Unity: An Elusive but Necessary Goal for US Midwives and Their Advocates
Editor’s note: This article first appeared in Midwifery Today, Issue 120, Winter 2016.
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In most industrialized countries of the world, there is only one type of midwife. These midwives are licensed to practice by the health authority of the state, whatever that is, and they work without danger of criminal charges in the event of a bad outcome. Women in all but two of the industrialized countries have no trouble locating a midwife; they face no disapproval or criticism from partners or relatives for choosing a midwife who works outside of the medical model of birth. That is not to say that they have a good range of choices, but at least they don’t have to start from as far behind as we in the United States do.
We who live in the United States are fully aware how different our country is from most others when it comes to midwifery and the way the state looks at childbirth. If we try to list every variety of midwife that has come into existence during the last half-century, we have to write a very long sentence with lots of adjectives and commas. We lead the world in the number of criminal trials for the practice of midwifery or the practice of medicine, or even manslaughter or second-degree murder charges brought against unlicensed midwives. In this dubious sweepstakes, we have the company of our neighbor to the north, Canada, which got itself into a similar societal mess a century ago by neglecting to create a way for midwives to continue to exist by following the example of the rest of the industrialized world. In both countries, obstetrician-surgeons became the overlords of childbirth, and two generations of women came to consider it “normal” to have their babies in hospitals where there was no such person as a midwife.
Childbearing women in the United States live with another unusual feature when it comes to women’s rights in childbirth. Our country has the sad distinction of having come up with the court-ordered cesarean. This legal assault upon the integrity of a woman’s body allows public officials to pose as better caretakers of our babies than we are, by stereotyping women who oppose such surgery as “selfish” or bad mothers whose babies need state protection. It is galling—to say the least—that we continue to live with such a lack of legal protection in a country that prides itself on inventing feminism and on valuing motherhood as highly as apple pie.
Because our society includes such extremes, the arrival at some measure of unity among self-respecting midwives and those who advocate for them is much more challenging than in many other countries. Even so, I continue to believe that a goal of unity (focused vision) is well worth striving for. In fact, I believe that it is critical to the development of a responsible, autonomous, sustainable midwifery profession in the United States.
The question remains: what is the best way to proceed from our various standpoints, considering the often bewildering complexity of strategies that various midwives choose? Some unlicensed practitioners decide to remain unlicensed and uncertified, feeling that if they stand their ground, they will represent the best chance for midwifery to resist co-optation by the for-profit, dominant wing of the medical profession. Others (myself included, although I stayed with the previous strategy for more than twenty years) have opted for the path of certification and licensed practice, believing that this path holds the best chance for creating an independent midwifery profession that works in partnership with childbearing women. Still others lack the organization or agreement to carry out the legal struggle required for acceptable legal recognition or are currently engaged in such a struggle.
As I have traveled the world and studied the rights of midwives and childbearing women in many countries, I have noticed two nations that I believe we’d do well to emulate. One, of course, is The Netherlands, which is internationally noted for its government’s stubborn maintenance of the homebirth option and its state commitment to autonomous midwifery as the backbone of maternity care. This philosophical choice is reflected in more than one unusual feature of the Dutch system. Applied to obstetrical education, it means that obstetricians-in-training are taught by midwives about normal birth before they are introduced to pathology. It also means that the Dutch are dedicated to training a special variety of maternity care assistant, the kraamverzorgende, who is available to new mothers at all economic levels for reasonable hourly rates (partly subsidized by Dutch taxpayers for the first ten days following birth). These assistants attend the birth with the midwife or family doctor, visit the home of the new parents and look after mother and baby, provide health education, clean, prepare meals, walk the dog, babysit for toddlers, get the older children off to school and give breastfeeding support and consultation. Wouldn’t that be nice to have in the United States? Can that be one of our unifying ideas?
