Working In These Times
Midwifery: The Labor of Labor Seeks Rebirth
Mention “childbirth” to the average American woman and you'll likely evoke a reaction somewhere between terror and elation, conjuring images of harshly lit emergency rooms, cold white sheets, syringes—a mess of pain and joy sprawled before a team of antiseptic doctors.
But there was a time when bringing a baby into the world, while by no means easy, was a little more... personal. Today, traditional natural birthing practices survive through the work of midwives, who bring a human touch to an increasingly mechanized health care system. More than a vocation, midwifery embodies a physical and emotional communion in childbirth—an experience that modern medicine has scrubbed away in the “medicalization” of obstetrics.
Though still a widespread practice around the world, midwifery in America has long been marginalized in a medical field dominated by insurance corporations and high-tech hospitals. Currently, only only about one in ten vaginal births nationwide are attended by midwives, and midwife practitioners face tight legal restrictions in many states.
That doesn't mean midwives are becoming obsolete. According to the American College of Nurse Midwives, 70 percent of women receiving midwife care “are considered vulnerable by virtue of their age, socioeconomic status, education, ethnicity or location of residence.” Activists point out that giving birth outside a hospital is generally less expensive, though access is hampered by insurance barriers.
Meanwhile, the doctors' sector—perhaps more concerned about losing business than protecting patient safety—has repeatedly thwarted efforts to make midwife care more accessible, through litigation, American Medical Association resolutions, and recently, shutting midwives out of a hospital in Ventura County.
But in some states and in Washington, midwives are poised to inject a dose of humanity into a sick health care system.
Lawmakers in Wyoming, for example, are considering legislation to allow specially licensed Certified Professional Midwives to facilitate childbirth in hospitals, independent birth centers, and private practices. A pending bill in Minnesota would formalize standards for licensing and oversight of birth centers.
The Senate health care bill passed last December contained measures that would enhance midwife services, including reimbursement for midwives on par with physicians, and federal support for nurse education as well as health care services based in home settings or independent birth centers.
A generation ago, the movement for natural childbirth challenged common hospital practices like pumping moms with drugs and medical interventions such as Caesarean sections. Midwives emerged as a progressive alternative, enabling women to determine the environment and procedure for delivering a baby. Call it controlling the means of reproduction.
Though there is a significant scientific component to midwifery, the practice revolves around ensuring the mother's comfort, providing a non-institutional birth environment and close rapport with a trusted practitioner.
The profession is embedded in another kind of labor, too: a tradition of women serving women. Martha Ballard's career as an intrepid midwife in 18th and 19th-century Maine is a testament to the country's midwifery tradition: over a period of about three decades, she documented attending more than 800 births in her community (she writes in one journal entry, “How long God will preserve my strength to perform as I have done of late he only knows.”)
In modern times, the American College of Nurse Midwives places its practioners at the frontlines of the reproductive health crisis in disadvantaged communities, especially single women and women of color:
It is an unassailable fact that midwives care disproportionately for women at highest risk for poor pregnancy outcomes—women of color (African-, Mexican-, and Native-American), women who are adolescent and/or unwed and/or relatively uneducated and/or multiparous and/or receiving late or no prenatal care, and immigrant women. Yet it is a curious fact that midwives realize lower infant (including neonatal) mortality rates than do their medical colleagues.
Midwifery advocate Ina May Gaskin describes the tension between hyper-professionalized medicine and community-based home birth and midwifery:
Nothing in medical literature today communicates the idea that women’s bodies are well designed for birth. Ignorance of the capacities of women’s bodies can flourish and quickly spread into popular culture when the medical profession is unable to distinguish between ancient wisdom and superstitious belief. …
Midwifery care blossomed in the U.S. because of the home birth movement, as women who didn’t themselves want home births but who did want care that did not involve routine and unnecessary medical interventions and practices, such as pubic shaving, enemas, being forced to remain still while lying supine during labor (the painful position possible) and often mandatory pain medication, wanted to be able to choose the midwifery model of care in the hospitals where they would give birth.
Midwife-assisted birth certainly carries risks and isn't right for every woman, but advocates argue that giving birth safely shouldn't be equated with checking into a hospital. The medical profession's condescending attitude toward midwifery exposes the sharp gender divides in the health care system, which bears on the health of mothers and the independence of women in the workforce.
In a testimonial on Gaskin's website, Cheyenne reflects on her experience as a birth attendant at a hospital and later, as an expecting mother:
Watching other women give birth helped me greatly in choosing what kind of birthing to have. By this I mean to choose at least what was in my power to choose, for instance, the kind of care to receive during pregnancy and the kind of attitude to have during labor.
From the little experience I had accompanying women during their prenatal period, I learned about hospital policies. I watched women accept or reject these policies and learned from the outcomes of these labors that it doesn’t make sense to standardize labor, especially when it comes to deciding how long any woman should be allowed to labor.
In other parts of the world, midwifery isn't so much a matter of reproductive freedom as it is simply the only safe option. The international humanitarian community recognizes midwives as critical health personnel for serving distressed areas, like Haiti and Afghanistan.
A recent partnership between the World Health Organization and the University of Alabama provided skills training to birth practitioners from Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan, and Zambia. A follow-up study on some 120,000 births, reports the New York Times, found a significant reduction in stillbirths, especially among midwives and traditional birth attendants.
Advocates for indigenous communities in Mexico emphasize the role of midwives not only in providing vital care at a grassroots level, but also in reaffirming the wisdom and integrity of their native cultures.
(U.S. immigration authorities may not share this enlightened perspective. Last year, civil liberties advocates protested State Department policies that challenged the citizenship claims of some Mexican Americans born near the border under the informal care of midwives).
Sometimes the age-old craft intersects with contemporary politics. In the occupied territories, Midwives for Peace, a project of MADRE, has melded childbirth care with peace action in a partnership between Israeli and Palestinian midwives. The organization reports, “Women have increased access to well-trained midwives in their communities, lowering the risk associated with the difficult trips to the hospitals through heavily barricaded checkpoints.”
Their work may involve the most intimate of bonds, but midwives speak to universal public health challenges in pregnancy, birth and beyond. In light of the failures of profit-driven medicine, the labor of labor is overdue for some new appreciation.