By Kristin Loos
Midwifery
is not a well-known profession. Even on
the cusp of the twenty-first century the very word often evokes imagery of
back-woods traditional childbirth with a hint of witchcraft. Even pre-med. students are often inaccurate
in describing what a midwife is, saying she is a nurse’s nurse or someone who
delivers babies naturally, without the use of technology. Most people do not realize that the most
popular type of midwife, the Certified-Nurse midwife, is a bonafide health care
professional who is licensed, practices (or can practice) in a hospital, writes
prescriptions, is salaried, and whose services are covered by insurance.
I
cannot recall when I first heard of midwifery, but it was while enrolled in a
medical anthropology course that I was reintroduced to the idea that birth
wasn’t by nature a process of curing an illness. It was simply culturally defined in that way. This idea intrigued me and given the
opportunity this semester I decided to delve into the lives of midwives. What exactly is a midwife? How does a midwife differ from an
obstetrician? How do they negotiate
their professional status and their approach to birthing babies in an era of
medicalized childbirth? These questions
were partially answered through two months of interviews, reading and
observation. Throughout the process,
however, I discovered that I was interviewing midwives who had a variety of
stories to tell about how they got where they are now, where they practice and
how they practice. Yet, they all worked towards a similar goal and approach to
childbirth. Depending on their
situation, different obstacles from the medical community had to be overcome in
order to accomplish their goals. This
paper is a reflection of certified nurse-midwives, their goals, and how they
obtained them, as well as the obstacles they’d faced in the past and continue
to struggle with daily.
The
midwives’ stories all implicitly or explicitly demonstrated that certified
nurse-midwives are continuously confronted with two very different worlds of
birthing babies—the medicalized world and the natural world—and they must
bridge these worlds every day in order to survive as nurse-midwives. In order to understand the present
situation, it is necessary to look at the past and the evolution of
nurse-midwifery in the earlier parts of the twentieth century. We will then look at this medicalized world,
through the eyes of the midwives, some patients and some literature. The natural world, the one traditionally
supported by midwives, will be discussed in depth. It will then be pertinent to look at how different settings that
the midwives work in—the hospital, the clinic, the home, and the birth
center—present unique ways in which the two models coexist.
Setting and
Methods
My
first proposed plan was to study the certified nurse-midwife practice that was
situated at a relatively urban tertiary teaching hospital in a medium sized city
located in upstate New York. I was
hoping to observe midwives’ interactions with other health professionals and
their patients. Upon a preliminary
discussion with the director I realized I would need to go through the Research
Subjects Review Board and the time allotted for this project did not allow for
that. Furthermore, I was forewarned
that there wouldn’t be many interactions with obstetricians. I thus reorganized my project into
understanding what a nurse midwife does—birthing babies, gynecological exams,
prenatal visits, counseling—and what methods or techniques she employs in these
interactions. This research would be
done primarily by interviewing various midwives. This was the intent of the project until the very end, when I
realized the variation among the certified nurse-midwives that I had
interviewed.
I
spoke with five different midwives in four different practices throughout the
study. Two of the practices delivered
only in the hospital, although one practice had utilized a birth center that
has since closed. These two practices
also do clinic work. One of the groups
had three small practices specializing in adolescent pregnancy. I was able to
observe on two occasions at the adolescent clinic with one of the midwives from
this group. The other practice actually
had its offices at a medical center where they were able to see patients from
all walks of life, from the university professor to the unemployed single mom
living in the inner-city.
The third midwife had a
private practice in the city, but primarily did homebirths or hospital births
at a smaller hospital in the area. The
final midwife practiced only at rural birthing center, which was located next
to a Level One (rural) hospital.
I
also interviewed two women who had used midwives. One had used an obstetrician
for her first child, and then used a midwife in a hospital setting for her
second child. The other woman had used
a midwife in a birth center for her first child.
I
did not use a set interview script for the midwife interviews. While some of the questions were the same,
such as “how did you become interested in midwifery?”, some of the questions
appeared only in one or two interviews.
Part of this was due to the fact that the objective of the project kept
changing and so questions that were once applicable to obtaining the
information, no longer seemed appropriate.
Conversely, different questions had to be added when the scope of the
project changed. While in some cases it
was possible to go back and conduct a second interview with a midwife, it was
not possible to do so for each midwife.
Another reason why I did not follow a script was because some questions
did not seem appropriate because I knew the midwives were coming from different
settings and backgrounds and a question that would be applicable in one case,
was not so in another. Finally, I often
found that the method of asking questions leading from previous answers was
much easier and also allowed me access to answers I would have never had
questions about, than to set a fixed interview. Furthermore, due to the midwives’ hectic work schedule, it would
be very hard to get through a set script in one sitting, and seemed much more
effective if I was able to ask questions which I deemed most pertinent to the
answers I was trying to obtain at that time.
As
mentioned earlier, I was able to observe at an adolescent clinic on two
occasions. It was possible to observe
the midwives’ interactions with nurses, social workers and most importantly
with the patients. I did not formally
interview any of the patients but on occasion I was able to speak with them and
gain a little information about their thoughts on midwives. I was also able to casually interview the
midwife in between office visits, another valuable source of information. At the birth center and with one hospital
group, I was given a tour of the facilities which enabled me to gain a better
idea of the setting the midwife worked in.
They were obviously very different from one another causing me to think
about why there are these differences, which led to the final proposal for this
project.
This
project is not meant to be a conclusive report on the various practices
nurse-midwives have and the obstacles they face in each practice. Rather it is an attempt to find a common
thread among my notes and observations in the field over the last three months.
Before
continuing further it will be important to understand a little bit about the
rise of certified nurse-midwifery, which in itself, was a bridge between the
natural, traditional midwifery world and the medical world, at least in the
eyes of many doctors.
Before the scientific revolution of the mid 1750’s, midwives attended nearly all births in the United States, in part, due to the low number of medical schools that had an obstetric program. In the mid-1800’s, medicine was turning into a profession and obstetrics became formally recognized by the AMA in 1859 (Rooks 1997: 21). At this point, regulations for licensing all physicians came into practice, and those who were not licensed could perform very few procedures. Reciprocally, midwives were not encouraged to be licensed nor was any attempt made to continue or formalize midwifery education, in part because the clientele were primarily poor, immigrants, and non-white populations which physicians didn’t want to deal with. By the turn of the twentieth century, physicians were attending 50% of births (Rooks 1997: 22). High rates of maternal and infant mortality gave a reason for physicians to try to regulate births and make sure women go to a hospital and deliver under an attending physician. A period known as the American Midwife Debate ensued during the first third of the twentieth century where obstetricians were convinced that “as long as women untrained in the medical sciences continued to attend one-half of all births, the obstetrician would never receive his due recognition. They repeatedly emphasized that obstetrics belonged ‘to the scientifically trained physician and to none else’” (Litoff 1986: 6-7). This ideology was prevalent through the 1970’s when physicians in hospitals attended over 99% of births (Litoff 1986: 12). On the contrary, some public health advocates supported the midwives, showing how “trained and regulated midwives could help bring about dramatic declines in the nation’s infant and maternal mortality rates” (Litoff 1986: 8). And thus the debate raged on. However, a few progressive health workers and physicians noticed that a solution to this problem. They noticed that in foreign countries that had outstanding infant and maternal mortality rates, the nurse midwife was the prominent health care provider throughout the pregnancy and during birth (ACNM: 1997). In the mid-1920’s the nurse-midwife was born. She was a graduate nurse who had special instruction in midwifery, and her main purpose was to provide care for the poor and isolated woman. The Frontier Nursing Service (FNS) grew from this program and the New York City Maternity Center Association (MCA) was duplicated from the FNS. Nurse-midwives did not establish their independence from nursing until 1955 with the formation of the American College of Nurse-Midwifery (ACNM) (now the American College of Nurse-Midwives). Animosity from physicians continued well into the 1970’s. It was only in 1971 that the American College of Obstetricians and Gynecologists expressed support for nurse-midwives saying they were a medically directed team (Litoff 1986:12).