The second country offering us some powerful tools is another small one: New Zealand. I first visited there in 1977, returning in 1981 and 2000. New Zealand’s homebirth movement was in its infancy in 1977, having only a handful of midwives who were willing to accommodate the wishes of women who simply did not wish to give birth in a hospital. The beginning issue for the midwives was not the legitimacy of their homebirth practice, which was already perfectly legal. All of New Zealand’s midwives were duly licensed to practice in any setting. The homebirth movement there has never been powered by lay midwives. The issue for them was how they could be paid more than a pittance for each birth (one of the government’s ways of discouraging homebirth was to pay the midwives less than $50 for each birth).
New Zealand’s three homebirth midwife pioneers were hard working and politically savvy. Gradually, their numbers grew. Inspired by the work of David and Lee Stewart, founders of NAPSAC (National Association of Parents and Professionals for Safe Alternatives in Childbirth), the US organization that published so many valuable books during the 1970s, they organized home birth associations all over the country. In 1980 the local associations in New Zealand resolved to become a national body: The New Zealand Homebirth Association (NZHA). Each local branch preserved its own autonomy and continued producing its own newsletter and local initiative to government bodies and the media. The National Executive of the NZHA was structured to rotate from local branch to branch “in order to give the branches an opportunity to develop their political skills rather than to establish a ‘power base.’”
Even though the number of midwives grew over the years, it’s important to note that most of the members of the NZHA were women who had themselves given birth at home. The midwives and the members of the homebirth associations stood together in their belief that the continued survival of the domiciliary midwife was vital to the whole movement questioning invasive obstetrical procedures. In 1983 the Auckland Homebirth Association formed the “Save the Midwives Association” to fight an amendment to the Nurses Act that attacked all midwives. National support forced the bodies responsible for the attack to moderate their stance. Whenever lobbying efforts were necessary, midwives and homebirth consumers together made their visits to members of Parliament and the Health Minister. This message of partnership between domiciliary midwives and their clients was not lost on the politicians whom they lobbied.
In 1986 the Homebirth Association Conference took an important step that surprised and divided the midwifery community for a while: it approved the establishment of Domiciliary Midwives Standards Review Committees to annually review homebirth midwifery practice. Because the first committee included two consumers (plus a domiciliary midwife, a hospital-based midwife and a homebirth general practitioner), this step was controversial. How could consumers reviewing midwives’ practices be considered professional? critics wondered. Even so, the committees continued and exist to this day.
The Standards of Practice developed by the New Zealand College of Midwives (NZCOM) provide a tool for measuring actual practice and appropriate usage of midwifery’s body of knowledge. They are featured in NZCOM’s Midwives Handbook for Practice.
- The midwife works in partnership with the woman.
- The midwife upholds each woman’s right to free and informed choice and consent throughout the childbirth experience.
- The midwife collates and documents comprehensive assessments of the woman and/or baby’s health and well-being.
- The midwife maintains purposeful, on-going, updated records and makes them available to the woman and other relevant persons.
- Midwifery care is planned with the woman.
- Midwifery actions are prioritised and implemented appropriately with no midwifery action or omission placing the woman at risk.
- The midwife is accountable to the woman, to herself, to the midwifery profession and to the wider community for her practice.
- The midwife evaluates her practice.
- The midwife dissolves the midwifery partnership.
- The midwife develops and shares midwifery knowledge and initiates and promotes research.
For more details, visit NZCOM’s Web site at www.midwife.org.nz/index.cfm/Standards.
In 1988 the New Zealand College of Midwives (NZCOM) was formed. (Notice this happened so many years after the formation of all the groups concerned with preserving women’s birth options!) Here, it is important to understand that the professional body that New Zealand midwives had previously belonged to was the New Zealand Nurses Association (italics mine). Following the formation of the NZCOM, an office for new national organization was duly established—under Karen Guilliland’s bed. (Karen was, at that time, President of the NZ Nurses Association’s Midwives Section).(1) In recognition of the domiciliary midwives’ partnership with women, members of the New Zealand Homebirth Association were included as members of the NZCOM with voting rights on both regional and national committees.
