from the Yale Journal of Law and Feminism
Also really long, but a good read - part 1
MIDWIFERY IS NOT THE PRACTICE OF MEDICINE
by Suzanne Hope Suarez
RN, BSN., J.D., AAUW Educational Foundation National Fellow, 1991-1992. chair, Healthy Start Coalition Advisory Board for Florida, 1991. Florida Bar Foundation Public Service Fellow, 1989-1992
from the Yale Journal of Law and Feminism
Note: the Footnotes (in red) are listed separately so that you may read them simultaneously with the text of the article. Click here to move to the footnotes page.
For the great majority of American women, the right to choose the place and manner of giving birth has quietly, but continually, narrowed.1 In just half a century, allopathic physicians2 in the United States have enticed ninety-nine percent of us into their places of business (hospitals) for childbirth, forced on us a medical model of birth that has never been proven safe or beneficial, raised the price of services which have diminished in quality and quantity, and lobbied state legislatures for laws that would require us to submit to their exclusive control during pregnancy and childbirth.
Unfortunately, the role of obstetrics has never been to help women give birth. There is a big difference between the medical discipline we call "obstetrics" and something completely different, the art of midwifery. If we want to find safe alternatives to obstetrics, we must rediscover midwifery. To rediscover midwifery is the same as giving back childbirth to women. And imagine the future if surgical teams were at the service of the midwives and the women instead of controlling them.3
Although obstetricians worldwide use the same sophisticated technology and drugs in pregnancy and childbirth as American physicians, doctors in other countries use them differently.4 Doctors in the country with the lowest infant mortality rate, Japan, use little or no drugs and are much slower to interfere with the natural process of birth.5 In the United States, the economic alliance between doctors and the producers of technological equipment has obstructed preventive maternity care. "Medical priorities are set by the medical industrial complex, which focuses on providing health care at a profit.6
In Europe, the infant mortality rate is significantly less than in the United States.7 An important attitudinal difference accompanies this statistical difference. Europeans consider birth to be a normal event, and midwives deiiver the majority of babies.8 The European Economic Community standards for midwifery education and training programs require three years of intensive study and apprenticeship.9 Many European'midwives10 work without physician supervision and are not required to study nursing as a prerequisite to rnidwifery training.11 Decades of misinformation and misapprehension, on the other hand, have taught women in the United States that birth is a dangerous and pathological event, requiring care by medical specialists.12 Obstetricians far outnumber midwives in our country and the excellent statistics of the midwives are a well-kept secret.13
Significantly, Dr. J. G. Kloosterman, former Professor of Obstetrics and Gynaecology at the University of Amsterdam and Director of the Midwives Academy in Holland from 1947 to 1957, has noted that obstetricians cannot improve upon nature: "By no means have we been able to improve spontaneous labour in healthy women. Spontaneous and normal labour is a process, marked by a series of events so perfectly attuned to one another that any interference only deflects them from their optimum course.14 The capacity to intervene has led to the notion that intervention is always desirable, even though "[t]here is strong evidence that modern western obstetrics is perverting the physiology of human parturition.15 The obstetrician, says Kloosterman, is always on the lookout for pathology, eager to interfere, and the interferences themselves cause pathology that then needs further "treatment."16 Dr. Marsden Wagner, Director of the World Health Organization's (WHO) European Regional Offlce, told doctors at an international medical conference in Jerusalem that hospital births "endanger mothers and babies&emdash;primarily because of the impersonal procedures and overuse of technology and drugs."17 The very surroundings and equipment in hospitals increase the risk of iatrogenic, or "doctor-caused" complications18 which result in excessively high costs to consumers.19
In her 1975 book, Immaculate Deception, Suzanne Arms described the manner in which obstetricians justify preventive interferences during childbirth "to [turn] sloppy old nature into a clean, safe science:" [J]ust in case you hemorrhage, we'll give you simulated hormones before you expel the placenta; just in case your perineum tears, we'll make a nice clean incision before delivery; just in case labor tires you out, we'll give you an early sedative; just in case you need a general anesthesia [for an emergency caesarean], we'll keep a vein open [put in an IV] and stop you from eating and drinking throughout labor, even if it takes twenty-four hours; and just in case you totally lose control, we'll knock you right out ...20
According to Arms, it is no wonder that a pregnant woman believes that birth is "loaded with unpredictable horrors that only her doctor can prevent.21 The "normal" length of the stages of labor has been shortened in medical texts, allowing for earlier medical intervention.22 The length of the stages of labor for hospital births in the 1940s and before was actually longer than the length of labor in home births in the early 1970s in which nature was allowed to "take its course."23 Nevertheless, by the late 1960s and 1970s, labor in hospitasl births was nearly five hours shorter than in home births, with an apparent increase in fetal distress and other complications.24 Hospitals and doctors push the birth process along to assure that a certain number of deliveries will occur when the meximum number of personnel are available&emdash;in other words, during office hours. Waiting for the natural process to occur spontaneously does not serve "institutional needs."25
Although prolonging a pregnancy beyond forty-two weeks can be risky, inducing labor does not increase the baby's chances of survival.26 Drug-induced labor after forty-two weeks, however, is a routine practice.27 Hospital rituals and interventions in the birth process comfort the obstetrician who may otherwise have to deal with feelings of uncertainty about the birth.28 By managing normal birth in the same way as 'abnormal birth,' doctors make each birth more predictable.29
If professional midwives conducted the majority of births, women with completely healthy pregnancies could feel protected from unnecessary obstetrical interferences. The midwife screens her clients carefully so that she takes only low-risk cases. She is trained to recognize abnormalities and is fully capable of transferring a woman to a hospitai safeiy during labor if necessary. Dr. Kloosterman estimates that under midwifery care, only three to five percent of healthy mothers would require physician care during delivery.30 If physicians were consulted in only three to five percent of cases, he states, the infant mortality rate would drop to between two and four in one thousand.31
Most women attended by nurse-midwives in our hospitals are poor African Americans.32 The white population, which generally tends to be healthier, is more likely to be attended by specialist obstetricians. It seems no coincidence that this healthier, and thus lower-risk, group which is nevertheless more likely to be treated by an obstetrician, has more caesarean sections.33 If mothers and babies were the paramount concern of the physicians, the increased incidence of caesarean sections would statistically peak within the "higher-risk" black population where their use could be justified. Instead, these expensive interventions are applied to those who can pay the most.34
Economics is the hidden agenda when midwifery regulation is discussed in state legisiative sessions. In testimony before legislative committees, the medical lobby overemphasizes the potential of pregnancies to become pathological.35 Though pathology occurs in only a small minority of pregnancies, many legislators are convinced that physician treatment should be required for the safety of mother and infant.36 Implicitly, under this medical model of pregnancy and birth, the profession of midwifery is subordinated and maternity care becomes "the practice of medicine" subject to state statutes that regulate the practice of medicine. No evidence exists, however, that this system is actually safer than home birth with a competent midwife. Public health experts and researchers are recognizing that midwifery will not disturb the system of obstetrics. Instead, international research indicates that the two professions are compatible, complementary and necessary to each other for an efficient and cost-effective system of care.37 The fallacy-ridden dominant belief that "home birth is dangerous"38 makes it relatively easy for the medical lobby to convince lawmakers that pregnant women who reject doctor control endanger themseives and their babies and that midwives are safe practitioners only if they are also nurses. Physicians cite the safety of the infant (and, secondarily, the mother) as a primary concern. Doctors have successfully prioritized the rights of the unborn39 and maintained control over the wishes of the parents who pay their fees. Ironically, consumers are afforded little control even though they, not the physicians, bear the ultimate responsibility of pregnancy and birth.