As is well-known , the late sixties and early seventies were active years for the woman’s movement and nurse-midwifery gained a new popularity. Concurrent with official recognition and the women’s movement was the fact that people who had experienced nurse-midwifery care were letting other potential consumers know about it through writing articles in the popular press. Around this time, nurse-midwives began to participate in federally funded programs that aimed to improve maternal and infant care and provided family planning services (Varney 1997:12-13).
Certification of the nurse-midwife began in the 1970’s as well as the accreditation of the nurse-midwifery educational programs. By the turn of the decade, nurse-midwives were seen as in competition with physicians. While some physicians supported the midwifery model, nurse-midwives struggled to gain professional status. Varney states:
opposing physicians tried to restrict the growth of nurse-midwifery through state legislative battles over statutory recognition of nurse-midwives, mandated third party reimbursement, and prescriptive authority; denial of hospital privileges; and pressure on supportive physicians vis-à-vis their malpractice insurance (Varney 1997: 14).
Throughout the 1980’s the Maternity Center Associated jumped into the free-standing birth center movement, which allowed women the option of not birthing in hospitals. Women could also give birth at home, a practice which was primarily faciliated by lay midwives, who organized themselves to create the Midwives Alliance of North America (MANA) in the early 1980’s.
By the 1990’s, over 5000 nurse-midwives had been certified. However, due to the movement of the health care system toward managed care, midwives were forced to struggle to be recognized as legitimate health care providers. In New York State, the place of focus for this study, the Practice Act became effective in 1993 (see Appendix A), which effectively only allowed certified nurse-midwives to practice legally (see Davis-Floyd: 1998). It also allowed for the creation of an ACNM accredited professional midwife, a professional “direct-entry” midwife. This Act has upset many direct-entry midwives who are organized under MANA and has created conflict between the two groups (for a complete discussion see Davis-Floyd: 1998).
From
the literature and speaking with midwives and patients, I gained an
understanding of what the obstetric world or model consists of. As a disclaimer to this section, the
Director of one of the midwifery groups I worked with reminded me that the
obstetric model is a broad generalization.
She asserted:
physicians and midwives are individuals first and foremost. Its not that all physicians are this way and all midwives are this way, and male physicians are this way and female physicians are this way and it depends on what sex you are also makes a difference. But this isn’t necessarily true. So when we speak of this its general.
However, the
basic theory behind the obstetric model of pregnancy is that pregnancy is an
illness that must be cured. The
education process of obstetricians tends towards screening for problems,
objectifying the patient, giving her little choice in the decision-making
process and emphasizing the use of technological and surgical skills.
In an office visit, he will
check the baby’s growth, take the woman’s blood pressure and then ask if there
are any problems. If there are no
problems, then its “out the door” as one midwife said. Doctors are on a tight schedule and do not
have hours of time to spend with each patient.
Furthermore, their education process has conditioned them to objectify
the patient instead of seeing them as a live human being. Robbie Davis-Floyd spoke to one resident who
said:
as interns we lose why we went into medicine—whatever humanistic interest we had. It’s very hard to sit there and listen to someone tell his life story when you’ve got six other admissions, bloods to draw, you’ve got to be up all night. Every second you spend being compassionate means that much less time to sleep. So you become very efficient at not really listening to people—just getting the information you need, and shutting them off (Davis-Floyd 1992: 266).
One midwife mentioned, “In [labor and delivery] the physician’s approach is to screen for problems, so [they are] award of everything that can go wrong and the emphasis is on what can go wrong rather than what will go right. So the tendency to rely more on technology to help to find out if something’s going wrong early such as external fetal monitoring”. The reliance on technology is a big part of the obstetric model. Most of the technology applied to obstetrics leads to successful outcomes. This allows obstetricians “to acquire and pass on a strong sense of the value of the technology which they experience as successful most of the time” (Davis-Floyd 1992: 267). In fact, many obstetricians assimilate the whole process of giving birth as being mechanical. “The doctor is managing the uterus as machine and the woman as laborer” (Martin 1987: 64). The woman plays a rather passive role and has little control over what is happening to her. Martin provides the following example:
If a woman’s labor slows down because her
contractions are not sufficiently strong (hypotonic uterine dysfunction), most
obstetric texts suggest these causes: the pelvis is too small; the fetus is not
positioned properly; or the uterus is too distended. Nowhere is it suggested that the woman’s general state of mind
(fear, anxiety) might have led her to stop her labor, even though “in many—perhaps one-half—of instances the
cause of uterine dysfunction is unknown”
Seeing uterine contractions as “involuntary” [out of the woman’s control] has implications for the recommended treatment of course. The only measures obstetric texts suggest are external maniupulations of the woman’s body: rupturing the amniotic sac, an oxytocin droip, which acts chemically on the uterus, or a cesarean section, which makes further contractions unnecessary (Martin 1987: 62)
Many women feel
obstetricians will do cesarean sections and other operative procedures just
because they can. One midwife I
interviewed comments:
many physicians being more surgically oriented with the ability to do cesarean section sections are more likely to do an operative delivery, either forceps of section, sooner than a midwife might, just because they have that ability and because they’re surgically trained and because they don’t see that certainly anything out of the ordinary.
In a similar vein, a woman who had witnessed a friend go through a delivery comments:
[the birth] was an emergency c-section because they couldn’t get the baby to be read on the fetal monitor and they woke up the doctor. …I personally didn’t think that we needed to finish through with the cesarean. There was reason for concern, but we didn’t have to go freaky and run down this hall, because as soon as we moved the mother, we got the baby’s heart back. So it was just a matter of positioning. But the doctor was already awake, so he’s already going to go do it.
In the obstetric model, the
lack of control a patient has over her birth and the birth process is also
prominent. A patient who had used an
obstetrician for the birth of her first child recalls her labor and delivery
and labor experience.
We go in and I am very much in labor…and basically they put me in this room and they put me on the bed and they just start strapping all this stuff to me. They put in an IV, they put on a fetal monitor, they put on a blood pressure cuff. And they say “we’ve got this full ward, so we’ll be out here at the desk and you need to just lie there, and we’ll come in if you need something, because we’ve got all these people here on the ward”. And I just felt like all my control had been taken away. I knew that the labor would progress more rapidly if I could get up and walk, that there hasn’t been any actual proof about the efficacy of fetal heart monitors, and all these kinds of things. So I would start to try and take off some of the stuff and any time I would, they would come back in and put it back on me. …And anytime I would try to get up, they would try to sit me back down, and they kept pressing medication. The doctor came in and he’s like “let’s get the show on the road”. I think he had rounds to do and I think he was ready to deliver the baby. They put in pitocin. They didn’t tell me that they were putting in pitocin. It was only afterwards. …They gave me an episiotomy and I hadn’t wanted an episiotomy, or I at least wanted to be informed why I needed one and could it be a partial episiotomy. There was none of that. No negotiation.
