Abstract
In the United States well into the 20th century, a midwife attended nearly all women who gave birth at home, regardless of their race, ethnicity, or socioeconomic status. No obstetricians, hospitals, or fetal heart monitors were used, and everyone usually did just fine. Today, the mention of a midwife as the primary childbirth practitioner conjures up images of long-haired, colorfully dressed women who wear Birkenstocks and insist on drumming throughout the labor process. This stereotype is at least partly to blame for the fact that 8,000 midwives currently attend only 9% of U.S. births. However, the authors of Mainstreaming Midwives contend that political divisiveness within the profession, along with the public's assumption that obstetricians are the best attendants for birth, pose the most significant obstacles to the widespread use of midwives' uniquely woman-centered care.
Robbie Davis-Floyd and Christine Barbara Johnson are anthropologists and sociologists who have devoted much of their careers to championing the midwife ethic of care. In Mainstreaming Midwives, they examine the development of direct-entry (lay) midwifery in the United States and the attempts toward professionalization and legitimization in a culture that has socialized women to rely on a model of care involving physicians, drugs, and technology. In contrast, the midwife model of childbirth is woman empowering, places trust in the birth process, and provides women with choices, believing that she, not the practitioner, is the best expert on her own body. Davis-Floyd and Johnson are very clear in their agenda that “midwives should become the primary caregivers for most American women throughout pregnancy and birth” (p. 508), and they present their findings from years of qualitative interviews with midwives and their clients.
The book is divided into three parts. Part One examines challenges of direct-entry midwives as they fight for legitimization and acceptance in the profession. “Fight” is the appropriate word here, as Davis-Floyd details the robust divisiveness between the two primary professional associations of midwives: direct-entry mid-wives, who enter the profession without a college degree and with training consisting of apprenticeships and self study, and nurse-midwives, who have a college degree in nursing and believe it a necessary requirement for the profession. Lay midwifery arose as a grassroots movement on the tails of feminism in the 1960s; nurse-midwifery came from a conscious effort to set educational standards and ensure credentialing. Not surprisingly, nurse-midwives have viewed lay midwives as a threat to their hard work toward professionalization.
At well over 200 pages, Part Two constitutes the longest section of the book, comprising six chapters that describe in excruciating detail the legislative efforts of midwives in six states toward licensure and legitimization as childbirth practitioners. Although this section contains a few interesting case studies, it is by far of more interest to readers intrigued by political strategies and legislative action.
The strength of this book lies in Part Three, which examines critical issues in the efforts of midwives to emerge from the margins of society. One fascinating chapter focuses on “renegade” midwives—individuals who are willing to bend protocol (i.e., attending breech deliveries) to place the desires of their clients first. The risk, however, is that these midwives jeopardize the hard-fought legitimacy of the profession with their alternative practices. Moreover, the crux of the political struggle between midwifery and institutional medicine is illuminated in a chapter describing what happens when midwives must transport a client to the hospital for medical intervention. Although midwives too often face a medical staff that is blatantly dismissive of their care, the authors are careful to describe numerous cases in which the midwife's knowledge was honored and respected, representing a kind of reconciliation between the two separate cultures.
Interestingly, I found the last chapter of this book, titled “Why Midwives Matter,” to be the most engaging. I only wish it had been the first chapter because it provided the clearest elucidation of “the ethic of midwifery caring” (p. 510) or specific midwife practices that promote empowerment and autonomy in women. Ten major points are outlined, most notably, that midwives view themselves as supporters or “attendants” at birth (versus physicians, who “deliver” the birth), recognizing that it is the woman, not the practitioner, who does the hard work of labor and birth. Further, midwives “normalize the uniqueness” (p. 521) of each woman's labor and delivery experience, allowing her to maintain her sense of efficacy and confidence.
Although the interdisciplinary nature of this book increases its appeal to a diverse readership, it is clearly one-sided. The editors, who coincidentally authored 7 of the 13 chapters, take every opportunity to remind readers that midwife-assisted births have the same, if not better, outcomes than physician-assisted births. No specific statistics are presented to validate this claim, however, despite an impressive list of empirical citations. Another limitation lies in the authors' heavy reliance on a dizzying array of acronyms to name the many professional midwife societies and credentials/licenses to which they refer. These acronyms become extremely cumbersome, as readers unfamiliar with this topic will need to constantly refer to the glossary for clarification. As such, they compromise the readability of this volume and detract from its otherwise significant message.
Despite these criticisms, there are important lessons to be learned from the story of American midwives. With their emphasis on autonomy, empowerment, uniqueness, and choice, midwives can offer women a healing experience from the destructive influence that society often has on them regarding their bodies and health care. Further, it is clear that, for midwives (or any social movement) to emerge from the sidelines, an organized political voice is indispensable. Feminist psychologists have long faced similar challenges, and Mainstreaming Midwives reminds us that unifying and finding common ground within our profession is a critical step toward acceptance in a patriarchal society conditioned to accept the status quo.