Strained economic times and grossly high infant mortality rates have led states to consider midwifery as a way to make maternity care accessible and affordable in spite of doctors' protests. In the 1992 Florida legislative session, House Bill 553, proposing the legalization of three-year training schools for direct-entry (non-nurse) midwives, was heatedly debated.40 Although the direct-entry schools were based on the European training model and the Senate Health Care Committee had studied and recommended passage of the bill, the Florida Medical Association (FMA) opposed it.41 The FMA told the lawmakers that "Many midwives do not have the education nor the training to practice without posing [a] serious threat to the public."42 When asked by tbe Senate Committee to verify their position with statistics or facts they could not do so. The space for that information was left blank. The FMA wanted the penalty for unlicensed midwifery in the state of Florida increased from a misdemeanor to a felony. The physicians claimed that, unless these "other" midwives were legally placed under obstetrical supervision (like the nurse-midwives), they would refuse to provide emergency back-up services.43 The bill passed anyway.44
Independent, non-nurse midwives, not subject to doctor control, are unwelcome business competition. ln 1990, the U.S. Department of Health and Human Services reported that "female with delivery" was the most common hospital discharge category.45 Since hospital birth is a major source of revenue for most public and private hospitals,46 it is understandable that hospital associations join with physicians to lobby against out-of-hospital births.
When independent "direct-entry" midwives attend a laboring woman at home, the facility fee (for a room in a hospital or birth center) is nonexistent. The difference in cost between a home birth with a licensed midwife and a normal hospital birth is considerable. For example, licensed direct-entry midwives in Florida charge $700 to $1600 for their services,47 compared with an average of $4500 for a normal hospital birth.48
Nevertheless, economic disincentives often discourage even nurse-midwives from providing home birth services. Even if they can locate physicians who will work with them, insurance companies in most states do not cover the cost of midwifery services if birth is not performed in a hospital or birth center.49 Medicaid often does not reimburse midwives for home deliveries.50 The National Center for Health Statistics reports that in 1989, out of 4,040,958 births (national total for all races), only 11,383 (.28%) were planned home births attended by midwives. Of these births, nurse-midwives attended only one-third (.09%).51
Birth centers52 provide a practice place for nurse-midwives who reject the subordinate role forced on them in hospitals. With increasing physician ownership, these centers have been reclassified as "safe" alternatives to hospitals in most states even though physicians are usually not in attendance. A recent study demonstrated that birth statistics of nurse-midwives in birth centers are better than those of nurse-midwives working with obstetricians in hospitals.53
Obstetrical interventions pass for science, even though their use in normal pregnancy is irrational.54 According to anthropologist Robbie Davis-Floyd, obstetrical interventions fulfill a rational societal function by diminishing our high-tech society's extreme fear of birth.55 Specific cultural services are performed when obstetricians "bring forth a new social member through a maze of wires and electronic bleeps."56 Obstetrical rituals convey core values that center around science and technology. Belief in them as "necessary" sustains patriarchal institutional management.57 We let monitors, intravenous devices, and drugs give birth instead of women, turning the bodies of women who give birth into "machines."58 Faith in technology provides a comfortable refuge from the unknown.59
The entrance of women into the field of obstetrics has not made a significant difference in the way obstetricians preside over birth.60 As a group, female obstetricians tend to conform more to the philosophy of their male colleagues than to that of female midwives. Medical school selection processes, socialization during medical education, the stresses inherent in obstetric residency programs, and the minority status of women in medicine are all factors likely to contribute to female physicians' unwillingness to buck the system. Moreover, medical schools convey the consistent and pervasive message to medical students that technology is always an advantage.61 There is apparently little difference in the degree to which this "indoctrination" affects female and male obstetricians.62
In physician-chosen settings, nurse midwives must work under "doctor's orders." Outside the hospital, nurse-midwife services are constrained by requirements for supervision by physicians. One commentator, discussing restrictions on nurse-midwifery in the context of malpractice insurance policy, compared physicians and hospitals to lawyers who have worked to prevent paralegals and others from the practice of law:
[M]any professions, including both medicine and law, have erected rather stringent barriers to prevent entry by others who would like to practice in the field. In pure market terms, that cuts directly against private enterprise. In effect, the professionals do not allow open and free competition... I happen to think it's not right.... [A]ccess [to independent midwives] is generally contained by requirements for supervision by physicians .... If the public were allowed to choose the lower-cost alternative freely, knowingly accepting the risk, I think that there would undoubtedly be more competition in the medical field. I believe nurse-midwives have lower claims frequency and severity rates.63
In hospitals and physician-controlled birth centers, the physician defines what is normal and what is abnormal. Physicians control the training of midwives and the services they can provide.64 As such, hospital-based nurse-midwifery is thus no real threat to medical control.
The distinction between nurses and midwives has been pointed out by researchers who find the combination of the two professions disturbing.65 A nurse is trained not to make decisions but to defer to physician authority. Like the physician, the nurse has been taught to expect problems and complications in every birth. The midwife, on the other hand, understands that the birth process seldom requires intervention. Her forte is normal birth, although she is well-trained to recognize and address abnormalities.66 Her experience at handling normal birth gives her skills that obstetricians do not possess. She serves the mother, not the physician, and although she will quickly transfer the mother to the hospital when the labor deviates from normal expectations, her main role is support and protection so that unnessary interventions do not occur.67
From Europe, there is also evidence that a strong independent midwifery profession is an important counterbalance to the obstetrical profession in preventing excessive interventions in the normal birth process. Consequently, it is perhaps not surprising that in the U.S. one finds the highest obstetrical intervention rates as well as a serious problem with malpractice suits. The European experience and our data strongly support the urgent need for the introduction of widespread, independent midwifery practice in the United States as a most important counterbalance to the present situation.68
Midwifery, with its shift of control from the doctor to the mother, is seen as a threat by organized medicine. The superb safety record of birth centers, with their popular "home-like" atmosphere, has been such a threat that hospitals have annexed "birthing rooms" and expanded midwifery service.69 Most nurse-midwives, however, are employed by physicians who forbid them from providing home-birth services.70 Control of the practice setting for other nurse-midwives is also strictly regulated by doctors."71
Part I of this article will describe the history of the elimination of the American midwife and the concurrent takeover by organized medicine. Part II defines types of midwives in the United States and provides a modern definition. Part III analyzes the differences between the medical model of birth and midwifery. Part IV argues that the legisisture is the appropriate forum for reform, especially since attempts at change through the judicial process have failed. Moreover, strong policy arguments exist for reforming the current regime of medical hegemony over childbirth.