This individual clearly felt the obstetric model was
too involved in technology and didn’t give much consideration or control to the
woman and her family. Many other women
also feel that they have no power over the decision making process if
obstetricians are involved.
A
midwife I spoke with makes it clear that doctors like to establish a strong
rapport with their patients and have a good relationship with them. However,
the education process physicians go through lends them to objectify the woman,
treat the pregnancy like an illness, and rely heavily on technological and
surgical skills. If a woman is treated as an object instead of a person, her
feelings or desires do not need to be considered and the resident or
obstetrician can proceed with the delivery when and how he likes. Obviously, this leads to a lack of
understanding and control of what is going on, which the woman and her family
feel during the birthing process.
How
does a midwife differ from an obstetrician?
At first glance, particularly when associating with midwives who work in
a hospital, there doesn’t seem to be much difference. The first time I met with the group over at the hospital I was
surprised to see the midwives in scrubs or white lab coats. They hold their office visits at the
ambulatory center at the hospital that they share with physicians and other
health professionals. They use the same
birthing center as the physicians, and often employ the same technology. It is true that there are variations in how
and where a midwife practices, which will be addressed later, but there are
certain critical ideas that separate the midwifery approach to childbirth from
the medical obstetric approach. (At this point it is necessary to mention that
all nurse-midwives are trained in and have gynecological/well-woman care as
part of their practice. For the purpose
of this study, I am concentrating on the obstetric side of the midwifery
profession).
In
order to understand the midwifery model it is first necessary to realize what
the primary goal the midwives have for the families that are giving birth. The
model then becomes a question of how they facilitate this goal.
Every single midwife interviewed, when asked what she saw as her role in pregnancy and childbirth, responded along the lines of making the experience as positive as possible for the family involved. One midwife firmly asserted “what I really wanted to do was be with families during birth and make it as beautiful and as comfortable and as much as a miracle, as much as a natural process as possible. …The birth is normal, natural and it’s not a disease.” Often, according to several midwives, patients haven’t seen how birth can be empowering. The midwife in private practice mentions that as well as providing medically safe care for people she provides “care that encourages and takes advantage of the potential there is in the situation in pregnancy and birth for people to grow and change.” The midwife helps to facilitate this growing and empowering experience, as well as demonstrating that the process of birth itself can be a beautiful experience.
This goal is achieved
through listening, educating, giving patients choices and control, and allowing
patients and families’ participation in all parts of the experience, elements
which, as far as my study determined, universal in the midwifery model.
The model has long been
described as being non-interventionist.
One midwife described that:
having a baby is a natural physiological process; its been going on for millennia and in the absence of any assistance whatsoever most likely it will go right. Our role we see as supportive, educational, preventative. Rather than screening for the problems that develop, we have more of a “how do we prevent this problem from developing” approach.
In order to do this, it is important for the midwife to get acquainted with the entire person, not just a swollen abdomen. Initial office visits are generally scheduled for an hour, but will run over if necessary. Knowing the entire person, her social, emotional and physical state of well-being, is necessary in order to really be able to support the patient. A midwife described a situation that exemplifies this:
I’ve had a patient meet with somebody and then met with them afterwards and I say to the person who met with them before I did “did you know that she doesn’t have anywhere to live” and they’re like “no”. And of all that things that could impact a person’s life, being homeless is a pretty major one and can impact their health and everything.
Through careful questioning and listening a midwife is able to gain a good understanding of where the patient is coming from on all different levels. I was able to sit in on such an initial exam at a clinic. Following is an excerpt from my field notes on the experience:
The first thing the midwife did was say that she was going to ask for information about the patient and then give lots of information to the patient. The midwife sat on a low stool facing the patient who was on the exam table and higher up. I sat on a chair against the wall. The midwife goes through name, address, phone numbers, DOB, etc. Then she asks who the father is and the patient isn’t really sure. But both possible fathers are aware that she is pregnant. The midwife then asks who she would like to be the father. The woman says D, because she knows he would help take care of the baby. The midwife makes sure that the patient understands that the father of the baby cannot be determined until the baby is born and a blood test is done. The midwife asks if she’s thought about terminating the pregnancy. The patient says she doesn’t want to. The midwife explains all of the options and that the midwives are there to offer support in any of her decisions. The midwife is sympathetic and says she knows it’s hard when everybody else is telling you what you should do. She emphasizes that the choice is the patient’s and only her choice. She also explains that her choice may change throughout the course of the pregnancy (“a lot of women discover throughout the course that a baby is more than they can handle and want to put it up for adoption”). She explains that the midwives will help find resources and support her in any of those decisions.
The midwife then goes through the medical history. She asks the patient what symptoms besides missing her period that she’s had of pregnancy. Getting fat was the primary one. She mentioned all her friends noticed and that her best friend told her she’s pregnant, even though she didn’t want to be. She also felt tired. Did she throw up at all? Once, but it wasn’t a lot. The midwife then goes on to figure out due date. “Has anybody told you your due date yet?” she asks. The patient says no and the midwife replies “Oh I get to be the first!” in a playful tone.
The next subject is drinking
and smoking. The patient stopped
smoking once she found out she was pregnant and smoking made her sick anyway.
The midwife commented on this saying that she loved the side effects of being
pregnant because it makes smoking hard to do.
The patient rarely drinks but said that right after she got pregnant she
drank a lot one night and asks the midwife if that would hurt the baby. The midwife said that it probably wouldn’t
but she could make no guarantees. She
goes on about how drinking and smoking affect the baby but they don’t know how
much. She said something like “you probably know someone who can drink tons and
not seem drunk whereas I have one glass of wine and I’m ready to hit the
floor.” We all chuckle. “So the same is true for babies. We don’t know how much it effects them. But what it does is damage the brain. The
baby will come out looking okay but its brain is all screwed up”
Whenever the patient had a
question, the midwife would stop and answer the question simply, not using
medical terms and often drawing examples from her own life or situations in
which the patient was familiar with. When
the midwife was going through the packet of information with the patient, and
the APF stuff came up about amniocentesis, the midwife asked if she knew what
that was. The patient said she didn’t and the midwife described the process.
The patient then said something like “I heard that you can check who the father
is that way” and the midwife said no, but you may have seen something on a
science show about researchers trying to come up with something like that. She explained how the procedure was invasive
and it wasn’t really worth the risk of something going wrong (4% of mothers who
walk in regardless will have something go wrong she explains) to determine
paternity.
This example also shows the amount of support the patient has. The midwife stated that their group would support the woman in all of her decisions. She lets the patient ask questions and takes the time to answer them in a way in which the patient understands. The midwife also interacted on a more personal level, kidding around with the patient, perhaps in an attempt to build trust and make the patient feel comfortable around the midwife. It is important to realize that the midwife emphasizes the things that are necessary to do or not do in order to ensure the baby’s health, but she gives the woman options.
