Mainstreaming Midwives

The Politics of Change

Robbie Davis-Floyd, Christine Barbara Johnson, Robbie Davis-Floyd, Christine Barbara Johnson

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136059544
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Providing insights into midwifery, a team of reputable contributors describe the development of nurse- and direct-entry midwifery in the United States, including the creation of two new direct-entry certifications, the Certified Midwife and the Certified Professional Midwife, and examine the history, purposes, complexities, and the political strife that has characterized the evolution of midwifery in America.
Including detailed case studies, the book looks at the efforts of direct-entry midwives to achieve legalization and licensure in seven states: New York, Florida, Michigan, Iowa, Virginia, Colorado, and Massachusetts with varying degrees of success.

Part I

Developing Direct-Entry Midwifery in the United States

Chapter 1	ACNM and MANA: Divergent Histories and Convergent Trends
Chapter 2	Idealism and Pragmatism in the Creation of the Certified Midwife: The Development of Midwifery in New York and the New York Midwifery Practice Act of 1992
Chapter 3	Qualified Commodification: The Creation of the Certified Professional Midwife

These three chapters cumulatively paint a national picture of the development of nurse- and direct-entry midwifery in the United States in terms of history, politics, and national certification. In chapter 1, Robbie Davis-Floyd presents a comparative overview of ACNM and MANA through their divergent histories and contemporary convergent trends, analyzing the respective motivations of their members for creating two separate national direct-entry certifications, the CM and the CPM, at close to the same historical moment.

In chapter 2, Maureen May and Davis-Floyd describe the creation of the CM in the context of the history of nurse-midwifery in New York, which is intimately tied to the history of nurse-midwifery in the nation. They analyze the characteristics of the culture of pragmatism that developed among nurse-midwives and the ways in which this culture influenced their very practical reasons for conceptualizing and then working hard to create a new kind of midwife who would be both licensed in New York and certified by the ACNM Certification Council, without having to pass through nursing training. May and Davis-Floyd also describe the unsuccessful efforts of New York’s homebirth direct-entry midwives to be included in the law that legalized the CM—the New York Midwifery Practice Act of 1992—and its effects on their practices and lives.

In chapter 3, Davis-Floyd analyzes the creation of the CPM by the North American Registry of Midwives, a daughter organization of MANA, using commodification theory to describe the alchemical process by which the requirements for this certification were developed as its creators struggled to “sell midwifery without selling midwifery out.”

1

ACNM AND MANA: DIVERGENT HISTORIES AND CONVERGENT TRENDS

Robbie Davis-Floyd

• A Brief Social History of American Midwifery • Nurse-Midwifery’s Shift to Hospital-Based Practice and the Founding of the ACNM • Lay and Direct-Entry Midwifery • The Founding of MANA and Its Work during the 1980s • The Carnegie Meetings of the Interorganizational Work Group • Apprenticeship in Canada and the United States • The Late 1990s: Convergent Trends • From Lay to Direct-Entry: The Development of the Certified Professional Midwife • ACNM, the Development of the Certified Midwife (CM), and MANA’s Response • The Contemporary Status Quo • Conclusion: A Convergent Network of Options for American Women • Timeline of Events in the Comparative History of ACNM and MANA

The scene is the 1997 MANA conference in Seattle. The conference room is filling up with so many midwives that walls have to be moved to accommodate the crowd. I am on my way to the slide projector and I am so nervous that I drop my tray of slides, then have to work frantically to get them back in order before the panel—which I am facilitating—is supposed to start. Over the past ten years, I have given hundreds of public lectures and have chaired dozens of conference panels, so why am I trembling? Because this is the most politically charged topic I have ever taken on—a panel designed specifically to address the major issues that place MANA at loggerheads with ACNM.

The current president of ACNM is on this panel, along with the vice president and a past president. Representing MANA are its president, a board member of MANA’s sister organization the North American Registry of Midwives (NARM),¹ and a well-known direct-entry midwifery educator. The title of the panel is “ACNM and MANA: A Direct-Entry Dialogue,” and the burning question of the day is: What will be the relationship of the two new direct-entry certifications developed by MANA and the ACNM?

NARM began work on national direct-entry certification in the early 1990s and had its process up and running by 1994. A prime motivator for key members of the NARM board had been their belief that ACNM was going to stick to nurse-midwifery and leave direct-entry certification up to MANA and NARM. Thinking they had an open field, NARM board and committee members devoted thousands of volunteer hours to creating a new direct-entry credential, the Certified Professional Midwife (CPM).