I. HISTORY OF THE ELIMINATION OF THE AMERICAN MIDWIFE
The midwife's traditional role in childbirth went unchallenged until delivering babies became both a science and a business. In the Colonial period, midwives attended the majority of births.72 Childbirth was a social, not a medical event, in which women offered aid and comfort to each other during the delivery. Women relatives and friends served and assisted the laboring mother.73 Physicians' participation in childbirth in this period was limited to attendance at the most difficult births, and was prompted by the perceived need for the use of instruments.74
After 1750, men with European medical training began to practice in the American colonies.75 The first colonial medical school was founded in 1765, and by the first decade of the nineteenth century, midwifery was taught at five American medical schools.76 By this time, physicians were beginning to call their participation in childbirth "obstetrics"&emdash;"a scientific-sounding title free of the feminine connotations of the word "midwife."77 Physicians in both England and the United States were transforming childbirth into a medical/scientific event.78 Nevertheless, American doctors first assumed that midwives would continue to handle normal deliveries and that they would intervene only in difflcult cases.79 Some limited training opportunities in the "obstetrick art" were extended to female midwives;80 by 1820, however, physicians' interest in instructing midwives had ceased to exist.81 As early as 1760, a well-known journalist stated that the growing popularity of the "medical men" and their instruments was directly related to the ability of men to convince women that they had superior skills, that childbirth was dangerous, and that midwives were incompetent.82 Physician-assisted birth became an isolating experience for the mother.83 The doctor often dismissed family and supportive friends because they were a hindrance to his practice.84 Despite the disruption to traditional rituals of childbirth that the physician's presence caused, upper- and middle-class women appreciated his superior skills in managing pathological cases and his reputation for having acquired scientific knowledge.85 Dramatic rescues by doctors convinced large groups of people that the physician was necessary to childbirth.86 Increasingly, physicians were called to attend normal deliveries as well as problematic ones. In the nineteenth century, upper- and middle-class families became convinced that normal pregnancy was so potentially or actually abnormal that it constituted a medical condition.87
The American midwife gave way to the medical doctor as the chief birth attendant for the middle and upper classes during the nineteenth century.88 Physicians endorsed more extensive interventions in birth, moving away from the conservative approach of the midwives.89 In spite of this more interventionist care, the maternal and infant death rates were much higher in the United States than in European countries.90
The successful strategy of the physicians was to develop a demand for a "higher standard of obstetrics"; normal pregnancy and delivery were said to be a fallacy.91 The actual dangers of birth were greatly exaggerated,92 and routine medical intervention during birth was firmly established as "necessary."93 Upper- and middle-class American women who could afford to use male practitioners were taught to value obstetric skills and fear the dangers of childbirth to the point that no precautions were considered excessive.94 At the same time, most newly graduated doctors had no clinical experience in attending birth.95
Early twentieth century studies disclosed that "maternal mortality rates were lowest in those localities reporting the highest percentage of midwife attended births."96 The Children's Bureau published articles that alerted the country to the many "preventable" deaths that were occurring in childbirth, and their reports prompted studies of the outcomes of both physician and midwife care.97 A national conference was held at the White House in 1925 to announce that "the record of trained midwives" actually "surpasses the record of physicians in normal deliveries"; midwives, the conferees reported, took better care of women inlabor because they exhibited patience and let nature take its course.98 Dr. Josephine Baker, who served with the New York City Department of Health for 25 years, established a school in 1911 to train midwives and utilized their services extensively in the City for that time period. By 1921, the infant mortality rate for ail of New York City had decreased by one-half.99
Despite strong evidence that the new obstetrical practices were not improving the outcome of childbirth,100 the move toward physician-controlled childbirth continued. Many women perceived hospital stays as the way to alleviate the risks of childbirth.101 "By 1930, only fifteen percent of births were attended by midwives."102 Nevertheless, puerperal fever, an often fatal condition resulting from infection acquired during labor and delivery,"103 was widespread in the maternity wards as well as in physician-assisted home birth.104 This dreaded disease contributed to the image of pregnancy as an illness, even though it was spread by the doctors themselves.105 By the mid-1930s, several factors had contributed to reduction in the incidence of puerperal fever: a reduction in needless operations; the discovery of antimicrobial drugs such as sulfa and penicillin; blood transfusions; shortening of pathologically long labors; and "a general improvement in women's health."106 At the same time that hospitals were becoming safer, women were turning to hospitals to avoid pain during childbirth.107 By the 1940s, more than half of all births occurred in the hospital;108 and by 1950, eighty-eight percent of the public used hospitals for births.109 By this time, hospital birth resembled a "production line," characterized by physician supervision and control, wilh "every precaution ... taken to prevent disaster."110 Women often experienced hospital birth as dehumanizing and cruel.111
During the 1960s, women pushed for reform, striving for increased autonomy.112 "Natural childbirth" gained popularity as women sought greater safety for themselves and more control over their bodies during the birth process.113 The medical profession reacted negatively to this new interest.114 From the 1940s to the 1970s, a woman entering the hospital who insisted on natural childbirth was considered "hostile."115 Her request was considered unreasonable because it required too much time. Only private patients who could afford to pay higher prices could convince obstetricians to deliver their babies "naturally."116 In the 1950s, husbands were allowed to stay with their wives during the early stages of labor, but until the 1970s they were forbidden to accompany their wives during labor and birth.117 The Lamaze program of "prepared childbirth," initially lauded for transferring some control to the laboring woman, was adopted by hospiitals because it helped them promote medical interventions as "natural."118 Instead of being educated as to which of the hospital routines were unnecessary or arbitrary, the pregnant woman was taught breathing exercises to help her accept whatever was done to her.119 Lamaze instruction continued medical domination over women during labor and birth.120
As long as women continued to give birth in hospitals, doctors accepted some parts of the new movement toward "naturalness." The Lamaze method did not significantly interfere with rnedical control over birth.121 By 1970, "prepared childbirth" in the hospital was "natural" and included episiotomy, outlet forceps, demerol, and epidural anesthesia, in addition to the Lamaze method.122 Unlike the home-birth movement and the midwifery model that support control during birth by the mother herself, "prepared childbirth" does not challenge physician control.123
II. TYPES OF MlDWIVES & MODERN DEFINITION
According to D . J. G. Kloosterman, former director of the Midwives Academy in Holland the modern midwife should have at least three years of training.124 Part of her training should be in the hospital so that she becomes very familiar with pathology in order to recognize it early and refer cases to obstetricians. Midwives can thus free obstetricians to concentrate on their real task of studying human parturition and handling pathology.125
There are several types of midwives in the United States. Some midwives are formally educated while others are not. Some are tested and certified while others are not. Some enter directly into midwifery training126 without becoming nurses first and some have been formally educated in both nursing and midwifery. This can be confusing for consumers since, until recently, there have been no agreed-upon professional standards for non-nurse midwives.
To develop those standards has been a challenge for the American College of Nurse-Midwives (ACNM)127 and the Midwives Alliance of North America (MANA),128 the nation's two largest midwifery organizations. There has been controversy within these organizations regarding the use of the term "professional" to describe midwives since some believe that it should require formal education, while others assert that the term should also be applied to midwives trained through apprenticeship. Nevertheless, members of the organizations, working in tandem, have developed the following definition:
The professional midwife is a primary care provider who independently renders care during pregnancy, birth and the postpartum period to women and newborns in her community. With additional education and training, the professional midwife may render well-woman care and gynecological care. The midwife works with each woman and her family to identify their unique physical, social and emotional needs. Midwifery care occurs within a variety of settings and includes education and health promotion. When the care required extends beyond her abilities the midwife has a mechanism for consultation, referral, continued involvement and collaboration.129
"Traditional" birth attendants in the United States are empirically or apprentice-trained midwives. Direct experience constitutes the majority of their training. Some states regulate and register them, while many others have made their practice illegal. Their competence and training varies from state to state. Many are well trained and competent, but are not allowed to practice under their state's laws.130 The term "lay midwife" has no "specific meaning that is widely understood or accepted. It [has been] used to describe all kinds of midwives who may or may not be formally educated, may or may not have met some legal requirements for the practice of midwifery, and may or may not share [a commom or near-common] philosophy regarding birth.131 Thus the term may be used erroneously to discredit well-trained direct-entry midwives.
