On Her Own Responsibility

by Elizabeth Davis

The struggle for independent midwifery in the United States


The United States is the only country in the world that virtually eliminated the practice of midwifery. This took place around the turn of the century, when obstetrics became a profit-generating and male-dominated profession. Women could not acquire the requisite credentials because they were denied access to university education, and traditional midwives fell victim to a campaign organized by physicians to discredit their work.

The renaissance of midwifery in the United States occurred on two fronts: with the marriage of midwifery and nursing at Frontier Nursing Service in 1939, and with the resurgence of the traditional midwife in response to the consumer-based home birth movement of the late 1960s. Since then, midwives of diverse training backgrounds have struggled to legitimize their profession. Traditional midwives have endured criminal prosecution in states where their practice is defined as illegal, and nurse-midwives have experienced discrimination by means of limited access to backup and hospital privileges. All have recently accelerated their efforts to maintain their place in the health care system, while upholding their right to professional self-determination. Legislative and political efforts have met with varying degrees of success, while strategies for self-regulation, including a national certification process for traditional midwives, appear to be the wave of the future.

As declared repeatedly by the World Health Organization, midwifery care is essential to maternal-child health in every society. Innumerable studies have proven the efficacy of the midwifery model, with outstanding outcomes for midwife-assisted birth in any setting. The five countries in the world with the lowest perinatal mortality rates make generous use of midwives, who assist 70% of all births. In the United States, where political and economic constraints limit midwives to only 5% of births, a disgraceful perinatal mortality rank of 24 clearly results from the lack of health-promoting midwifery care.

Attacks against midwifery in the United States accelerated at the turn of the century when medicine became a profession for profit, and the newly emerging male physician became eager for the revenues of childbirth. Women were barred from university, thus those wanting to attend childbirth could not acquire the necessary credentials. Midwifery was nearly eradicated at this point, so vehement was the campaign of male physicians to discredit midwife practitioners, who were portrayed as slovenly, immoral, drunken, promiscuous and perverse, “whores with dirty fingers”. In medieval times, midwives were branded consorts of the Devil; now they became “loose women” intent on their own ways of healing, in contrast to “good girls” who pursued nursing and accepted roles subservient to the physician and his methods.

Predictably, physician-attended birth proved to be both expensive and unsafe. Remember the high incidence of childbed fever associated with hospital birth in the early 1900s, which not only cost women their lives, but cost their families for the attendant hospital stays. On the other hand, women who could not afford to be in hospital continued to rely on the midwife’s skill in preventative medicine: her emphasis on cleanliness, good nutrition and the use of herbs. Thus midwives of the past fostered their clients’ strength while providing education and counselling on a variety of health and family issues, much as they do today. The midwife’s scope of practice has traditionally been care “from womb to tomb”, employing a community health approach in treating a spectrum of women’s diseases and afflictions.

For midwives to continue to assert their time-honored scope of practice meant war with the increasingly powerful medical profession – a war that continues to this day. Left to themselves, midwives would never have survived; they were poor, politically powerless and disorganized. Midwifery is alive in our society today for one reason only, and that is women’s insistence on midwifery care. Midwifery is simply a fact of life, perpetuated by the needs and desires of birthing women and their supporters.

Although traditional midwives trained by apprenticeship have practised almost continuously in the United States, the development of nurse-midwifery is fairly recent. The Frontier Nursing Service began training midwives in 1939, using a model developed in England. There are now over 30 programs preparing nurse-midwives, although barriers to practice are considerable. Physicians have mixed reactions to the nurse-midwife – on the one hand, they find her a valuable adjunct to a busy practice, on the other, if she seeks to practise independently with her own case load, she is little more than a threat, an economic competitor. That the physician expects the nurse to play a subordinate role is rooted in our cultural oppression of our women healers, and is likewise endemic to our technocratic model of medicine. In contrast, the midwife’s responsibilities require that she have the autonomy to make her own decisions in case of crisis, and to use interventions, maneuvers and procedures in the event of an emergency that inadvertently cross into the physician’s self-proclaimed scope of practice.