But in 1994, after countless hours of deliberation on their own part, the ACNM passed a motion to develop its own direct-entry credential, which was later named the Certified Midwife (CM). From MANA’s point of view, this was a massive infringement on the territory it had staked out—direct-entry or non-nurse midwifery. Making matters worse for MANA and NARM, ACNM had sent out a letter to legislators all over the country stating ACNM’s support for its own CM credential and casting doubt on the validity of other certifications—an action many in MANA and NARM interpreted as a frontal attack.

Both organizations were facing battles to legalize these new direct-entry certifications in state legislatures across the country. What the 350 MANA midwives packed into the room wanted to know was, were they going to have to fight both the doctors and the ACNM to get their credential legalized, or could their sister midwives in the ACNM be convinced to support both certifications and work collaboratively with them to get both CPMs and CMs legalized and regulated in all 50 states?

So at one point, I asked the ACNM president to clarify whether she might support both certifications. Her response was that she could only stand by ACNM’s standards and could not support the standards established by NARM.

Midwife after midwife, some speaking as members of MANA and some as members of ACNM, came to the mikes in dismay to plead for ACNM to take a more supportive position. And then Anessa Maize, the MANA representative from Canada, took the microphone in hand and said, “You know, in Canada, we have resolved these problems and we don’t fight with each other like this. We believe we are creating systems that work, that are unifying and not divisive, and we invite you to come and take a look!”

In many areas of cultural life, Americans have prided themselves on establishing models of success that other countries try to emulate. But when the midwives of Canada initiated their worldwide search for the best models of midwifery education, legislation, and practice on which to base their “new midwifery” (Bourgeault, Benoit, and Davis-Floyd 2004), they did not look to the United States because they saw the American situation as something not to emulate but to avoid. Canadian midwives tend to view American midwifery as a fractured profession (Bourgeault and Fynes 1997), noting with dismay that the divisions between nurse- and direct-entry midwives have diverted their energies on multiple occasions into feuding with each other.

Since 1996 these struggles have constituted a focal point of my anthropological research—necessarily so, since my research project (described in the Introduction) has concentrated on the historical emergence at almost the same point in time of the two direct-entry certifications mentioned in the story above. These two new certifications encapsulate one significant agreement between the ACNM and MANA—that nursing should not be a mandatory part of midwifery education—and several significant disagreements over standards of education and practice.

Canadian midwives have both watched and participated as American midwives have tripped over pitfalls that the Canadians later worked hard to avoid. There were several attempts during the first part of the twentieth century, and again in the 1970s, to create American-style nurse-midwifery in Canada (Bourgeault and Fynes 1997:1056–1057), a number of American-trained nurse-midwives have long lived and practiced in Canada, MANA’s second conference was held in Toronto (in 1984), and a number of Canadian midwives have been and are still members of MANA. Yet as midwives in Canada have worked to develop their new midwifery over the past two decades, the American story has served not as a model of inspiration, but rather as a cautionary tale.

In this chapter I will tell that tale, or at least the parts of it most relevant to our focus in this book on American midwives’ efforts to mainstream themselves, in part through the development of direct-entry certification. I will occasionally refer to the Canadian perspective as a useful lens through which to view the American situation. An intracultural, U.S.-oriented telling would recount this story in its own terms, missing the important cross-cultural and transnational perspectives provided by taking an outsider’s point of view. And indeed, the U.S. midwifery story has already been thoroughly recounted from an insider’s point of view by Judith Rooks in her comprehensive book Midwifery and Childbirth in America (1997; see also Donnison 1977, Donegan 1978, Leavitt 1986, Litoff 1978, Wertz and Wertz 1977).

In this chapter I seek to complement Rooks’s work through an anthropological analysis that focuses directly on the relationships between nurse- and direct-entry midwives, and on points of time in which their interests either converged or diverged. I seek also to lay out the background information essential for understanding the transformations and divisions in contemporary American midwifery that are key to understanding the other chapters in this volume. Because these stem directly from historical developments, a portion of this chapter will recount that history to identify the evolutionary trajectories of nurse- and direct-entry midwifery that made today’s clashes all but inevitable. I will identify some historical moments at which things could have unfolded differently, for therein lies the cautionary part of the cautionary tale: not to seize a moment that could lead to unity is, in effect, to accept and perpetuate the disadvantages of division. But that’s not how the key players saw it at the time, and that’s not how many of them see it even now. Division has its advantages too, and when midwives of good conscience see more to gain from staying separate than from joining together, those who seek to learn from their experience may wish to understand the reasons why.

