emphasis on education, research, and administration and have a lesser commitment to care at the bedside.4*7TgThese concerns are familiar to nurse-midwifery educators, clinicians, and researchers in the United States. Midwives are licensed in Iceland upon the successful completion of their midwifery education. Currently, there are no continuing education requirements; but this matter is under consideration by several midwives. s7 The Icelandic Midwives Society was founded in 1919.5 This professional organization represents Icelandic midwives on educational and employment-related issues such as salary and working conditions. The Society has published the Midwioes Journal since 1922.5 Currently, the journal is published three times yearly and includes professional articles written by midwives and announcements of interest to the society’s membership.rO There are two other professional groups to which many Icelandic nurse-midwives belong. They are the Icelandic Nurse’s Society and the nurse-midwives division of the Icelandic Nurse’s Society. All the groups serve a purpose in the professional development of midwives, especially during this time of vast changes in the profession. MIDWIFERY EDUCATION The Icelandic School of Midwifery occupies one floor of the University Hospital Maternity Department. Approximately 10 students per year are admitted to the 2 year program. To date, no males have graduated from the program, but applications from Vol. 32, No. 5, September/October
1987
males receive the same review as do applications from females. Students are selected by the Headmaster of the School (a university professor and obstetrician) and the Head Midwife of the Maternity Department. The Director of the Midwifery School has some input, but does not render the final decision.g The Director serves in more of a guidance capacity than in an actual educational administrative role compared to American midwifery program directors. The Head Midwife, whose function is comparable to our Director of Nurses, assumes more of the educational administration and clinical supervision of midwifery students4yg Staff midwives and shift supervisors on the various units are generally responsible for clinical teaching and evaluation of both midwifery and medical students. Didactic exams are constructed and administered by the midwife and physician lecturers. During the author’s visit, the midwives involved in clinical teaching expressed interest in upgrading the evaluation methods used for both didactic and clinical evaluation of their students.4p7,g Several evaluation methods used in United States midwifery programs were shared with these midwives; the exchange was interesting and helpful for all involved. The midwifery school houses a beautiful obstetrical library that is available to all students and midwives. Many contemporary European and American obstetrical books and journals are found here, as well as up-to-date audiovisual equipment. The library was established by the late Professor Sigurdur S. Magnusson, the Midwifery School Headmaster until his death in 1985.
MIDWIFERY PRACTICES One striking feature of childbirth in the busy labor and delivery unit at the University Hospital is the intense calm surrounding each labor and Journal of Nurse-Midwifery
??
birth. Sometimes as many as five to six deliveries occur per shift but the bustle and clamor so often witnessed in United States university hospitals was joyfully absent. Four to five midwives staff the unit on each &hour shift, with one midwife assigned to each laboring woman. Because the clinics and inpatient units each have separate midwifery staffs, often the midwives in the labor area have not met the women prior to labor. The Icelandic midwives handle this situation well, but they frequently use this example when discussing concerns over providing continuity of care.2,7 The midwife provides complete care for the woman during her labor and is responsible for the conduct of the delivery. As the time of birth approaches, the midwife summons the assistance of another midwife and a house doctor. This doctor attends the birth to administer the oxytocic drugs and examine the baby after birth, but the management of the delivery is clearly the province of the midwife. An obstetrician is available in house at all times, but generally attends only complicated births. There are five birth rooms equipped with labor/delivery/recovey beds that are used to accommodate the preferred semi-sitting position for birth. Heparin locks are routinely started for the administration of drugs, but the use of continuous IV fluids is rare. External fetal monitoring is routine; the practice seems well received by both the midwives and the laboring women. The midwives interpret the fetal heart rate tracings cautiously, and readily seek an obstetric consultation if any tracing is questionable. Icelandic midwives tend to use more obstetrical anesthesia and analgesia than midwives in the United States. Many women are medicated during labor with Petidin, a synthetic narcotic. Women also self-administer nitrous oxide by mask during active labor and second stage, and epidural anesthesia is common. Considering