The question of how to establish and maintain legitimacy within the current medical system has caused sharp divisions among nurse-midwives. There are nearly even ranks in the American College of Nurse-Midwives (ACNM) of those who align more strongly with nursing than midwifery, and vice versa. The debate continues as to whether training as a nurse is of benefit to the aspiring midwife. It is noteworthy that in the Netherlands (where midwifery is long- established), midwifery applicants lose points for having a nursing background, for it is well understood that the nurse must follow orders, whereas the midwife must be able to think and act independently. The United States is the only country in the world that utilizes the title nurse-midwife — everywhere else, a midwife is simply a midwife!

Nurse-midwifery does enjoy fully secure legal status in the us, whereas traditional midwifery is illegal in many states. Although traditional midwives have struggled to reanimate old midwifery laws and/or forge new ones, they continue to meet with bitter opposition from the richest and most powerful legislative lobby in the country, the American Medical Association. In California alone, seven attempts at legalization were made over a ten-year period, during which more than 50 midwives were investigated, arrested and prosecuted. Traditional midwives once numbered 350 in the “golden state”, but a decade later their ranks dwindled down to sixty or so. How, and why, did this happen?

In 1976 midwife Kate Boland was visited by a pregnant agent wired for sound, who garnered evidence to the effect that Kate was found guilty of practising medicine without a licence. Thus in California (as in numerous other states), the practice of midwifery was defined by case law as an automatic misdemeanor. The law further directs that any misdemeanor practices associated with death or injury, regardless of whether death/injury was unpreventable or accidental, shall be subject to felony charges of manslaughter or murder. It has cost midwives a tremendous sum – tens of thousands of dollars – to defend themselves and their colleagues against counts of murder. This money has been hard to come by, and could have been used for political organization, or to educate the public regarding midwifery. We do not exaggerate in terming this modern-day war against midwives a “witch hunt”.

And yet, the continued threats of criminal prosecution in combination with dwindling ranks and resources have been undeniably strong motivators of the effort to legalize midwifery practice. It is a testament to the fortitude and vision of traditional midwives that they have been able to survive the costs – not just financial, but personal – of such difficult and seemingly endless legal battles!

We owe the evolution of midwifery’s legitimacy to the vision and persistence of these, our contemporary founding mothers, who encouraged the next generation to take up the banner of self-regulation. By the early ’80s, traditional midwives began creating their own standards of practice and mechanisms for certification state by state, even in jurisdictions where legislative efforts appeared futile. And then, in 1982, the Midwives Alliance of North America (MANA) was founded to enable midwives “of every stripe” to articulate their goals and visions, and find support in their struggle for legitimization. Traditional midwifery is now legal in 33 states, although legislative provisions run the gamut from simple decriminalization to more restrictive licensure. This has led to a somewhat confusing barrage of professional titles: LM/licensed midwife, CM/certified midwife, and dem/direct-entry midwife. (The latter pertains to educational preparation more than title, denoting a midwife who has been trained to the profession directly, without a nursing background.)

Several historic events bear mentioning at this juncture. At the annual convention in 1985, MANA members first considered the possibility of national certification. However, the notion was shelved indefinitely, for fear that setting national standards for midwifery competency might negatively impact states just beginning to develop their own grassroots processes of self-regulation. Then, in 1991, the Carnegie Foundation funded a task force of midwives from diverse educational backgrounds to address the future of midwifery education. This group produced a document entitled Midwifery Certification in the United States, historic in that it established identical competencies and scope of practice for all midwives, regardless of training route and/or nursing background. Before long, there was renewed discussion of national certification for traditional midwives.