A better example of the undaunting support of midwives is a story that one of the hospital midwives told me:
I had a family who their baby was going to die. And the family knew very early that their baby had a lot of anomalies, like at 15 weeks or something. And she was well known in this practice and had had a baby in this practice before. So this was her second baby. Well, they decided to keep this baby and to go to term even though they knew it would die at birth. And I was like “Why don’t they have an abortion?” You know, I was like “why are they doing this?” I was really kind of like, in my heart, I was like this was kind of stupid. I just went along with it. I never, never voiced it to anybody. It was just how I felt to my own self. Like these people should really have an abortion and they’re really crazy for doing it this way. But, I was the midwife that was on when they came in to have their baby. And it was the most beautiful birth I have ever participated in and probably will ever participate in, cause it was just so, everything happened so nicely and was orchestrated in the sense that the mom helped deliver the baby, the four-year old daughter was there, they had holy water from the Jordan river, her mother was there, the priest was there. It was all videotaped. A beautiful, beautiful birth. And they loved that baby. And I realized how stupid I was to think that they could make this whole situation go away by terminating that pregnancy. To them, that would have been the worst thing possible to do. Whenever I think of them, I’m so happy I never said “why don’t you just have an abortion”. That was my own particular, personal bias and stupidity. And I’ve now talked to that family about that. I was so lucky to be given the opportunity to change my ideas about what I think people should do. And they helped me to do that because I saw they held fast to what they needed to do despite the fact that this baby was going to die and despite the fact that everybody was just like “this baby has no life”. Well to them it had a lot of life. And yet I don’t discourage people if they were in another situation, I don’t say “oh well don’t terminate because I had this other beautiful situation”. It was just that I was so amazed at how wrong I was about them. And that I was given the opportunity to be proven wrong in such a loving, wonderful way. To really see, if someone had told me about it I would have said “yeah, right. I’m sure it was”. But to feel it, and watch them, I’ll never forget it. Never forget it. Being able to see that it was so right for them and they knew that. And then when I told them about my misgivings, I don’t know how to describe my feelings about it. To be able to share with them. I remember them saying that they were really happy that they were able to, that I was on and that they were able to impact me in that way. Because for them, they know that that will make me more sensitive to other people in the future that might come with not the same situation, but where I have some preconceived idea and the families really know that they’re right and stuff. I guess they really advocated for me in that case.
The amount of control a woman has can really be exemplified by talking to patients who have used midwives. The woman who spoke earlier of her obstetric experience, used a midwife for the birth of her second child. Basically she decided what she wanted to do. An excerpt from her experience is below:
And it was just awesome. I got in the whirlpool, which was awesome. And then I was like “I think I need to get out now” and they’re like “okay”. “Yeah” I said, “I think the baby’s coming”. And they’re like “okay, come on”. And I was like “this is the way I want to be sitting” and they’re like “That’s fine, if you want to do it like that. Fine.” And it was such a crack-up because I had done prenatal yoga and was really trying to prepare myself. So I was like “you know, I’m going to do some vocalization techniques” so they’re like “great, no problem.”… At one point I was pushing, and I said “I feel like I need permission to push” because I was used to the doctors and the L&D nurses telling me when and for how long I can push for. And she was like, “you can do whatever you want. You don’t need permission. You can push or you can wait. You know. Do what your body is telling you to do.”
Through all of this the midwives do maintain that safety is always first. While always labeled as being non-interventionists, one midwife describes that they are actually very interventive, but patients don’t notice because the midwives are interventive in the sense that they stop a problem before it happens. There is a nurse with 20 years of OB experience and a midwife who is trained in OB right there in the room all the time unless everything is going okay and the couple wants privacy. This allows for constant observation. There are lots of subtleties in obstetrics which are hard to quantify such as observing contraction patterns. If the midwife is there the entire time, she can pick up these patterns and if the contractions slow down, they can do something about it like say “let’s go for a walk”. In a hospital, residents wouldn’t necessarily notice because they are not constantly with their patients and thus the intervention time would be a lot slower. When the residents finally do intervene, more aggressive approaches are often needed to ensure the well-being of the mother and the baby, such as using pitocin. By intervening earlier, before the problem starts, allows the birth to stay natural and normal.
Scope of the Midwifery Practice
After looking at both the
obstetric and midwifery models, one realizes that the two models are very
different, in part because we are dealing with two separate professions, each
with a different scope. Before moving
on to how midwives must negotiate between the two models in various settings,
we need to clarify exactly what the scope of midwifery practice is, regardless
of the setting in which they practice.
Midwives specialize in normal
birth. As one source puts it,
physicians and midwives are trained in different areas:
Physicians have more extensive knowledge of anatomy, physiology, pathology, biochemistry, pharmacology, anesthesiology, diagnosis, and therapy. Midwives have more extensive knowledge of normal labor and birth, the psychology and lives of women, family dynamics, lactation, methods of communication and teaching, and nonmedical methods to comfort women during labor. (Rooks 1997: 127)
All certified nurse-midwives are qualified to work in the hospital setting, the setting that most midwives call the easiest to work in, presumably because there is a technological and personnel support system. Usually, a midwife will build up her skill in the hospital before deciding to participate in homebirths or work in a birth center. Regardless of where they practice midwives are not able to do anything high risk and they cannot do surgery. One midwife explains:
Where’s the potential that something could you know have a pre-term delivery or if they have kidney problems. If somebody who has kidney disease before they were even pregnant, their kidneys are going to be overworked in pregnancy and they are at risk for having you know renal shut down and lots of things that are just not in the midwife’s scope of practice. You know, I’m interested in dealing with the normal and that’s what I’m good at. I have no interest, nor do I have any skill nor do I have any license to be taking care of somebody who has kidney disease because they need a special kind of care, they need more things looked at. So that’s what classifies high risk. What is the risk? The risk is that they or their baby will die, you know unnecessarily. You know, in the event that something goes wrong, they are more at risk for death or bad outcome of their baby dying or delivery prematurely. So that’s what classifies it. There is a list, you know protocols. We each have one of whom we’ll follow and whom we won’t.
This list of risks includes
any multiple births. While the midwife
says that twins aren’t really high
risk, her practice does not do it and she believes that most practices, unless
they’re co-managing with an obstetrician, won’t do multiple births. I also
asked about breech deliveries. The
midwives that I spoke to will not deliver breech just because of the threat of
head entrapment, although the midwife I was speaking with has never experienced
that before. She has delivered breech
as a nurse and nothing like that has happened to her. She says that at the 35th week it can be determined
whether the baby is correctly positioned or not. If not, at the 37th
week, the mom goes into the hospital and the perinatalogists tries to
manipulate the baby. This is done in
L&D in case the woman goes into labor because of it. If that doesn’t work, the perinatalogist
will offer a C-section, if it’s a first baby, in a way that makes the woman
choose that option. If it’s a second
baby or more, the perinatalogist will often deliver it. If a woman refuses a C-section, some perinatalogists
will refuse to deliver a breech baby and the woman will have to transfer.
Because all licensing laws
are done by state, this paper will concentrate on New York State. Coincidentally, New York is one of the most
progressive states of the country in terms of professionalizing midwifery. It is one of 17 states which regulates
direct-entry midwives (see Appendix C) which means that a nursing degree isn’t
required but there is a certain education program which must be adhered to in
order to become a direct-entry certified midwife. Since 1982, insurance companies have been mandated to reimburse
New York CNMs’ services. In 1992, New
York state CNMs became able to write their own prescriptions, and also became
fully professional, and have the authority to practice how they deem necessary
without someone always looking over their shoulder. At the tertiary hospital in the city, the midwifery group was
extremely close to being able to admit their own patients, and if it passes,
they will be the first non-physicians in that hospital to be able to do
so.