Vol. 32, No. 5, September/October 1987
the amount and type of medication used, babies are surprisingly vigorous at birth. An obstetrical lubricating cream, Hibitane, is used for vaginal exams and perineal massage. Though delivery over an intact perineum is usually attempted, mediolateral episiotomies are used when indicated. Intravenous Methergine is routinely given to reduce postpartum bleeding. Mucus traps, rather than bulb syringes, are used for infant suctioning. As is common in many Scandinavian countries, the baby is held up by the ankles immediately after birth. It is believed that this practice is necessay for proper drainage of mucus and initiation of breathing. As soon as breathing is established and the baby is examined, the infant returns to the mother for the remainder of her immediate post-delivery recovery; in most cases, at least 2 hours. Fathers and other support people are encouraged to remain with the mother throughout the labor and birth, and are frequently called upon to help with positioning and early breast feeding. If forceps or vacuum extraction is required, the obstetrician performs the delivery in the birth room and the midwife resumes primary care immediately after the birth. Cesarean births are performed in the surgical suite adjacent to the labor and delivery area. Epidural anesthesia is used most often for cesareans and is administered by an anesthesiologist. An observer of a cesarean birth in Iceland would be extremely impressed with the quiet, respectful nature of the surgery. The moment of evey birth is surrounded by impressive dignity. Respect for each woman is shown by both the physicians and the midwives. The postpartum stay ranges from 4 days to 1 week, and is characterized by modified rooming-in and liberal family and sibling visitation. Most infants are breast fed. The long postpartum stay seems well received by the staff and families, who view it 321
as a well-deserved respite from the demands of parenthood. The paperwork surrounding each birth is quickly accomplished by the midwife. Because Icelanders do not believe in excess or waste of materials, organized and concise obstetrical records are kept. This surely would be welcomed by most American midwives. And finally, the midwife’s responsibilities include cleaning and sterilizing instruments, restocking the birthroom, and making up the fresh birthing bed.
landic midwife’s look of concentration turns to joy after each and every birth.
4. Tomasdottir, K. Personal communication with the Head Midwife at the University Hospital Labor Unit. July 19, 1986, Reykjavik, Iceland.
The authors wish to express their gratitude to the Icelandic midwives who were so willing to share their time and experiences toward the composition of this article, and to N. Katherine Brown for her editorial assistance, “HGfundar vilja lata i lj6s thakklaeti sitt vid thaer islensku lj&maedur, sem voru svo vingjamlegar ad gera thessa grein m6gulega med thvi ad deila med okkur tima sir-rum og reynslu.”
5. Einarsdottir, ES: Midwifery Education in Iceland: Yesterday and today. J NURS-MIDWIF 28(6):31-32, 1983.
REFERENCES SUMMARY
A visit to Iceland, where midwifery is supported and respected, and where malpractice issues are unheard of, would surely delight any American midwife. Though in some ways, our practices are as different as our languages, the spirit of international midwifery is manifest when the Ice-
322
1. The Europa Yearbook 1986: A WORLD SURVEY. London, Europa Publications Limited, 1986. 2. Maternity Care in the World, 2nd Ed. International Survey of Medical Practice and Training. Britain, Joint study group of IFGO and ICM, 1976. 3. Magnusson, SA: Iceland-Country and people. Reykjavik, Iceland, Iceland Review, 1978.
Journal of Nurse-Midwifery
6. Limburg, A: Obstetrical care in the Netherlands. J NURS-MIDWIF 29(3):215-216, 1984. 7. Eggertsdottir G, Haraldsdottir KR, Hauksdottir A, Matthiasdottir R, Nielsen H, Wlsdottir B, Saemundsdottir M. Personal communication. August 17, 1986, Reykjavik, Iceland. 8. Sigurdardottir, R. Personal communication with the Head Midwife of the University Hospital Neonatal Unit. July 18, 1986, Reykjavik, Iceland. 9. Einarsdottir, ES. Personal communication with the Director of the School of Midwifery. July 18, 1986, Reykjavik, Iceland. 10. Nielsen, H. Personal communication with the Editor of the MIDWIVES JOURNAL. August 17, 1986, Reykjavik, Iceland.
??Vol.
32, No. 5, September/October
1987