Modern midwifery in the United States has been thought of, for the most part, as a function performed by nurses. Registered nurses, whether they possess an associate's degree (generally two years of college) or a bachelor's degree (generally four years of college), can complete a certificate program in nurse-midwifery in fourteen months.132 If a nurse desires a master's degree in midwifery, however, she must first earn a bachelor's degree (which can be in another discipline) and complete a two-year graduate midwifery program. Whether the midwife trains by the direct-entry route or by the nurse midwifery route, the American College of Nurse-Midwives states that she must achieve certain core competencies: "The [American College of Nurse Midwives] believes that the standards for professional midwifery practice should be identical whether nursing is a base for midwifery or not."133 Unlike some nurse professionals, the ACNM values competency as the ultimate goal of training and does not push for or require college degrees:
[The ACNM] has adopted a policy of opposing mandatory degree requirements for state licensure for certified nurse-midwives. This position is stated in the "Guidelines for State Statutes and Regulations" ... approved by the ACNM Board of Directors in July 1984 .... Because there is no evidence that degrees enhance the clinical competence of a nurse-midwife, the ACNM believes that the requirement for a degree should not be in the law or in rules which have the force of law.134
Leaders in the field, such as Jo Anne Myers-Ciecko, Executive Director of the Seattle Midwifery School, feel that midwifery must be redefined depending on the country and culture where it is practiced. The Seattle School trains direct-entry midwives, and few of the students have had nursing training previously.135 In its philosophy, the school recognizes first, that the principles of normal birth are best learned in non-institutional settings, and second, that the best way to learn the art and science of midwifery is from experienced midwives. The School is known for its high standards of education. While Myers-Ciecko recognizes the importance of village midwives in Third World countries, she believes that "in the United States, where the population is highly mobile, culturally diverse, and generally relies on professionals for everything from food production to health care, more formal, explicit, and standardized requirements for entry into a service field involving life and death decisions are appropriate."136 The Seattle School program is based on the European three-year, direct-entry model in which the required nursing skills are built into the program.137 Like that of the American College of Nurse-Midwives, the educational philosophy of the Seattle Midwifery School is based on teaching the core competencies necessary to the entry-level practice of midwifery. 138 Two schools similar to the Seattle School are expected to open in Florida in the fall of 1993.139
Ernest L. Boyer, President of The Carnegie Foundation for the Advancement of Teaching, and Senior Fellow of the Woodrow Wilson School at Princeton University, is responsible for instigating a meeting and collaborative effort of the American College of Nurse-Midwives (ACNM) and the Midwives Alliance of North America (MANA). Representatives of the ACNM and MANA have held several controversial meetings over the last few years. Boyer recently explained the reasons for his midwifery project: "In education, public policy isn't just turned over to teachers to decide, yet for decades physicians have shaped the debate for health care. We should first look at the interests of mothers and babies."140 According to Dr. Boyer, the time has come for midwifery in the United States to become an independent profession.141 He has proposed "a decade-long national crusade" describing midwives as "the noblest [c]hoice."142 Dr. Boyer wants the crusade to "tell the truth" about midwifery and describe vividly the impeccable credentials and the outstanding achievements of this profession."143
Conferees of Boyer's program, who came from many backgrounds, agreed that multiple entry routes are required to increase the numbers of professional midwives.144 As direct-entry programs are approved, midwives hope to shape a core curriculum that will define clearly and coherently the fundamentals of the profession. As well as agreeing on a modern definition of a professional midwife, midwives have defined "core competencies" in which all midwives, regardless of the entry pattern, should be versed by the end of their training. The vice-president of the ACNM has noted that nurse-midwives and direct entry midwives trained in comprehensive programs have very similar requirements:
[A] comparison of the ACNM core competencies for the practice of nurse-midwifery and the statement of core competencies from the MANA midwifery educators' group [proponents of the direct entry/non-nurse schools] resulted in almost complete agreement. Although the two documents were written differently, the essential content is the same.145
The collaboration of these two organizations has great potential for developing midwifery as a profession in the United States and making it available to many more thousands of American women. Even greater responsibilities for these broad-thinking midwives include bringing all types of midwives together and promoting midwifery as an independent and autonomous profession.146
A 1982 survey by the ACNM indicates that ninety-two percent of all nurse midwives would like to provide services in birth centers or in the home. But by 1987, only fifteen percent of nurse-midwives worked in birth centers,147 and far fewer provided home birth services.148
III. A COMPARISON OF THE MEDICAL
AND MIDWIFERY MODELS OF BIRTH
The two philosophies of childbirth&emdash;the medical model and the midwifery model&emdash;differ distinctively, as the following chart illustrates:
Pregnancy is normal. ..Pregnancy is a "condition."
Pregnancy includes physical ..Pregnancy causes "symptoms."
changes.
The pregnancy is part of the .The pregnancy is "external"
woman. ....to the woman, not a part of her.
Pregnancy is a "working norm" Pregnancy is almost entirely a
for any woman. ....mechanical event" and is a
.......stressor.149
Both before and after birth, the medical model conceives of the baby and the mother as conflicting entities with conflicting needs&emdash;the baby needs attention and feeding; the mother needs rest. In contrast, the midwifery model treats the needs of the mother and the needs of the infant as interlocking, during pregnancy and labor and after birth. The midwife interprets the mother's need for "rest" as the need for relief from activities other than caring for her baby. The baby needs to be with the mother.150
A. The Medical Model
In the Netherlands, a doctor who wants to handle normai deliveries must study midwifery formally for one year.151 But U.S. medical schools do not consider midwifery training necessary for American doctors,152 who have little or no knowledge of the midwifery model of birth. Physicians in our country can graduate from medical school without having delivered a single baby. They can become board-certified in obstetrics and gynecology having never seen a normal birth conducted without interventions.153
In contrast, nurse-midwife and direct-entry midwife trainees manage a substantial number of births prior to certification or licensing. The ACNM does not mandate a minimum number of deliveries for a student nurse-midwife to manage during her educational experience,154 but some university-based nurse-midwifery programs require trainees to manage up to forty deliveries.155 Direct-entry trainees at the Seattle Midwifery School and in the Florida midwifery-schools must manage fifty births prior to graduation.156 Midwife trainees in the European Community are required to manage forty normal births and assist with forty complicated births in order to graduate.157
While midwifery can be described as primary care, obstetrical care is acute or tertiary care, developed specifically to treat genuinely pathological pregnancies and emergencies. Physicians determine the need for acute care by calculating the perceived risk; "the definition of risk is ... central to the medical model of birth."158 In the calculation of risk approach, childbirth is seen and described as a life-threatening situation.159 This approach creates fear in the minds of the public, which then demands acute care.160
Acute care, with its many interventions and drugs, ensures that the risk approach becomes a self-fulfilling prophecy.161 The infant mortality rate in the United States far exceeds that in Japan and Europe, where birth is considered normal and midwives are the attendant of choice. The following table provides infant mortality rates for many "First World" countries and shows how poorly the United States has done:
INFANT MORTALITY RATES 1989: 162
COUNTRY ..........NUMBER OF DEATHS PER 1000 LIVE BIRTHS
................ Japan . ................................4.4
................ Finland.................................5.8
................ Sweden ...............................6.0
................ Switzerland...........................6.8
................ Netherlands .........................6.8
................ Canada................................ 7.1
................ Hong Kong ...........................7.4
................ France ................................7.4
................ Singapore............................7.5
................ Germany .............................7.6
................ Australia .............................7.7
................ Norway................................7.8
................ Spain ...................................7.8
................ Austria ................................8.3
................ Denmark .............................8.4
................ England & Wales (U.K.) .........8.5
................ Italy....................................8.8
................ Belgium ...............................8.6
................ United States .......................9.7
................ Greece ................................9.8
MIDWIFERY IS NOT THE PRACTICE OF MEDICINE
by Suzanne Hope Suarez
RN, BSN., J.D., AAUW Educational Foundation National Fellow, 1991-1992. chair, Healthy Start Coalition Advisory Board for Florida, 1991. Florida Bar Foundation Public Service Fellow, 1989-1992
from the Yale Journal of Law and Feminism
Note: the Footnotes (in red) are listed separately so that you may read them simultaneously with the text of the article. Click here to move to the footnotes page.