Midwives don’t intend to
have the same surgical ability as doctors—they are specialists in normal birth
and they are specialists in treating birth as a natural process, not as a
disease. Needless to say, the
objectives of midwives and doctors are so similar that the differing approaches
they take often run into conflict.
Variations in Settings and Practices
Regardless of the fact that midwives and obstetricians have different scopes, due to the facts that a) the two professions share similar objectives, namely birthing babies, b) the approaches of midwives are quite different from the approaches of the obstetricians and c) midwives have just recently been recognized as professional health care providers, there are constant negotiations between the medical and midwifery models. For clarity’s sake, I will generalize some different types of midwives and discuss their individual approach by discussing the several different settings: the hospital, the clinic, the homebirth, the private practice and the birth center. A discussion of if, how, and to what extent the midwives must negotiate or adhere to the medical model in each setting will follow each section.
The Midwife in the
Hospital
All of the midwives I interviewed had at one point or another worked at a hospital, but two did both visits and births only at the hospital and another one saw patients at a medical center but delivered only at a hospital. Both hospitals are now completely on the single-room labor and delivery system, which means that each woman gets a private room where she stays to labor, to deliver and to recover. At one of the hospitals, this change only occurred within the past two years, although the beginnings of an “alternative” birthing center were in effect in the early 1980’s. The tertiary hospital still had an L&D area which was used by physicians for more complicated births. As far as I could tell, most normal births, attended by either physicians or midwives, were done in the one of the two nearly identical birthing centers. I had the opportunity to visit a birthing room at one of the hospitals and the following excerpt is from my field notes:
The birthing room was large and roomy but rather sterile. The bed (not a proper birthing bed which confused the midwife as to why it was there) was in the center and was a typical hospital bed with a tray that rolls up onto it, containing a plastic cup for water, some pamphlets, linens etc. To the left was an oak paneled baby bed with a blue and pink blanket. The midwife explained that a heating lamp could go over the top of it, but usually the midwives just give the baby to the mother after it is born. On the other side next to the large window was a blue vinyl reclining chair as well as a table with two seats. A large television was suspended from the opposite wall. There was a private bath with a Jacuzzi (used before and after birth). There were no pictures or other decorations on the wall, and besides the blue chair, the blanket and the oak paneling on the baby’s bed, there was nothing but static white color.
The exam rooms one group of midwives used were in the ambulatory center (AC) of the tertiary hospital. The following is a description of the room and other technological features that were available for the midwife to use:
It looked like any “typical” exam room—an exam table
with the white paper on it, the normal examining instruments such as a blood
pressure cuff and a stethoscope, a sink, cabinets, and a little built in desk
on the opposite wall. The midwife then took me to the ultrasound room, which contained a very
advanced ultrasound machine that apparently transmits the image into a room
across the corridor where physicians can congregate and examine the images. H mentioned that she had no clue how to work
the machine and a technician performed and interpreted the actual
ultrasound. Apparently, an ultrasound
is offered at 18 weeks and it is up to the mother (unless there is some risk
factor that requires one) whether she wants one or not. Negotiating through
more hallways in the Ambulatory center, we end up in a fetal monitoring
room. H explained how it was used. Again it was all hooked up to the computer
network, so it could be accessed anywhere in the hospital.
To the untrained eye, a midwife working in a
hospital setting appears to be no different from a doctor. She is working in a high technology,
state-of-the-art, sterile, busy, and often chaotic environment.
Dynamically speaking, in a
hospital setting, there is usually more than one midwife on duty during the
day. At the tertiary hospital, on any
give day there was a midwife in the birthing center, another midwife in the
ambulatory center and a third midwife on call.
There is a rotating 24-hour on-call system. If a woman goes into labor during the night, she will call the
midwife on call, and the midwife will meet her patient at the hospital. During the course of her pregnancy, the
woman has had the opportunity to meet with all the midwives in the group so
that no matter who is on call to deliver her child, she will know her
attendant.
The midwives saw all types
of patients at both hospitals, from the working poor to the University
professor; from those who really wanted to have this baby, to those where the
pregnancy was an accident, and everywhere in-between. Thus there tend to be more “high-risk, normal” births in a
hospital—women who are drug abusers, women who are depressed or have been
abused.
Working in a hospital the
midwives are exposed to the medical model of obstetrics on a daily basis.
Simultaneously, the midwives integrate some of that model into their practice
as well as resisting it. One of the
larger points of the model the midwives negotiate with is their exposure to
technology. One midwife describes how from her experiences of midwifery school
she came to realize that not all technology is bad:
I think I just did [ultrasounds] enough, and saw it enough and though about it enough and read about it more and decided that ultrasounds don’t cause holes to grow in babies bodies. There’s a lot of weird stuff out there in the literature that is not necessarily accepted in the medical world. Ultrasounds are so widely used in other countries that they don’t even bother with the silly little measuring tape that we use in this office. They just do an ultrasound every trimester. Which hasn’t really proved to be beneficial but they believe so strongly that it is more scientifically accurate, that that’s what they use. You know I don’t agree with that, because it’s a flawed technology. In my clinical experience, it’s caused a lot of problems (with misdiagnoses). So you don’t want to over-scan people necessarily but you shouldn’t necessarily be afraid of doing an ultrasound if you think that there’s one indicated or it could possibly give you information that you need.
While the midwife is clearly not saying that ultrasound is completely safe and is a wonderful piece of technology that should be universally implemented, she apparently does not believe it is a bad thing. Instead, it can prove to be rather helpful in certain cases, such as diagnosing placenta previa.
Conversely, another midwife describes some of the unfortunate effects technology has had on her:
Well, the Hospital has a lot of technology. It kind of just, I’m always having to figure out how I’m going to sidestep it. You know I like working here but you know there’s all this fetal monitoring and its all centralized, like its all in computers, and there’s computers all over the place and you can be at one end of the hospital, like you know in the AC. You can be in the AC and you can see all of the fetal monitors on the computer that are, that everyone’s that’s being monitored in Labor and Delivery and in the birth centers. That means that you can be really far away and know that there’s a deceleration of the baby’s heart rate and with that you don’t know anything else that’s going on in that room. And so, I could be standing in that room actually taking care of that patient and the person is pushing and its normal to have a deceleration of the fetal heart rate, you know, with pushing. And um about everyone can see it if the patient’s on the monitor. So I’m always trying to figure out how I can keep patients off the monitors. Also nurses really buy into the technology. If you have a patient on a monitor then you hardly have to go into the room. It picks up the contractions, it picks up the baby’s heart rate. You know, you don’t have to, you know you type things into the computer and stuff. You know, it’s too convenient in an obtuse kind of way.
The midwife means that the care provider does not
have to watch the patient at all, as the machines will let him or her know if
there is a problem of not. The
implications of this are that the care-provider will be treating a problem if
it arises but will not partake in preventative measures. Furthermore, if machines are always watching
the patient, the care-provider will not need to interact with the patient as
much, making it easier to objectify the woman and her family.
