A Black woman in a dress and apron walks away from the camera down a dirt road. A small house is in the distance

Designing Women: Midwives, Class, and Choice

A couple of weeks ago The New York Times ran an article that asked its readers, “are midwives becoming trendy, like juice cleanses and Tom’s shoes?”  Turns out, yes.  At least for “the famous and the fashionable.”

Although the article highlights an increased social acceptance of midwifery, the idea of midwives as being the marker of social status seems to diminish its value somewhat. My midwife, I thought, was an advocate, not…a fashion accessory. Still, the New York Times piece got me thinking. What might it mean that midwives have become the newest trend for the trendy?  Does mainstreaming midwifery ultimately lead to increased access to it, or serve to privilege it to an already privileged class of people? In a weird way, I think the Times article put a finger on something I have been wondering for some time now: Is American midwifery gaining legitimacy primarily through its association with affluent white women?  And if so…does that matter?

It would not be the first time that race and class has had a hand in changing the way women give birth in the United States.  In fact, as Judith Walzer Leavitt argues in Brought to Bed: Childbearing in America, 1750–1950, native-born white women of means were the primary agents in the shift from homebirth to hospital birth, and primary motivators in the shift from natural non-interventionist techniques to medicalized birth.  The historical record demonstrates that the women of this demographic largely dreaded the pain of childbirth, were worried about personal or fetal injury and death, and had an increasing faith in science and medicine.  These women actively decided who would attend their confinements, and they requested the drugs, technologies, and attendants that were viewed as being on the cutting edge of American progress.

Ironically, this agency had unintended consequences.  By expressing their power to make choices about their own childbirth experiences, and by increasingly relying on the power of scientific expertise, affluent women effectively moved childbirth into the hospital – not just for themselves, but for the majority of American women, and contributed to a decrease in decision-making childbirth options for women.  By the 1950s it was no longer laboring women, but physicians, lawmakers, and hospital administrators, who were the primary motivators for change in American childbirth.

When the Times piece states the idea that midwifery has become the “enlightened” birth choice of the upper crust, I wonder what kinds of effect, if any, celebrity endorsement might have on American birth options.  Mainstreaming midwifery through popular culture certainly makes it less radical, which might make it more socially acceptable.  Is it possible that mainstream acceptance will also affect policy?  Is there some kind of childbirth trickle-down effect and, if so, will it expand laboring women’s options?  Or will it, as in the case of the shift to hospital birth, ultimately limit the possibilities for other women?

If I’m being honest, I worry about midwifery only becoming an option for affluent white women.  Safe, affordable, and compassionate birth attendants are largely unavailable for many women, especially those who cannot afford an option.  Midwifery could definitely provide a realistic solution to this problem.  But let’s be cautious of taking too many of our cues from those who have the opportunity to purchase choice.  And let’s think about the possible consequences.  Midwifery, and a widespread acceptance of it, is a good thing.  But let’s not throw the organic baby out with the locally grown bathwater in an attempt to satisfy a fetishized vision of what childbirth “should” be.

For more, see Judith Walzer Leavitt, Brought to Bed: Childbearing in America, 1750-1950, (New York: Oxford University Press, 1986).

About the Author

No Comments

Jacqueline Antonovich

Meggan, this is a great post! I am wondering about a few things – now that some states are allowing Medicaid to cover midwifery services, do you think this will help democratize access to midwives or could it perhaps create a two-tiered system of midwifery? Also, do you think the SCOTUS decision today will have any impact on the profession?

Meggan Woodbury Bilotte

Thanks, Jacki!  As long as we have a pay-for-services system, I think healthcare will always exist in multiple tiers.   I mean, that’s kind of the point, right?   That being said, I absolutely think the move towards covering midwifery under Medicaid will help to democratize it by offering a choice to lower-income women.  It makes more fiscal sense, too, which brings me to the SCOTUS decision.  Since midwifery tends to have much lower costs associated with it, it seems logical that the insurance companies that don’t cover it already will start seriously considering it as a rational and realistic option.  All of this, of course, only applies to state-recognized practitioners, particularly nurse-midwives (CNM) who are anchored to ob/gyns, which presents the question of the medicalization of midwifery and the possible effects of that on care, but as long as the data continues to demonstrate lower costs for equal or better care ( which I think it will) it seems the SCOTUS decision will, eventually, have a major impact on the access to and utilization of midwives in this country.  Great questions! Thanks!