MANA had already established the North American Registry of Midwives (NARM) some years earlier, charged with administering a national certification process. Then a core group of state leaders, many of whom had formulated and passed midwifery legislation in their respective jurisdictions, got wind of these developments and came together to form the Certification Task Force (CTF), with dual purposes of developing a prototype certification process and providing technical assistance to NARM. After numerous meetings at both state and national levels, a process was approved by the MANA membership, and in 1995, the first Certified Professional Midwife (CPM) was recognized by NARM.

NARM Certification is a competency-based assessment process. No specific educational pathway is delineated, but the candidate must be able to demonstrate entry-level midwifery knowledge and skill. The process is composed of certain key elements commonly found in licensing and certification mechanisms: 1) verification of requisite clinical experience; 2) verification of requisite skills and caregiving abilities; 3) character assessment via letters of recommendation; 4) comprehensive written examination. Once certified, the midwife must agree to fulfil continuing educational requirements, update neonatal and cpr resuscitation, work within the confines of MANA’s core competencies, and uphold professional standards and ethics of practice.

In contrast, the ACNM offers certification only to those who have passed the national exam and have completed an accredited program. Barriers to accreditation are formidable for direct-entry programs, and are difficult to adapt to the apprenticeship model of midwifery education. This is why both the CTF and NARM focused on constructing a certification process that would incorporate a variety of educational routes to practice.

How does national midwifery certification interface with state licensure or certification? Although the process is relatively new, it seems likely that national certification will eventually be adopted state by state as the universal process for assessing midwifery competence. States with unduly restrictive practice provisions could use the national process as rationale for legal amendment, or other regulatory changes. Many states already utilize NARM’s test as their licensing or certification board exam. As more and more states adopt the national process in its entirety, reciprocity will be increasingly available for midwives wishing to relocate, and the entire profession will benefit from increased self-regulation.

Self-regulation is certainly the point where battle lines are drawn between midwives and the medical profession. Nurse-midwives hold the position that higher education, i.e., masters-level midwifery, is the key to greater professional autonomy. Conversely, traditional midwives believe that no credential will be enough as long as physicians are the ruling class, and that it is better to define midwifery on its own terms, rather than jumping through an endless series of legitimacy hoops. Leaders of the midwifery movement nevertheless predict that midwives “of every stripe” will, despite their differences, unite one day behind the issue of independent practice. This day may come sooner than later, as the fight for autonomous midwifery has become an international battle; there is not a single culture in the world where midwives are not somehow restricted in caregiving. German midwives may assist deliveries but cannot give prenatal care; Italian midwives can give prenatal care but must call the physician when delivery is imminent. In order to address the world-wide struggle of midwives to meet their communities’ needs and take their rightful place in the health care system, the World Health Organization drafted the International Definition of a Midwife in 1972, which was adopted by both the International Confederation of Midwives (icm) and the International Federation of Gynecologists and Obstetricians (FIGO):

“A midwife is a person who, having been regularly admitted to a midwifery educational program duly recognized in the jurisdiction in which it is located, has successfully completed the prescribed course of study in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery.

“The sphere of practice: She must be able to give the necessary supervision, care and advice to women during pregnancy, labour and postpartum period, to conduct deliveries on her own responsibilities, and to care for the newborn and the infant. This care includes preventive measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance, and the execution of emergency measures in the absence of medical help.

“She has an important task in counselling and education – not only for patients, but also within the family and community. The work should involve antenatal education and preparation for parenthood and extends to certain areas of gynecology, family planning and child care.

“She may practise in hospitals, clinics, health units, domiciliary conditions or any other service.”

Particularly powerful in this statement are the assertions that the midwife may “conduct deliveries on her own responsibility”, and “execute emergency measures in the absence of medical help”. This definition is remarkable not only for what it says, but for what it leaves unspoken. Nowhere do we find any stricture regarding the “risk status” of our clients, nor any attempt to limit our practice to “childbearing women”, “well women”, or “interconceptual care” – terms commonly used in statute to restrict the midwife’s scope of practice.