Another more subtle
influence of the hospital is the effect that the medicalization has had on the
midwives. A midwife who works in a
hospital explains how her desire to work in a homebirth environment has ebbed
because of what she’s seen going on in a hospital. She describes what her ideal vision was and how being in a
hospital has affected that:
If I became a midwife I was going to do homebirth. I’m slightly surprised but I think it’s because I’m older and I’ve seen a lot and I’m scared. I can’t bring myself to trust the birthing process. Because I saw lots of stuff and maybe all that stuff I saw didn’t need to happen because it was so medicalized, but I still saw it and it affected me and how I view birth. I have the luxury now to do what I need to do but I have the technology to back me up. I don’t wholly believe that all this technology is necessary.
Furthermore, the hospital does not always support the midwifery model in terms of regulations. For instance, the obstetric model is that laboring women are not allowed to eat, in case something goes wrong and she needs surgery. However, the midwives generally don’t think that eating is a problem. If the woman is hungry during labor, she should be able to eat. When the midwife mentioned they allow their “normal” patients to eat, I asked what the doctors think about that. She replied:
We are pretty careful. I wouldn’t tell somebody to eat if I thought they might need a C-section. If someone’s really hungry and she’s doing great and she asks, then “yeah, go ahead.” Not everybody’s gonna have normal experience so you can’t act like it.
There are also certain protocols in a hospital that the midwives who work in the hospital must follow or risk the chance of losing practicing privileges at the hospital. An example one of the midwives gives concerns meconium stained amniotic fluid (meconium is the baby’s first stool which is sometimes passed in utero, and if the baby inhales this, there could be potential problems). The hospital says that if there is meconium stained amniotic fluid, then the health care provider must continuously monitor the patient, even if that is something that the midwife would not normally do. Therefore there are some necessary modifications of the practice due to being in the hospital setting.
Another way in which the hospital does not cater to the midwifery model is in terms of the dynamics. One midwife explains how the midwifery model cannot fully be achieved in the hospital due to the mere fact that it is in a hospital:
It’s different in a hospital than in a birth
center. It’s not as comfortable or
personal. It’s not as easy if the family wants to bring kids. You can’t keep eye on the kids in a hospital
whereas they could just sit at the birth center and watch TV. You can’t let kids out of room at hospital.
If the kids aren’t comfortable with the birth, it’s hard for them leave. If the kid wants juice, you have to get the
juice, because they probably want to leave. That’s why they’re telling
you. And you have to listen to those
signals. It’s also hard for people to leave six to 12 hours after birth. The staff is worrying about getting all the
paper work done. There’s a little
medical overlay. It’s not so
dreadful. We’ve been there for a while
influencing practice patterns. Nurses
routinely try to put the monitor on though.
We always tell our patients if they don’t want it, tell the nurses “no”
if the midwife isn’t there yet. The
nurses are okay with that. We will
write on the birth plan “no fetal monitor”.
And we’ll highlight that, and the nurses respect that.
Also there’s the shift of
nurses. I counted six nurses in 45
minutes. It’s really annoying and I
can’t control that.
While there are obvious limitations to implementing the midwifery model in the hospital, being in a hospital setting has given the midwives a special opportunity to influence the practices of other health practitioners around them. The hospital-based midwives I spoke to said that generally the chief of OB was supportive of midwifery. The attitudes towards midwives are passed down through the hierarchy so if the chief is pro-midwifery, the doctors and nurses will generally tend to be as well. Thus, while the fight was not easy to instill some of the midwifery philosophy in the obstetricians, it was possible. I paraphrase how one midwife describes the gradual process of change:
When the Group first arrived at the hospital, all women were given an IV, they could take nothing by mouth, except maybe an ice chip. Nobody could get out of bed to go to a chair or the bathroom or walk around. Things were generally pretty medically oriented. Everybody delivered in the delivery room. There were very few birthing rooms and they were reserved for the “perfect births” for fear that if something happened they couldn’t take the two minutes to get the patient down to hall to the delivery room. The C-section rate was around 23 percent. The midwives integrated their own philosophy and the nurses who worked with them thought that it was great that they could actually give the patient the water at the bottom of the ice chip cup. One of the midwives in the group was so annoyed that there was no bathtub anywhere; only a central corridor of showers. The midwives would have to drag their pateints there and stand in the showers with them. Apparently, one day this midwife opened the wrong door and there was a bathtub under piles of junk. She threw everything out, got a can of AJAX, scrubbed the tub and then let her patient labor in it. This action caused a great stink because it wasn’t sterile. In fact, it isn’t a big deal whether the bathtub is sterile if the woman is just laboring there because the water won’t enter into the uterus by itself.
Then we started working more on L&D because residents needed help covering. Patients come in and residents evaluate what’s going on and then call their attending physician and tell them what’s going on. Job as resident is to make sure the doctor is in the hospital so that they call them just in time when the baby is crowning. The resident is doing all the checking. So they needed help so we started helping them. We were house officers. We covered L&D half the time in the month doing the physical and the initial assessment. Taking care of the doctor’s patient. Eventually, the residents got pulled and went to the University hospital so there were no resident house officers so the midwives stepped in and did it full time for a year. It was just midwives and attending physicians. The section rate went down to 17%. The vacuum rate and forceps rate all dropped quite a bit because we didn’t have to show anybody how to do it—nobody had to learn. We didn’t have to do any unnecessary ones, which aren’t uncommon, because the incidence rate for need is so low. And it doesn’t cause any harm because they’re not like putting the vacuum on for an hour. Now we have both residents and midwives. The women can drink clear fluids of any kind. Nurses automatically give juice when they come in. The women don’t get an IV right away. The nurses are comfortable taking monitors off after 20 minutes. The nurses encourage patients to try different positions. The nurses really like the way we practice.
Interestingly, the nurses, if they have gotten used to the midwifery style, will often become annoyed at the midwife if she appears to be doing something too “doctor-like”. One midwife who works at the hospital told me about the following situation (which I paraphrase here):
One day a woman was in for a labor check. Labor had been going on for three days, and she was exhausted. She was sobbing and her contractions were crap. I took the aggressive approach and asked if she wanted to have baby now. And the woman said yes. I suggested starting pitocin. The woman was fine with that. She’s like, “let’s do it.” I told nurse the plan about breaking her water and nurse lit into me (this nurse was older and had done a lot of work about being a labor coach and was really into the midwifery approach). She exclaimed, “This is NOT THE WAY A MIDWIFE HANDLES THINGS” –-right in front of the patient. I’m like “Excuse me? You wouldn’t be giving me this lip if I was Dr. B as opposed to Midwife B.” And she said, “a midwife doesn’t do things this way.” And I said, “well what does a midwife do? A midwife doesn’t let a woman labor until her uterus ruptures either. You haven’t seen this person for the last three days and talked to her during the nights. I have.”
The midwives through the years, have gained respect in the hospital setting due to their gaining a professional status, and have even had the ability to influence practice patterns.
Thus the hospital, the most technologically advanced and medicalized setting for a birth, provides some benefits but also poses many problems that the midwives must work around. They have the back-up technological support if they need it, but they also have to deal with certain protocols and regulations of the hospital, rules that cater to the medical philosophy of birth. However, because they are adhering to hospital protocol, and their actions are visible to other health professionals, the midwives have gained respect in the hospital setting and have even had the ability to influence practice patterns.