For the great majority of American women, the right to choose the place and manner of giving birth has quietly, but continually, narrowed.1 In just half a century, allopathic physicians2 in the United States have enticed ninety-nine percent of us into their places of business (hospitals) for childbirth, forced on us a medical model of birth that has never been proven safe or beneficial, raised the price of services which have diminished in quality and quantity, and lobbied state legislatures for laws that would require us to submit to their exclusive control during pregnancy and childbirth.
Unfortunately, the role of obstetrics has never been to help women give birth. There is a big difference between the medical discipline we call "obstetrics" and something completely different, the art of midwifery. If we want to find safe alternatives to obstetrics, we must rediscover midwifery. To rediscover midwifery is the same as giving back childbirth to women. And imagine the future if surgical teams were at the service of the midwives and the women instead of controlling them.3
Although obstetricians worldwide use the same sophisticated technology and drugs in pregnancy and childbirth as American physicians, doctors in other countries use them differently.4 Doctors in the country with the lowest infant mortality rate, Japan, use little or no drugs and are much slower to interfere with the natural process of birth.5 In the United States, the economic alliance between doctors and the producers of technological equipment has obstructed preventive maternity care. "Medical priorities are set by the medical industrial complex, which focuses on providing health care at a profit.6
In Europe, the infant mortality rate is significantly less than in the United States.7 An important attitudinal difference accompanies this statistical difference. Europeans consider birth to be a normal event, and midwives deiiver the majority of babies.8 The European Economic Community standards for midwifery education and training programs require three years of intensive study and apprenticeship.9 Many European'midwives10 work without physician supervision and are not required to study nursing as a prerequisite to rnidwifery training.11 Decades of misinformation and misapprehension, on the other hand, have taught women in the United States that birth is a dangerous and pathological event, requiring care by medical specialists.12 Obstetricians far outnumber midwives in our country and the excellent statistics of the midwives are a well-kept secret.13
Significantly, Dr. J. G. Kloosterman, former Professor of Obstetrics and Gynaecology at the University of Amsterdam and Director of the Midwives Academy in Holland from 1947 to 1957, has noted that obstetricians cannot improve upon nature: "By no means have we been able to improve spontaneous labour in healthy women. Spontaneous and normal labour is a process, marked by a series of events so perfectly attuned to one another that any interference only deflects them from their optimum course.14 The capacity to intervene has led to the notion that intervention is always desirable, even though "[t]here is strong evidence that modern western obstetrics is perverting the physiology of human parturition.15 The obstetrician, says Kloosterman, is always on the lookout for pathology, eager to interfere, and the interferences themselves cause pathology that then needs further "treatment."16 Dr. Marsden Wagner, Director of the World Health Organization's (WHO) European Regional Offlce, told doctors at an international medical conference in Jerusalem that hospital births "endanger mothers and babies&emdash;primarily because of the impersonal procedures and overuse of technology and drugs."17 The very surroundings and equipment in hospitals increase the risk of iatrogenic, or "doctor-caused" complications18 which result in excessively high costs to consumers.19
In her 1975 book, Immaculate Deception, Suzanne Arms described the manner in which obstetricians justify preventive interferences during childbirth "to [turn] sloppy old nature into a clean, safe science:" [J]ust in case you hemorrhage, we'll give you simulated hormones before you expel the placenta; just in case your perineum tears, we'll make a nice clean incision before delivery; just in case labor tires you out, we'll give you an early sedative; just in case you need a general anesthesia [for an emergency caesarean], we'll keep a vein open [put in an IV] and stop you from eating and drinking throughout labor, even if it takes twenty-four hours; and just in case you totally lose control, we'll knock you right out ...20
According to Arms, it is no wonder that a pregnant woman believes that birth is "loaded with unpredictable horrors that only her doctor can prevent.21 The "normal" length of the stages of labor has been shortened in medical texts, allowing for earlier medical intervention.22 The length of the stages of labor for hospital births in the 1940s and before was actually longer than the length of labor in home births in the early 1970s in which nature was allowed to "take its course."23 Nevertheless, by the late 1960s and 1970s, labor in hospitasl births was nearly five hours shorter than in home births, with an apparent increase in fetal distress and other complications.24 Hospitals and doctors push the birth process along to assure that a certain number of deliveries will occur when the meximum number of personnel are available&emdash;in other words, during office hours. Waiting for the natural process to occur spontaneously does not serve "institutional needs."25
Although prolonging a pregnancy beyond forty-two weeks can be risky, inducing labor does not increase the baby's chances of survival.26 Drug-induced labor after forty-two weeks, however, is a routine practice.27 Hospital rituals and interventions in the birth process comfort the obstetrician who may otherwise have to deal with feelings of uncertainty about the birth.28 By managing normal birth in the same way as 'abnormal birth,' doctors make each birth more predictable.29
If professional midwives conducted the majority of births, women with completely healthy pregnancies could feel protected from unnecessary obstetrical interferences. The midwife screens her clients carefully so that she takes only low-risk cases. She is trained to recognize abnormalities and is fully capable of transferring a woman to a hospitai safeiy during labor if necessary. Dr. Kloosterman estimates that under midwifery care, only three to five percent of healthy mothers would require physician care during delivery.30 If physicians were consulted in only three to five percent of cases, he states, the infant mortality rate would drop to between two and four in one thousand.31
Most women attended by nurse-midwives in our hospitals are poor African Americans.32 The white population, which generally tends to be healthier, is more likely to be attended by specialist obstetricians. It seems no coincidence that this healthier, and thus lower-risk, group which is nevertheless more likely to be treated by an obstetrician, has more caesarean sections.33 If mothers and babies were the paramount concern of the physicians, the increased incidence of caesarean sections would statistically peak within the "higher-risk" black population where their use could be justified. Instead, these expensive interventions are applied to those who can pay the most.34
Economics is the hidden agenda when midwifery regulation is discussed in state legisiative sessions. In testimony before legislative committees, the medical lobby overemphasizes the potential of pregnancies to become pathological.35 Though pathology occurs in only a small minority of pregnancies, many legislators are convinced that physician treatment should be required for the safety of mother and infant.36 Implicitly, under this medical model of pregnancy and birth, the profession of midwifery is subordinated and maternity care becomes "the practice of medicine" subject to state statutes that regulate the practice of medicine. No evidence exists, however, that this system is actually safer than home birth with a competent midwife. Public health experts and researchers are recognizing that midwifery will not disturb the system of obstetrics. Instead, international research indicates that the two professions are compatible, complementary and necessary to each other for an efficient and cost-effective system of care.37 The fallacy-ridden dominant belief that "home birth is dangerous"38 makes it relatively easy for the medical lobby to convince lawmakers that pregnant women who reject doctor control endanger themseives and their babies and that midwives are safe practitioners only if they are also nurses. Physicians cite the safety of the infant (and, secondarily, the mother) as a primary concern. Doctors have successfully prioritized the rights of the unborn39 and maintained control over the wishes of the parents who pay their fees. Ironically, consumers are afforded little control even though they, not the physicians, bear the ultimate responsibility of pregnancy and birth.