Other pivotal documents have been drafted and approved by the membership of MANA, including MANA Standards and Qualification for the Art and Practice of Midwifery, The MANA Statement of Values and Ethics, and MANA Core Competencies for Midwifery Practice. Yet another key organization that has contributed to the professionalization of midwifery is the Midwifery Accreditation Council. MEAC was founded by a group of midwifery educators who wanted to promote better quality learning experiences for students by linking midwifery educational programs to accountability mechanisms. MEAC’s primary goal is to preserve a variety of educational routes to midwifery practice, particularly apprenticeship. (Please find addresses for MEAC, MANA, ACNM, and NARM at the end of this paper.)

True midwifery care is individualized care. Although there are certain parameters of safety she must uphold, the midwife knows that wellness is an amorphous state, with periodic and acceptable deviations from normal. Her task is to decipher the unique patterns of her client’s well-being. The more thorough and continuous her care, the more likely she is to detect a complication at its inception. And the better her communication with her client, the more readily they will work together to develop and implement a prompt solution. She and her client are a team, but the locus of responsibility is with the pregnant mother – she is at the helm of her perinatal experience.

Standardized, fear-based medical care has decreasing appeal for today’s woman: what she really wants is competent, sensitive attention to her entire condition. It is nearly impossible to realize woman-centred childbirth in the hospital setting, where practice is circumscribed by protocol, and protocol is designed to cover liability bases that have little to do with good care, let alone common sense. We have lost some of our finest obstetricians since the advent of the malpractice crisis: those who could not, in good conscience, perform requisite tests or procedures clearly at odds with a patient’s well-being. It is more than unfortunate that our malpractice system fails to differentiate between acts of fate and those of misconduct; our trial lawyers, posing yet another threat to midwifery and choice, stand to profit whenever there is unhappy outcome in childbirth, regardless of fault. For midwives, this has meant a dearth of good backup, and more urgency than ever to advance a woman-centered model of maternity care.

The only way we can realize this goal of woman-centered midwifery care is by upholding the autonomy of midwifery practice. Midwifery should be held accountable to its own scope and standard of practice, not to that of medicine! Remember, midwifery is a tradition of care “from womb to tomb”, in which midwives revere and celebrate all the physiologic milestones of women’s lives – menarche, birth, menopause and death. These times of transition are more than biological, and are traditionally known as Blood Mysteries. This is because women gain wisdom in these life passages that transcends reason, i.e., is mysteriously borne on the body. Many indigenous cultures have deliberately created rites of passage for men involving self-immolation and suffering, such as the Native American Sundance or vision-quest, in order to replicate the growth and transformation rendered naturally to women through their Blood Mysteries.

Thus midwives have natural concern with women’s well-being in a whole life context. Midwives know that women who labor on their own terms and feel the triumph of spontaneous birthing will mother in a fiercely independent fashion, with newfound inner certainty. Happy mothers also reach out confidently for whatever assistance they require. The evolutionary social aspect of midwifery is that it motivates women to extend to one another the power and responsibility they discover in giving birth, to break away from the isolation of the nuclear family, to network and share their resources, to raise their children cooperatively. Thus midwifery is linked to social innovations in childcare, renewed emphasis on extended family, and holistic healthcare that acknowledges factors of nutrition, lifestyle, rest and support as crucial to women’s well-being. Client and practitioner alike, women who choose midwifery seek connection, they long to rise above divisiveness and competition, they yearn to establish support systems and create community.

They traditionally seek the comfort, privacy, and opportunity for family participation found in the home birth, as well as the decreased likelihood of interventions. Research has repeatedly shown that the more relaxed and at ease a laboring woman feels, the more efficiently will her body function. Should she be stressed or frightened, she will release catecholamines which inhibit cervical dilation. The C-section rate in the us is nearly 30%, whereas midwifery statistics show less than 5%. When women are in charge of their environment, when they have the privacy to labor undisturbed, when they feel completely at ease and supported, outcomes are always superior.

By employing mechanisms for self-regulation, professional representation and political activism, United States midwives remain passionately committed to doing whatever they can to further this ideal.

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