In direct contrast to the
hospital, the clinic I was able to observe at is old and rickety. It is located on the fourth floor of a
building in the center of the city. I
immediately got a sense of organized chaos with several different reception
desks. I met with the midwife in a back
office where there were several uncoordinated stools and chair and a countertop
that ran the length of the wall. Boxes
containing free samples of lotions, formulas and the likes, and hordes of
information pamphlets and packets on pregnancy, childbirth, STDs, AIDS and more
on the desks and shelves.
The exam rooms are smaller
than the ones at the hospital and are not in as prime shape as the exam rooms
at the hospital. There was a small sink
and counter against the back wall and a couple of mismatched chairs against the
adjacent wall. There was an old laundry
basket of children’s toys underneath one of the chairs.
There is a small lab at the
clinic where routine urinalyses and other simple tests are carried out. All ultrasounds and fetal stress tests are
done over at the hospital. The midwives
do not hesitate to employ such forms of medical technology if they deem it will
be useful.
This particular clinic is described
as health services serving ages 12-25.
Obviously, the clinic is for primary care, but offers prenatal care as
well. Therefore the only prenatal
patients are younger women. They are
primarily inner-city women from low-income families. Some of the patients are really looking forward to the birth of
the babies and are really into the entire process, whereas others are more
passive, and don’t always take care of themselves. One midwife describes it as
such:
I think its interesting because a lot of midwives who work in the clinics like we do, we see very unhealthy people, and we see very compromised people in terms of their lifestyle. I look at some doctors who are practicing in the suburbs and they are taking care of these healthy, middle-class women who have access to cars, to the grocery store, to healthfood stores, that can read, that have access to all sorts of things.
The staff consists of a doctor, several nurse
practitioners, several social workers and the midwife who works on a part-time
basis.
Obstetricians
do not usually deal with clinic patients apparently for a couple of reasons.
One reason is that it is cheaper to hire a midwife and the other is that
obstetricians don’t have the time or the desire to do this work. The midwife who I observed working at the
clinic gave the following reasoning:
A lot of physicians who are busy and don’t like doing that really find them a lot more work than they’re worth monetarily. You need social work to be helping you etc. and if you’re in private practice you can’t afford a social worker to do all that. So if the insurance company reimburses you $1000 to take care of a patient and you have to spend $300 on other kinds of services then you tend not to want to take care of those kinds of patients because you will need those other kinds of things. It takes more time, and it can be pretty exasperating. Its not that [the patients] want to be exasperating, it’s just their situation, where they are in their development.
Through my observations I noticed that things at the clinic could get very hectic, with patients arriving late or calling up saying that they can’t come in because they don’t have transportation.
Issues that are unique to the clinic revolve mostly around the clientele. Some midwives don’t like to or refuse to work in a clinic setting because it often involves patients who don’t want to be or are unable to be involved in their pregnancy and birth of their child. It leads to too many frustrating situations. As mentioned earlier, patients often show up late, or they come in under the influence of alcohol or drugs. The following is an excerpt from an interview with one midwife who was recalling a frustrating experience with a woman who called up in the middle of the night (I is the interviewer and M is the midwife):
M: It’s hard taking care of women who are using
drugs. It’s really hard. It’s real challenging to me. Its very hard to, it’s not even the baby that they’re damaging,
it’s just so depressing. Their life is
just so depressing. And so
overwhelming. It takes over everything for them. And you know it. They don’t come for appointments, they show
up late, they have all kinds of excuses and they’re very charming. Its part of the addiction is that you’re
good at manipulating things (sigh). SO
I find that really hard. And I don’t
like taking care of them in labor because they’re not helping at all. And you know their needs are difficult to
deal with. It’s just hard to understand. Hard to understand their whole
life. I kind of wondered, I kind of
thought it would be interesting to do home visits on people to see where they
live. I suspect it’s nothing like I know.
You know I’ve gotten phone calls from people at 3 o’clock in the
morning, complaining about a backache. This was a patient that it was like a
fourth baby and she was twenty. And I knew her. I had been taking care of her for several of her
pregnancies. And here she is, she’s 20,
25 weeks pregnant or something and she’s complaining her back hurts. “Did it just start?” “No, its been going on
for days” “What made you call now?
Did something change?” “No, I was just here and you know kind of figured
I may call.” You know, she had a free
moment. And that sort of blew me away.
And I said, “what do you think I’m doing.
I’m just curious. Tell me what you think I’m doing” (teacher-student
voice). “Aren’t’ you like sitting by
the phone waiting for people to call you?”
“No, I’m in bed, asleep and my pager went off and you know, you have a
back ache for three days. What were you thinking calling me now?” And if I asked her to make an appointment,
call the next morning to make an appointment to come in, she wouldn’t. She wouldn’t wake up probably until noon, 2
o’clock in the afternoon and then it takes a little while and before you know
it its 4 o’clock and she thought she’d make it by 3 and hell, she didn’t make
the appointment, that’s it. But what also amazed me was that her three-year-old
was up. And he was talking to her. He
was bugging her while she was on the phone.
And I said “what he is doing up” and she said “oh he’s awake, well he’s
awake now. He’s staying up with me. He sees that mom’s awake. He’s keeping me company”. And I’m like “oh”
(drawn out in disbelief)
I: Does that discourage you at all?
M: Well you
know he’s not going to do very well in kindergarten is he? He’s not even gonna make it in school. It’s very discouraging.
I: Was he a
baby that you delivered?
M: Oh yeah, yeah he’s going nowhere. Its suddenly, you know, for me, someone opened the door and I looked in and saw what’s going on in this person’s life which is beyond my ability to comprehend. Like you know, that whole picture. And suddenly realizing how hard it will be for him to go to school. And his mother has no, she started having babies when she was 14 or 15, her life is complete chaos. She has no control over her life whatsoever, over her self, over her reproductive ability. Anything. She’s kind of out there. She has no boundaries. She has no idea how to be a mother, how to be a parent.
Some of the midwives do enjoy working with adolescents in the clinic, and that is what attracts them to that sort of work. While it can be discouraging at time, having the ability to provide the support and teach individuals that they are worthy is very rewarding. One midwife explains:
[Adolescents are] not easy to work with but they were fun to me. Most people didn’t want to deal with that group. Therefore probably because of my attitude [the adolescents] knew that I wouldn’t dislike them. Not that I had a whole lot of skill taking care of emotionally disturbed children. But I wasn’t judgmental and pretty understanding.
So when they would say they didn’t want to deal with young people in L&D I’d be the first to say, “oh, I’ll take this patient.” And then people got so they knew I would always volunteer so I always got the assignments because nobody else wanted to take care of them, and I really thought it was no big deal and actually thought it was fun.
It’s not that I believe 15 years old should be having babies, it’s just that they are having babies in reality and I can’t change that. I can try to impact a woman’s life in a positive way and give her tools to empower herself but I can’t make anybody do anything.
Midwives have traditionally worked with lower-income women and this is the realm where they have been most accepted over the years, since doctors generally don’t want to work with this population anyway. The negotiations involved in the clinic arena mostly involve the patients themselves: counseling, supporting and advocating for people who cannot do it themselves. The midwives will fill out WIC applications for their patients, will help arrange GED classes, will talk to their patients’ employers or school to discuss the situation. All of these things are ways in which the midwife advocates for her patients. Sometimes it can be frustrating, but other times it can be rather rewarding. The clinic setting is unique in that there seem to be very few negotiations with the medical obstetric model. The midwife is the only one at the clinic who has a thorough knowledge of birth. Thus she is at the top of the hierarchy in that sense, whereas in other settings she is often struggling to obtain equal professional status with the physicians. Technologically speaking, the midwives who work at the clinic are the same ones who work at the hospital. Therefore, their feelings about employing technological and other medical measures appeared the same as if they were in the hospital.