Strained economic times and grossly high infant mortality rates have led states to consider midwifery as a way to make maternity care accessible and affordable in spite of doctors' protests. In the 1992 Florida legislative session, House Bill 553, proposing the legalization of three-year training schools for direct-entry (non-nurse) midwives, was heatedly debated.40 Although the direct-entry schools were based on the European training model and the Senate Health Care Committee had studied and recommended passage of the bill, the Florida Medical Association (FMA) opposed it.41 The FMA told the lawmakers that "Many midwives do not have the education nor the training to practice without posing [a] serious threat to the public."42 When asked by tbe Senate Committee to verify their position with statistics or facts they could not do so. The space for that information was left blank. The FMA wanted the penalty for unlicensed midwifery in the state of Florida increased from a misdemeanor to a felony. The physicians claimed that, unless these "other" midwives were legally placed under obstetrical supervision (like the nurse-midwives), they would refuse to provide emergency back-up services.43 The bill passed anyway.44
Independent, non-nurse midwives, not subject to doctor control, are unwelcome business competition. ln 1990, the U.S. Department of Health and Human Services reported that "female with delivery" was the most common hospital discharge category.45 Since hospital birth is a major source of revenue for most public and private hospitals,46 it is understandable that hospital associations join with physicians to lobby against out-of-hospital births.
When independent "direct-entry" midwives attend a laboring woman at home, the facility fee (for a room in a hospital or birth center) is nonexistent. The difference in cost between a home birth with a licensed midwife and a normal hospital birth is considerable. For example, licensed direct-entry midwives in Florida charge $700 to $1600 for their services,47 compared with an average of $4500 for a normal hospital birth.48
Nevertheless, economic disincentives often discourage even nurse-midwives from providing home birth services. Even if they can locate physicians who will work with them, insurance companies in most states do not cover the cost of midwifery services if birth is not performed in a hospital or birth center.49 Medicaid often does not reimburse midwives for home deliveries.50 The National Center for Health Statistics reports that in 1989, out of 4,040,958 births (national total for all races), only 11,383 (.28%) were planned home births attended by midwives. Of these births, nurse-midwives attended only one-third (.09%).51
Birth centers52 provide a practice place for nurse-midwives who reject the subordinate role forced on them in hospitals. With increasing physician ownership, these centers have been reclassified as "safe" alternatives to hospitals in most states even though physicians are usually not in attendance. A recent study demonstrated that birth statistics of nurse-midwives in birth centers are better than those of nurse-midwives working with obstetricians in hospitals.53
Obstetrical interventions pass for science, even though their use in normal pregnancy is irrational.54 According to anthropologist Robbie Davis-Floyd, obstetrical interventions fulfill a rational societal function by diminishing our high-tech society's extreme fear of birth.55 Specific cultural services are performed when obstetricians "bring forth a new social member through a maze of wires and electronic bleeps."56 Obstetrical rituals convey core values that center around science and technology. Belief in them as "necessary" sustains patriarchal institutional management.57 We let monitors, intravenous devices, and drugs give birth instead of women, turning the bodies of women who give birth into "machines."58 Faith in technology provides a comfortable refuge from the unknown.59
The entrance of women into the field of obstetrics has not made a significant difference in the way obstetricians preside over birth.60 As a group, female obstetricians tend to conform more to the philosophy of their male colleagues than to that of female midwives. Medical school selection processes, socialization during medical education, the stresses inherent in obstetric residency programs, and the minority status of women in medicine are all factors likely to contribute to female physicians' unwillingness to buck the system. Moreover, medical schools convey the consistent and pervasive message to medical students that technology is always an advantage.61 There is apparently little difference in the degree to which this "indoctrination" affects female and male obstetricians.62
In physician-chosen settings, nurse midwives must work under "doctor's orders." Outside the hospital, nurse-midwife services are constrained by requirements for supervision by physicians. One commentator, discussing restrictions on nurse-midwifery in the context of malpractice insurance policy, compared physicians and hospitals to lawyers who have worked to prevent paralegals and others from the practice of law:
[M]any professions, including both medicine and law, have erected rather stringent barriers to prevent entry by others who would like to practice in the field. In pure market terms, that cuts directly against private enterprise. In effect, the professionals do not allow open and free competition... I happen to think it's not right.... [A]ccess [to independent midwives] is generally contained by requirements for supervision by physicians .... If the public were allowed to choose the lower-cost alternative freely, knowingly accepting the risk, I think that there would undoubtedly be more competition in the medical field. I believe nurse-midwives have lower claims frequency and severity rates.63
In hospitals and physician-controlled birth centers, the physician defines what is normal and what is abnormal. Physicians control the training of midwives and the services they can provide.64 As such, hospital-based nurse-midwifery is thus no real threat to medical control.
The distinction between nurses and midwives has been pointed out by researchers who find the combination of the two professions disturbing.65 A nurse is trained not to make decisions but to defer to physician authority. Like the physician, the nurse has been taught to expect problems and complications in every birth. The midwife, on the other hand, understands that the birth process seldom requires intervention. Her forte is normal birth, although she is well-trained to recognize and address abnormalities.66 Her experience at handling normal birth gives her skills that obstetricians do not possess. She serves the mother, not the physician, and although she will quickly transfer the mother to the hospital when the labor deviates from normal expectations, her main role is support and protection so that unnessary interventions do not occur.67
From Europe, there is also evidence that a strong independent midwifery profession is an important counterbalance to the obstetrical profession in preventing excessive interventions in the normal birth process. Consequently, it is perhaps not surprising that in the U.S. one finds the highest obstetrical intervention rates as well as a serious problem with malpractice suits. The European experience and our data strongly support the urgent need for the introduction of widespread, independent midwifery practice in the United States as a most important counterbalance to the present situation.68
Midwifery, with its shift of control from the doctor to the mother, is seen as a threat by organized medicine. The superb safety record of birth centers, with their popular "home-like" atmosphere, has been such a threat that hospitals have annexed "birthing rooms" and expanded midwifery service.69 Most nurse-midwives, however, are employed by physicians who forbid them from providing home-birth services.70 Control of the practice setting for other nurse-midwives is also strictly regulated by doctors."71
Part I of this article will describe the history of the elimination of the American midwife and the concurrent takeover by organized medicine. Part II defines types of midwives in the United States and provides a modern definition. Part III analyzes the differences between the medical model of birth and midwifery. Part IV argues that the legisisture is the appropriate forum for reform, especially since attempts at change through the judicial process have failed. Moreover, strong policy arguments exist for reforming the current regime of medical hegemony over childbirth.