A Brief Social History of American Midwifery

The Development of Nurse-Midwifery

Well into the 1900s, in both Canada and the United States, midwives remained, as they always had been, the primary attendants at childbirth. Native American midwives continued to attend women in their tribal groups, as did colonial midwives among the white settlers, Hispanic midwives in their southwestern communities, immigrant midwives accompanying their ethnic groups, and black granny midwives in the American South. Nevertheless, Canada and the United States are the only two Western industrialized nations in which, by mid-century, midwifery was largely eradicated from the health care system. In the United States, three factors were primarily responsible:

Physician resistance. Starting in the early 1900s, physicians determined to take charge of childbirth, along with public health professionals and nurses, waged systematic and virulent propaganda campaigns against the thousands of immigrant midwives practicing in the northeastern cities, as they were seen to be the greatest threat to physician’s attempts to take control of birth. These campaigns employed stereotypes of midwives as dirty, illiterate, ignorant, and irresponsible, in contrast to hospitals and physicians, which were portrayed as clean, educated, and the epitome of responsibility in health care. In The Medical Delivery Business (2004:31), Barbara Bridgman Perkins identifies “economic competition, professional and institutional needs to hospitalize birth [these include resident training], gender discrimination [specialization], and fear that midwife inclusion in the medical system would lead to more government regulation” as primary reasons for obstetric and academic rejection of midwifery.

Lack of professional organization by midwives. In Europe, midwifery developed as a profession with formal education and licensure requirements at a very early stage compared to the United States (DeVries et al. 2001). American midwives of the nineteenth and early twentieth centuries did not develop professional organizations to increase their political effectiveness and set standards and educational requirements. Cultural, socioeconomic, and language barrier contributed significantly; even professional immigrant midwives usually served only their own communities and were often not aware of the existence of other midwives serving other communities one neighborhood away. Other impediments to organization included legal and cultural prohibitions against women regarding public speaking, leadership, finances, and so forth, not to mention the non-existence of formal midwifery training programs in the United States, which resulted from all of the abovementioned factors. So in spite of the high level of training many immigrant midwives obtained in professional European midwifery programs and their extensive experience, it was easy for the medical profession to portray them as untrained and ignorant, and impossible for them to combat these stereotypes in the wider cultural arena.

Cultural influences on women’s choices. Fashion and assimilation played key roles here. As many of the ethnic communities within which midwives had flourished assimilated into the larger culture, they adopted its medical practices and values along with everything else. Minority women actively sought access to medical care in hospitals because the state touted it as the best care for their babies—but had also denied it to them for many years based on segregationist health care policies. Once these women finally gained access to hospitals, many began to perceive the use of midwives as “going backwards” (Holmes 1986:287; Brown and Toussaint 1998; Fraser 1998:103). The kind of culture that had supported midwives disappeared, and along with it the midwives (Borst 1988, 1989, 1995; DeVries 1996:179; Fraser 1995). In addition, from the late 1800s on in the United States, it increasingly became the fashion for middle-class women to employ male midwives and later, obstetricians, as the modern and progressive way to give birth. After all, male-developed technologies were bringing electricity, telephones, railways, cars, airplanes, vacuum cleaners, and a thousand other progressive and modern conveniences. Male, technological attendance at birth seemed part and parcel of this process of modernization—a way up the social ladder of progress (Wilson 1995).

Throughout the 1800s, midwives attended the majority of births in the United States, but by the middle of the 1900s, marginalized and often practicing illegally, they attended only a tiny minority of births.

In reaction to the propaganda campaigns promulgated by obstetricians, public health officials, and some nurses, nurse-midwives (who were the first to create an organized and cohesive professional system of midwifery in the United States) took great care from the very beginning to act, and to portray themselves, as the opposite of the negative Sairy Gamp stereotype created by Charles Dickens of the fat, lower-class, gin-swilling midwife on her way to a birth carrying a bag of dirty instruments (including catheters to perform abortions). Their mechanism for the elevation of midwifery above this damning stereotype was the union of midwifery with public health nursing. This union was initiated in the United States in New York and in Kentucky in 1925 by Mary Breckenridge, who studied both midwifery and nursing and found the British combination of the two to be ideal to meet the needs of the rural Appalachian poor she had dedicated her life to serve. The successful history of the Frontier Nursing Service (FNS) she founded in Hyden, Kentucky, has been recounted in detail elsewhere (Rooks 1997). Here, suffice it to say that the combination of nursing and midwifery Breckenridge imported also seemed ideal for New York City (see chapter 2), where nurse-midwifery gained a toehold through the establishment (with Mary Breckenridge’s help) in 1930 of the Lobenstine Clinic, the nation’s second nurse-midwifery service, and in 1931 the site o...