The Homebirth and the Private Practice
While much of the general
public associates midwives exclusively with homebirth, in all actuality, very
few midwives participate in homebirths for a variety of reasons that will be
described later on. However, three of
the midwives I interviewed had participated in homebirths and one still does them
frequently. Birthing at a home is
considered very low technology. If
there is a foreseeable problem, but is still within the scope of a midwife’s
practice, then the midwife will suggest that the baby be birthed in a hospital,
with the midwife in attendance. The midwife who still participates in regular
homebirths described some of the differences and similarities of a homebirth to
other hospital births:
You can use pitocin at home. Yes. Pitocin, methergine. There’s really no difference in technical support between the home and the hospital, except in the hospital you can hit a button on the wall and people come and do the pediatrician’s part and do resuscitation or deal with a baby that’s in distress. The whole responsibility is not on the midwife’s shoulder. And at home, once you’re there you’re there and there’s no red button on the wall. In terms of what you immediately do at birth, there’s nothing any different. It’s not a real hi-tech thing. Its not a real difficult, hi-tech thing to resuscitate a baby at birth. It more has to do with personnel. In the hospital, you can do all sorts of stuff, like put a baby on the respirator ultimately. But immediately, when the baby’s born, it’s not really different.
After a homebirth, the
follow-up procedures include the midwife or a nurse who works with the midwife
making a home visit within 24 hours to make sure both the baby and the mother
are doing okay. At the private practice
I visited, the mother and her baby would then come for an office visit a week
after the birth. The midwife also made sure that the pediatrician whom the
parents were using was notified in advance and the parents must agree to see
the pediatrician at a time interval the pediatrician recommended.
A woman may choose to have a
homebirth for several reasons. Usually
the women who choose this option are well informed of their choices and are
aware of the benefits and risks of birthing in a home versus birthing in a
hospital. These women are generally
looking for the place where they will be the most comfortable because they
realize that that is a crucial element during birth. Other women choose homebirth because of their religious
beliefs. The Amish, Mennonites,
Orthodox Jews, Christian Scientists, Jehovah’s Witnesses and Moslems are
several groups which may have members who “consider birth to be an important
spiritual and family event and prefer to avoid medical intervention and control
of the process (Rooks 1997: 155).
A
midwife who does homebirths describes her working with the Amish in the
homebirth setting:
I had lots of preconceived ideas of what the Amish were going to be like. I know that they live without electricity, but I sort of pictured they lived in an old fashioned way that was going to be hardy and healthy, and I was horrified to find that they have terrible nutrition and they suffer for it. And when Amish women started coming to me, I would think this has got to be the oldest pregnant woman around, and then find out she’s 35. They’re really beat. Their life is really hard on them. They get old really fast. There are a bunch of genetic problems because of intermarrying. You’re exposed to babies with congenital problems that you wouldn’t see anywhere else. They’re very common accepting of it. It isn’t a horrible disaster for them. Sometimes you wish you could get them to do something about it…lets stop having people that both carry this gene marry each other. There’s a congenital kidney malformation that’s present, and families will repeatedly have these babies that will only live three to six months. And they’re sick and miserable while they’re alive. There are some things about their way of life that really depresses me. They’re really nice people. I also managed to make good friends with them which I wouldn’t have normally done, because it’s a very closed community. It’s fun to see a different way of life.
Interacting with different types of people is a
“special gift” as one midwife describes.
In the homebirth setting, run off of a private practice, there is a more
intimate atmosphere than the hospital setting.
A midwife who has worked in a private practice doing home births and in
the hospital setting, describes it this way (and I paraphrase):
People treated me kindly at [the hospital]. I was treated with respect and it was a great place to brush up on high-risk skills. But for me it wasn’t home. It wasn’t where I would choose to work, because I have a different way of processing things than they do there. You could do pretty decent midwifery there, but at the same time while you were doing all that wonderful stuff you were taking care of thirty patients you had never met before. Some of who were pretty high risk, at all different stages. Some in labor. They had 12 labor and delivery and recovering rooms and you were responsible for overseeing all of those plus the antepartum and postpartum problems. I didn’t like providing care for patients I hardly knew. I found that stressful. Because one of the hallmarks of the midwifery is continuity of care, which means you have time to spend time with families, to get to know them and you also and see them repeatedly so you know their medical history while you also gain their trust.
The homebirth midwife who I met with was a very “grassroots, birkenstock wearing” type of caregiver. She was very much into natural, normal childbirth. Her philosophy on home childbirth and the use of any technology or drugs can be expressed in the following sentiment:
If you want to say it’s natural and normal, then if you start to mess around with it, it isn’t natural anymore and you don’t have that safety to fall on. Pitocin et cetera means messing around with what’s normal and hopefully you’re doing it for a reason, because if you’re doing it, it implies that something outside the normal is happening or else you wouldn’t be doing it. Therefore, you shouldn’t be at home.
Following the “natural process” theme, this midwife really tried to create an environment where the woman is completely in control. She described:
My very favorite situation or the births I think are the nicest are the ones where I’m really not necessary. Family/friends have it covered and the woman has emotional support and people taking care of her and she doesn’t need anything from me except to be there in case there’s a problem and to make sure everything’s okay, and to say, “yes this is all normal.”
When a woman calls in to say she is in labor, the midwife will usually judge over the phone whether her presence is needed or not. Sometimes, she will even drop by the family’s home to check on the progress.
Another aspect of homebirth midwifery is that the midwives have some control over for whom they’ll do homebirths. One midwife mentioned the following stipulations:
I won’t deliver a baby at home for anybody who
smokes, partly because I’m really allergic to it, and also the likelihood is
increased that the baby’s at risk. But
most of all it represents to me that if someone isn’t making enough of a
commitment to their health and their baby’s health by smoking when they’re
pregnant, and I’m asked to come to their house and make this really big
commitment, then its some indication to me that they’re really not into what
they’re putting into their end. I’m very willing to work with someone trying to
stop smoking during their pregnancy but not for someone who says I smoke and
I’m going to keep smoking. Doesn’t
really apply to hospital birth because it’s not as much risk and commitment
from me as a home birth is.
I by and large if someone is planning a home delivery I expect them to breast feed. Someone who is not interested in breast-feeding probably ought to have their baby in the hospital. Because breast feeding is part of the normal mechanism which keeps people from bleeding after they have a baby. If you want to say that this is a normal function, then you have to do the whole normal function which keeps the uterus contracting. I bent the rule once. I did a home delivery for someone who was bottle feeding. And I think the story was that we talked about it and she agreed to breast-feed for a little after the delivery and after the baby was out, she said “no way, Jose. Go get the bottle”. And there was nothing I could do at that point except proceed as we were proceeding. But after I left the house I got a call back and she was hemorrhaging and had to go to the hospital. I felt kind of burnt. I did a homebirth though recently (although ended up in the hospital) that wasn’t going to breast feed because she had a bilateral mastectomy for breast cancer previously. And I bent the rules because I felt like she was going for broke to do something positive that mattered to after having a really hard time. And I figured I would stay at h