Not Done Yet: Midwifing a Return to Social Birth

As a doula, I have the privilege of attending other women’s labors and deliveries. Recently I attended a delivery assisted by a midwife at a large-scale hospital. The midwife and the nursing staff supported the fearless mama as she labored away in a large room with a wall of windows looking out on a beautiful river. The room was decorated with pretty pictures of flowers and soothing paint tones. Most of the medical equipment remained hidden in easy-access drawers. Everything in this beautiful birthing suite was designed to make it feel more like home for the women who would deliver there. As a student of medical history, I felt thankful for the room’s design because it was a far cry from the maternity wards of the 1950s and 1960s. This hospital did everything it could to create a comfortable, personalized, and supportive environment. Still, it was a hospital, and the presence of medical intervention was inescapable. From the constant rise and fall of the heart monitors to the list of restrictions so complex that I was required to call for a nurse every time the patient wanted food, this was an environment controlled by the medical field.

Birth, despite the effort of many midwives, remains a medical event. This was not always the case. Prior to the twentieth century, birth was much more of a cultural event. Historian Judith Walzer Leavitt coined the term “social birth” to describe how women in colonial times gave birth.¹ They would gather in the home of the laboring mama to provide emotional and physical support that complemented the work of the midwife. To these women, birth was a natural process that required little intervention and monitoring unless something was obviously wrong. Women ate freely and shifted position based on their own comfort, not according to fetal heart tones. Leavitt explains that though midwives always maintained some authority in the colonial birthing room, the laboring mama was encouraged to make her own choices, seeking advice not only from the midwife, but also from the other women present who had already given birth. Social birth remained the norm until the twentieth century.

This past century has seen revolutionary changes for birth. At the start of the twentieth century, nearly every woman gave birth at home. By the 1940s, however, most American-born white women gave birth under the care of doctors in a highly sanitized and depersonalized hospital room. During this time, women of color and white ethnic immigrants could not afford hospitals and often lived too far from hospitals to access them. While they used midwives, as historian Gertrude Fraser explains in African American Midwifery in the South, their midwives were subject to hundreds of new regulations that limited women’s ability to make choices during labor.²

For example, in his midwifery manual that was distributed to many midwives in the early to mid-twentieth century, Doctor D.O. Cauldwell reminded midwives to remove items such as flowers from the birthing room in order to bring the medicalized hospital environment into the home.³ Thus, even though many births through the middle of the twentieth century were attended by midwives at the home of the laboring mother, social birth and the view of birth as a natural, normal process was being dismantled.

The 1960s and 1970s brought about a period of tumultuous change for America. The feminist movement, along with other social movements at the time, encouraged women to question the ways in which they were treated by society. Out of this, and combined with the natural birth movement that started in the 1950s, women began to demand changes in their births. A number of midwife-activists began practicing midwifery underground in order to help women who wanted alternative birthing methods. Ina May Gaskin, famous midwife and activist, explained that labor and delivery could occur without any pain or complications if allowed to proceed naturally.

In Birth Matters: A Midwife’s Manifesta, Gaskin enumerates the ways in which medical birth causes problems for women.⁴ Many childbearing women and midwives latched on to the return of midwifery, hoping it would eliminate the need for medicalized birth. By 1971, the American College of Obstetrics and Gynecology and the American College of Nurse Midwives released a joint statement that effectively legitimized midwives as birth attendants in the medical field. Slowly, state laws began allowing for highly trained nurse-midwives, who received both medical education and knowledge of how to trust women’s bodies during labor, to practice legally under the supervision of doctors. Some states even began to allow for lay-midwives, or midwives who learned their skill from self-education and apprenticeship, to begin working legally.

Today, every state allows Certified Nurse-Midwives to practice in some capacity and several states allow lay-midwives to seek certification and licensure. The midwives of today, however, are not the midwives of 50 or 100 years ago. They are highly-educated medical practitioners who must work within the medical field instead of alongside it. In “Midwives, Marginality, and Public Identity Works,” social historian Laura Foley explains that in her interviews with midwives, the women often placed their practice on a scale from “very medical model” to “not very medical model.”⁵ While most of the midwives identified as “not very medical model,” they still situated themselves on a continuum using the medical industry for markers. Through the work of midwives and other activists, birth has become significantly more comfortable and fewer and fewer routine interventions take place. Still, because they work within the medical field, midwives have been unable to restore our understanding of birth to a natural, normal process that requires support and love, but almost no intervention.

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.

Jordan Taitel

Jordan Taitel is an undergraduate student at Grinnell College, studying Religious Studies and Gender, Women's, and Sexuality Studies. Currently, Jordan is working on her certification to become an International Childbirth Education Association (ICEA) certified birth doula. One day, she hopes to be a midwife and write about birth.

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