I. HISTORY OF THE ELIMINATION OF THE AMERICAN MIDWIFE
The midwife's traditional role in childbirth went unchallenged until delivering babies became both a science and a business. In the Colonial period, midwives attended the majority of births.72 Childbirth was a social, not a medical event, in which women offered aid and comfort to each other during the delivery. Women relatives and friends served and assisted the laboring mother.73 Physicians' participation in childbirth in this period was limited to attendance at the most difficult births, and was prompted by the perceived need for the use of instruments.74
After 1750, men with European medical training began to practice in the American colonies.75 The first colonial medical school was founded in 1765, and by the first decade of the nineteenth century, midwifery was taught at five American medical schools.76 By this time, physicians were beginning to call their participation in childbirth "obstetrics"&emdash;"a scientific-sounding title free of the feminine connotations of the word "midwife."77 Physicians in both England and the United States were transforming childbirth into a medical/scientific event.78 Nevertheless, American doctors first assumed that midwives would continue to handle normal deliveries and that they would intervene only in difflcult cases.79 Some limited training opportunities in the "obstetrick art" were extended to female midwives;80 by 1820, however, physicians' interest in instructing midwives had ceased to exist.81 As early as 1760, a well-known journalist stated that the growing popularity of the "medical men" and their instruments was directly related to the ability of men to convince women that they had superior skills, that childbirth was dangerous, and that midwives were incompetent.82 Physician-assisted birth became an isolating experience for the mother.83 The doctor often dismissed family and supportive friends because they were a hindrance to his practice.84 Despite the disruption to traditional rituals of childbirth that the physician's presence caused, upper- and middle-class women appreciated his superior skills in managing pathological cases and his reputation for having acquired scientific knowledge.85 Dramatic rescues by doctors convinced large groups of people that the physician was necessary to childbirth.86 Increasingly, physicians were called to attend normal deliveries as well as problematic ones. In the nineteenth century, upper- and middle-class families became convinced that normal pregnancy was so potentially or actually abnormal that it constituted a medical condition.87
The American midwife gave way to the medical doctor as the chief birth attendant for the middle and upper classes during the nineteenth century.88 Physicians endorsed more extensive interventions in birth, moving away from the conservative approach of the midwives.89 In spite of this more interventionist care, the maternal and infant death rates were much higher in the United States than in European countries.90
The successful strategy of the physicians was to develop a demand for a "higher standard of obstetrics"; normal pregnancy and delivery were said to be a fallacy.91 The actual dangers of birth were greatly exaggerated,92 and routine medical intervention during birth was firmly established as "necessary."93 Upper- and middle-class American women who could afford to use male practitioners were taught to value obstetric skills and fear the dangers of childbirth to the point that no precautions were considered excessive.94 At the same time, most newly graduated doctors had no clinical experience in attending birth.95
Early twentieth century studies disclosed that "maternal mortality rates were lowest in those localities reporting the highest percentage of midwife attended births."96 The Children's Bureau published articles that alerted the country to the many "preventable" deaths that were occurring in childbirth, and their reports prompted studies of the outcomes of both physician and midwife care.97 A national conference was held at the White House in 1925 to announce that "the record of trained midwives" actually "surpasses the record of physicians in normal deliveries"; midwives, the conferees reported, took better care of women inlabor because they exhibited patience and let nature take its course.98 Dr. Josephine Baker, who served with the New York City Department of Health for 25 years, established a school in 1911 to train midwives and utilized their services extensively in the City for that time period. By 1921, the infant mortality rate for ail of New York City had decreased by one-half.99
Despite strong evidence that the new obstetrical practices were not improving the outcome of childbirth,100 the move toward physician-controlled childbirth continued. Many women perceived hospital stays as the way to alleviate the risks of childbirth.101 "By 1930, only fifteen percent of births were attended by midwives."102 Nevertheless, puerperal fever, an often fatal condition resulting from infection acquired during labor and delivery,"103 was widespread in the maternity wards as well as in physician-assisted home birth.104 This dreaded disease contributed to the image of pregnancy as an illness, even though it was spread by the doctors themselves.105 By the mid-1930s, several factors had contributed to reduction in the incidence of puerperal fever: a reduction in needless operations; the discovery of antimicrobial drugs such as sulfa and penicillin; blood transfusions; shortening of pathologically long labors; and "a general improvement in women's health."106 At the same time that hospitals were becoming safer, women were turning to hospitals to avoid pain during childbirth.107 By the 1940s, more than half of all births occurred in the hospital;108 and by 1950, eighty-eight percent of the public used hospitals for births.109 By this time, hospital birth resembled a "production line," characterized by physician supervision and control, wilh "every precaution ... taken to prevent disaster."110 Women often experienced hospital birth as dehumanizing and cruel.111
During the 1960s, women pushed for reform, striving for increased autonomy.112 "Natural childbirth" gained popularity as women sought greater safety for themselves and more control over their bodies during the birth process.113 The medical profession reacted negatively to this new interest.114 From the 1940s to the 1970s, a woman entering the hospital who insisted on natural childbirth was considered "hostile."115 Her request was considered unreasonable because it required too much time. Only private patients who could afford to pay higher prices could convince obstetricians to deliver their babies "naturally."116 In the 1950s, husbands were allowed to stay with their wives during the early stages of labor, but until the 1970s they were forbidden to accompany their wives during labor and birth.117 The Lamaze program of "prepared childbirth," initially lauded for transferring some control to the laboring woman, was adopted by hospiitals because it helped them promote medical interventions as "natural."118 Instead of being educated as to which of the hospital routines were unnecessary or arbitrary, the pregnant woman was taught breathing exercises to help her accept whatever was done to her.119 Lamaze instruction continued medical domination over women during labor and birth.120
As long as women continued to give birth in hospitals, doctors accepted some parts of the new movement toward "naturalness." The Lamaze method did not significantly interfere with rnedical control over birth.121 By 1970, "prepared childbirth" in the hospital was "natural" and included episiotomy, outlet forceps, demerol, and epidural anesthesia, in addition to the Lamaze method.122 Unlike the home-birth movement and the midwifery model that support control during birth by the mother herself, "prepared childbirth" does not challenge physician control.123
II. TYPES OF MlDWIVES & MODERN DEFINITION
According to D . J. G. Kloosterman, former director of the Midwives Academy in Holland the modern midwife should have at least three years of training.124 Part of her training should be in the hospital so that she becomes very familiar with pathology in order to recognize it early and refer cases to obstetricians. Midwives can thus free obstetricians to concentrate on their real task of studying human parturition and handling pathology.125
There are several types of midwives in the United States. Some midwives are formally educated while others are not. Some are tested and certified while others are not. Some enter directly into midwifery training126 without becoming nurses first and some have been formally educated in both nursing and midwifery. This can be confusing for consumers since, until recently, there have been no agreed-upon professional standards for non-nurse midwives.
To develop those standards has been a challenge for the American College of Nurse-Midwives (ACNM)127 and the Midwives Alliance of North America (MANA),128 the nation's two largest midwifery organizations. There has been controversy within these organizations regarding the use of the term "professional" to describe midwives since some believe that it should require formal education, while others assert that the term should also be applied to midwives trained through apprenticeship. Nevertheless, members of the organizations, working in tandem, have developed the following definition:
The professional midwife is a primary care provider who independently renders care during pregnancy, birth and the postpartum period to women and newborns in her community. With additional education and training, the professional midwife may render well-woman care and gynecological care. The midwife works with each woman and her family to identify their unique physical, social and emotional needs. Midwifery care occurs within a variety of settings and includes education and health promotion. When the care required extends beyond her abilities the midwife has a mechanism for consultation, referral, continued involvement and collaboration.129
"Traditional" birth attendants in the United States are empirically or apprentice-trained midwives. Direct experience constitutes the majority of their training. Some states regulate and register them, while many others have made their practice illegal. Their competence and training varies from state to state. Many are well trained and competent, but are not allowed to practice under their state's laws.130 The term "lay midwife" has no "specific meaning that is widely understood or accepted. It [has been] used to describe all kinds of midwives who may or may not be formally educated, may or may not have met some legal requirements for the practice of midwifery, and may or may not share [a commom or near-common] philosophy regarding birth.131 Thus the term may be used erroneously to discredit well-trained direct-entry midwives.