In many Canadian provinces, midwifery care is covered by our provincial healthcare insurance coverage. However, the federal government provides little support for direct midwifery services on Aboriginal reserve. Indeed, there is no job description of midwife (as there is for doctor and nurse) within the Federal Treasury Board, thereby making it impossible for the federal government to employ midwives. Aboriginal women and their infants have a two to four times higher morbidity and mortality rate than the average Canadian. Midwifery has been shown to improve health outcomes for Aboriginal communities. All Aboriginal communities deserve the right to choose midwifery care.
[I am a PhD candidate at York University, where I study the history of domestic medicine and female medical actors (including midwives) in late-medieval and early-modern England.]


Great post! I’ve also been thinking about these issues for a while as many of my friends and colleagues are becoming parents and are invested in choosing ”alternative” birthing options. I have certainly noticed a shift in discourses not only around midwifery but also around home birthing options. I know several older Black women who had home births but certainly not under the conditions that many of my peers are opting for in the contemporary moment. Home birthing has also become quite stylized and representative of a certain lifestyle or identity. I think it will also be interesting to think about how midwifery’s emerging relationship to affluent motherhood and, more specifically, affluent white motherhood will affect midwives relationships to their clients who do not occupy these identities. Again, great post. Thank you raising these questions.

Meggan Woodbury Bilotte

Thanks, Wpeeps! I too wonder about how midwife / client relationships might be influenced by the emerging trends. Of course most midwives, at least the ones I know and study, are first and foremost committed to quality care of mamas and babies. One does wonder, though, if care inherently changes once it becomes a business endeavor.


Hi Meggan,
I am also a student–my research focuses on the history of midwifery and the medicalization of childbirth in the twentieth-century US-Mexico borderlands. I’d like to respond to your post.

When Leavitt highlighted the role white privileged women in the US played in the move of childbirth from the home to the hospital, she was responding to calls made in the field to bring to light women’s “agency” in history. Other historians writing of the medicalization of childbirth in the US before her had represented it largely as a struggle between male physicians and female midwives and midwives were the victims. By showing that privileged while women were not completely victims in this process, Leavitt made an important contribution. Since her book, other scholars have shown that middle-class white women, as reformers, nurses, physicians, etc, were also key leaders and workers in campaigns to marginalize and eventually eliminate poor midwives and midwives of color throughout the twentieth century. This part of the story is especially interesting given that this group dominates the practice fo midwifery today.

This history continues, of course, to shape the practice of midwifery today. Just last month, midwives of color wrote a letter to the leadership of MANA, a national organization of midwives in the US, pointing out the ways that white privilege continue to shape organizational practices and interpersonal relationships. The official representative of midwives of color on the board stepped down and a number resigned.

MANA is yet another white-dominant organization that is uncomfortable with the lack of people of color in its membership and seeks to right that wrong but has proven to be unable to do so.

Not Done Yet: Midwifing a Return to Social Birth | Nursing Clio

[…] Modern midwifery has moved us much closer to seeing labor as a natural process, but because of licensing rules and restrictions and state-by-state laws that require midwives to perform perpetual medical testing on healthy pregnant women, we are not returning to social home birth as the norm for most pregnancies. Instead, we seem to be in a new era of compromise between the midwifery and medical models of birth. While medicalized birth has brought many life-saving procedures, something has still been lost; without social birth, women lack a connection to their culture and community through their birthing experiences. Even the most progressive of hospitals and birthing centers today typically require intermittent fetal monitoring. The midwife who used to be the neighbor who would run to assist births using her cultural wisdom, now subtly reinforces medicalization through prescribing a myriad of tests and treatments. As I look forward to training and working as a midwife, I am eager to hear how midwives walk this line in their daily practices, and how they imagine we might return to a birthing model that more closely reflects social birth. […]

Comments are closed.