Only two years later, with the passage of the Nurses Amendment Act, New Zealand midwives achieved the important goal of recognition as autonomous practitioners. Today, New Zealand midwives continue their struggle, acutely aware that they are not yet out of danger and that current developments still reinforce the medicalization of pregnancy and birth. But they are also aware of the great progress they have made in a relatively short period of time and that this progress puts New Zealand midwifery in a stronger position than midwifery occupies in any country except perhaps for The Netherlands.
What, then, are the most important lessons that we in the United States can learn from our sisters in New Zealand?
First, we should recognize how important the philosophy of partnership between midwives and mothers has been for achieving the positive changes realized since the homebirth movement began. In New Zealand, listening to women is not an empty phrase, but a reality. Every year, the domiciliary midwives I met there voluntarily put their records before their local Midwifery Standards Review Committee (composed of fellow midwives and elected consumer members of homebirth associations) for review following the Ten Standards set out in NZCOM’s Midwives Handbook for Practice. According to Maggie Banks, domiciliary midwife and author of Breech Birth Woman-Wise and Home Birth Bound, this process “requires us to face the issue of inappropriate midwifery practice when repetitiously faced with those who embrace medicalised childbirth. To be silent can only be taken as endorsement of such practices.” She goes on, “…if we are to go beyond a lip service of peer review, we need to ask the hard questions.”(2)
What are the advantages offered the domiciliary midwives by this voluntary review process? One major benefit, Banks assured me, is that going through this process encourages reflective practice that is responsive to individual client’s needs. When each of your clients provides you with a written statement assessing how well you lived up to each of the standards of your profession, you have a strong incentive (if you don’t already) to really listen to her needs and fulfill them. Furthermore, she is potentially a strong ally in your corner, if her birth outcome becomes fodder for a witchhunt. To give a concrete example of what I mean, let’s take the case of midwives who attend breech births at home. Going through such a process can make a significant difference for the midwife in the event of an adverse outcome from a birth that falls outside of the usual guidelines (as defined by obstetricians, not homebirth mothers). Thus, following such a process could well be an important element in preserving the skills and knowledge surrounding vaginal breech birth. In the United States, the adoption of standards similar to those followed by domiciliary midwives in New Zealand could form a unifying principle for the various kinds of US homebirth midwives, credentialed or not.
New Zealand law provides another valuable precedent that I would like to see the United States emulate in the first years of the 21st century. This law would address the discomfort that so many of us feel when women in our country are compelled to undergo unwanted and unnecessary surgery prescribed by an obstetrician or are punished by Child Protection Services for having chosen to give birth without assistance. The New Zealand law, simply put, protects women from the nightmare of court-mandated surgery, for whatever reason. I believe that homebirth mothers and we midwives could convince feminists in our country of the necessity of embarking on a campaign to pass such legislation. Does the New Zealand law protect women who opt for unassisted homebirth from sanctions brought by Child Protection Services? I can’t say exactly, as I don’t have the law at hand, but I doubt it. As far as I know, New Zealand women haven’t felt they needed to protect themselves from overly interventive midwives by choosing unassisted childbirth. Because we already have an unassisted childbirth movement in the United States (at least partly because of midwives who have imported medically interventive procedures into women’s homes), we should consider the needs and wishes of these mothers, too, as we attempt to forge the unified vision of the childbirth care we want for our daughters, daughters-in-law and grandchildren.
As a final note, I must mention that I inquired how many Maori midwives there were in the mid-1970s. The answer: zero. By 2000, there were almost 200. This achievement is extremely important, as it demonstrates that even a licensed, credentialed midwifery force, properly organized and connected with birthing women, can return midwifery to indigenous populations. Imagine what could happen in the United States if we could manage a similar achievement! Why don’t we give it a try?
- Donley, Joan. “The Culture of Home Birth in New Zealand.” The New Zealand College of Midwives Inc. Sixth National Conference, September, 2000.
- Banks, Maggie. “Nurturing Our Strengths.” The New Zealand College of Midwives Inc. Sixth National Conference, September, 2000.
- Shanley, Laura Kaplan. (1994). Unassisted Childbirth. Connecticut: Bergin & Garvey.