Modern midwifery in the United States has been thought of, for the most part, as a function performed by nurses. Registered nurses, whether they possess an associate's degree (generally two years of college) or a bachelor's degree (generally four years of college), can complete a certificate program in nurse-midwifery in fourteen months.132 If a nurse desires a master's degree in midwifery, however, she must first earn a bachelor's degree (which can be in another discipline) and complete a two-year graduate midwifery program. Whether the midwife trains by the direct-entry route or by the nurse midwifery route, the American College of Nurse-Midwives states that she must achieve certain core competencies: "The [American College of Nurse Midwives] believes that the standards for professional midwifery practice should be identical whether nursing is a base for midwifery or not."133 Unlike some nurse professionals, the ACNM values competency as the ultimate goal of training and does not push for or require college degrees:
[The ACNM] has adopted a policy of opposing mandatory degree requirements for state licensure for certified nurse-midwives. This position is stated in the "Guidelines for State Statutes and Regulations" ... approved by the ACNM Board of Directors in July 1984 .... Because there is no evidence that degrees enhance the clinical competence of a nurse-midwife, the ACNM believes that the requirement for a degree should not be in the law or in rules which have the force of law.134
Leaders in the field, such as Jo Anne Myers-Ciecko, Executive Director of the Seattle Midwifery School, feel that midwifery must be redefined depending on the country and culture where it is practiced. The Seattle School trains direct-entry midwives, and few of the students have had nursing training previously.135 In its philosophy, the school recognizes first, that the principles of normal birth are best learned in non-institutional settings, and second, that the best way to learn the art and science of midwifery is from experienced midwives. The School is known for its high standards of education. While Myers-Ciecko recognizes the importance of village midwives in Third World countries, she believes that "in the United States, where the population is highly mobile, culturally diverse, and generally relies on professionals for everything from food production to health care, more formal, explicit, and standardized requirements for entry into a service field involving life and death decisions are appropriate."136 The Seattle School program is based on the European three-year, direct-entry model in which the required nursing skills are built into the program.137 Like that of the American College of Nurse-Midwives, the educational philosophy of the Seattle Midwifery School is based on teaching the core competencies necessary to the entry-level practice of midwifery. 138 Two schools similar to the Seattle School are expected to open in Florida in the fall of 1993.139
Ernest L. Boyer, President of The Carnegie Foundation for the Advancement of Teaching, and Senior Fellow of the Woodrow Wilson School at Princeton University, is responsible for instigating a meeting and collaborative effort of the American College of Nurse-Midwives (ACNM) and the Midwives Alliance of North America (MANA). Representatives of the ACNM and MANA have held several controversial meetings over the last few years. Boyer recently explained the reasons for his midwifery project: "In education, public policy isn't just turned over to teachers to decide, yet for decades physicians have shaped the debate for health care. We should first look at the interests of mothers and babies."140 According to Dr. Boyer, the time has come for midwifery in the United States to become an independent profession.141 He has proposed "a decade-long national crusade" describing midwives as "the noblest [c]hoice."142 Dr. Boyer wants the crusade to "tell the truth" about midwifery and describe vividly the impeccable credentials and the outstanding achievements of this profession."143
Conferees of Boyer's program, who came from many backgrounds, agreed that multiple entry routes are required to increase the numbers of professional midwives.144 As direct-entry programs are approved, midwives hope to shape a core curriculum that will define clearly and coherently the fundamentals of the profession. As well as agreeing on a modern definition of a professional midwife, midwives have defined "core competencies" in which all midwives, regardless of the entry pattern, should be versed by the end of their training. The vice-president of the ACNM has noted that nurse-midwives and direct entry midwives trained in comprehensive programs have very similar requirements:
[A] comparison of the ACNM core competencies for the practice of nurse-midwifery and the statement of core competencies from the MANA midwifery educators' group [proponents of the direct entry/non-nurse schools] resulted in almost complete agreement. Although the two documents were written differently, the essential content is the same.145
The collaboration of these two organizations has great potential for developing midwifery as a profession in the United States and making it available to many more thousands of American women. Even greater responsibilities for these broad-thinking midwives include bringing all types of midwives together and promoting midwifery as an independent and autonomous profession.146
A 1982 survey by the ACNM indicates that ninety-two percent of all nurse midwives would like to provide services in birth centers or in the home. But by 1987, only fifteen percent of nurse-midwives worked in birth centers,147 and far fewer provided home birth services.148
III. A COMPARISON OF THE MEDICAL
AND MIDWIFERY MODELS OF BIRTH
The two philosophies of childbirth&emdash;the medical model and the midwifery model&emdash;differ distinctively, as the following chart illustrates:
Pregnancy is normal. ..Pregnancy is a "condition."
Pregnancy includes physical ..Pregnancy causes "symptoms."
changes.
The pregnancy is part of the .The pregnancy is "external"
woman. ....to the woman, not a part of her.
Pregnancy is a "working norm" Pregnancy is almost entirely a
for any woman. ....mechanical event" and is a
.......stressor.149
Both before and after birth, the medical model conceives of the baby and the mother as conflicting entities with conflicting needs&emdash;the baby needs attention and feeding; the mother needs rest. In contrast, the midwifery model treats the needs of the mother and the needs of the infant as interlocking, during pregnancy and labor and after birth. The midwife interprets the mother's need for "rest" as the need for relief from activities other than caring for her baby. The baby needs to be with the mother.150
A. The Medical Model
In the Netherlands, a doctor who wants to handle normai deliveries must study midwifery formally for one year.151 But U.S. medical schools do not consider midwifery training necessary for American doctors,152 who have little or no knowledge of the midwifery model of birth. Physicians in our country can graduate from medical school without having delivered a single baby. They can become board-certified in obstetrics and gynecology having never seen a normal birth conducted without interventions.153
In contrast, nurse-midwife and direct-entry midwife trainees manage a substantial number of births prior to certification or licensing. The ACNM does not mandate a minimum number of deliveries for a student nurse-midwife to manage during her educational experience,154 but some university-based nurse-midwifery programs require trainees to manage up to forty deliveries.155 Direct-entry trainees at the Seattle Midwifery School and in the Florida midwifery-schools must manage fifty births prior to graduation.156 Midwife trainees in the European Community are required to manage forty normal births and assist with forty complicated births in order to graduate.157
While midwifery can be described as primary care, obstetrical care is acute or tertiary care, developed specifically to treat genuinely pathological pregnancies and emergencies. Physicians determine the need for acute care by calculating the perceived risk; "the definition of risk is ... central to the medical model of birth."158 In the calculation of risk approach, childbirth is seen and described as a life-threatening situation.159 This approach creates fear in the minds of the public, which then demands acute care.160
Acute care, with its many interventions and drugs, ensures that the risk approach becomes a self-fulfilling prophecy.161 The infant mortality rate in the United States far exceeds that in Japan and Europe, where birth is considered normal and midwives are the attendant of choice. The following table provides infant mortality rates for many "First World" countries and shows how poorly the United States has done:
INFANT MORTALITY RATES 1989: 162
COUNTRY ..........NUMBER OF DEATHS PER 1000 LIVE BIRTHS
................ Japan . ................................4.4
................ Finland.................................5.8
................ Sweden ...............................6.0
................ Switzerland...........................6.8
................ Netherlands .........................6.8
................ Canada................................ 7.1
................ Hong Kong ...........................7.4
................ France ................................7.4
................ Singapore............................7.5
................ Germany .............................7.6
................ Australia .............................7.7
................ Norway................................7.8
................ Spain ...................................7.8
................ Austria ................................8.3
................ Denmark .............................8.4
................ England & Wales (U.K.) .........8.5
................ Italy....................................8.8
................ Belgium ...............................8.6
................ United States .......................9.7
................ Greece ................................9.8