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.

A foldable and adjustable birthing chair, made of walnut wood from the late 17th century. (Wellcome Images/Wellcome Library, London | CC BY)
A foldable and adjustable birthing chair, made of walnut wood from the late 17th century. (Wellcome Images/Wellcome Library, London | CC BY)

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.

In Birth Matters: A Midwife's Manifesta, 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, Ina May Gaskin, famous midwife and activist, explained that labor and delivery could occur without any pain or complications if allowed to proceed naturally.

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.

Birthing instruments from another era. The late-1800s "man-midwife" or obstetrician to whom these instruments belonged would usually only be called to attend wealthy women's births or if something went wrong and required surgery. (Medical Photographic Library/Science Museum, London | CC BY)
Birthing instruments from another era. The late-1800s “man-midwife” or obstetrician to whom these instruments belonged would usually only be called to attend wealthy women’s births or if something went wrong and required surgery. (Medical Photographic Library/Science Museum, London | CC BY)

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.

Further Reading

Borst, Charlotte G. Catching Babies: The Professionalization of Childbirth, 1970-1920. Cambridge, MA: Harvard University Press, 1995.

Davis-Floyd, Robbie, and Christine B. Johnson, eds. Mainstreaming Midwifes: The Poitics of Change. New York: Routledge, 2006.

Rooks, Judith. Midwifery and Childbirth in America. Philadelphia: Temple University Press, 1997.

Notes

  1. Judith Walzer Leavitt, Brought to Bed: Childbearing in American, 1750 to 1950 (New York: Oxford University Press, 1986). Return to text.
  2. Gertrude Jancita Fraser, African American Midwifery in the South: Dialogues of Birth, Race, and Memory (Cambridge, MA: Harvard UP, 1998). Return to text.
  3. D.O. Cauldwell, How To Be a Midwife edited by Haldeman Julius (Evanston, IL: Charles Deering McCormack Library of Special Collections, Northwestern University, 1948). Return to text.
  4. Ina May Gaskin, Birth Matters: A Midwife’s Manifesta (New York: Seven Stories, 2011). Return to text.
  5. Lara Foley, “Midwives, Marginality, and Public Identity Works” Symbolic Interaction 28.2 (2005): 183-203. Return to text.

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Cathy

This paints a very pretty picture of birthing in the past, however what is missing is also crucial: the fetal and maternal death rate of women who experienced such social births at home, versus those same numbers for women who give birth today.

I also think that one could argue that social births *do* currently exist, albeit in the more common social space of today. Facebook.

David Harley

Irvine Loudon, Death in Childbirth — deliveries by men-midwives were not safer than those by midwives until the late 19th century. We need to compare like with like.

Jessica

If the medical model is so successful, Cathy, why does the US have the highest rate of maternal and fetal mortality in the industrialized world? It’s a false assumption that more hospital births = better outcomes.

David Harley

The maternal mortality rate in some counties in Texas and the Mississippi Delta are at the level of the worst Third World countries.

I haven’t gone through the statistics county by county, and state by state, but I suspect that some specific locations are dragging down the median. It may not be the hospitals that are the problem but poverty, lack of transport, and lack of access to medical facilities. Add these to such factors as poor nutrition, obesity and disease. Class and race segregate American health care.

Even looking at the United States as a unit is a mistake, I would suggest. The physical distances and widely different environments make it more of a multiplicity than do the profound differences of class and race. National statistics, even state statistics, conceal more than they reveal. Black cancer patients have a worse recovery rate than white ones, but which patients, and where?

Cathy

That’s my point, Jessica — without that information people are left with the (possible) misconception that the death rate is less now than it was then. Or, to go with the data that perhaps exists, that the death rate in hospitals is higher in the US than it is with home births elsewhere in the industrialized world. A direct comparison would be hospital births in the US vs. home births in the US, or hospital births in, say, the UK vs home births in the UK.

Regardless, studies that show 20th or 21st century fetal/maternal death rate is higher in hospitals vs. with home births is what I’d like to see.

In my opinion, the study would also need to find a way to deal with the fact that high risk pregnancies are steered towards hospitals, and low risk pregnancies are steered toward home births. Because that alone would skew the numbers.

tenya

http://www.bbc.com/news/health-22888411

“A large Dutch study found the risk of severe complications to be one in 1,000 for home births and 2.3 in 1,000 for hospital births. . . In the study of nearly 150,000 low-risk women in the Netherlands who gave birth between 2004 and 2006, 92,333 had a planned home birth and 54,419 had a planned hospital birth.”
and references further
“A 2011 BMJ study of 65,000 English births found that home birth carried a higher risk for the babies of first-time mothers – but for second-time mothers giving birth there was no difference in the risk to babies between home, a midwife-led unit or a doctor-led hospital unit, it said.”

I don’t know, there is plenty out there regarding why the US doesn’t have similar studies, including from
http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Planned-Home-Birth like the fact the US rate of home birth is only 0.6%
and a quarter of them unplanned, so we’re talking about a pretty tiny number of women giving birth total. And additionally, so what if it only studies low risk women? It would be pretty unethical to conduct a study of high-risk women or unscreened women stating “uhm, yeah, we’re pretty sure this is a terrible idea, but we’re going to go ahead with this for science!” You could maybe do retrospective studies, but still, tiny number of women/babies with the unlikely scenarios of admitting they either got little or no adequate prenatal screening to determine they’d be high risk.
(further, I keep seeing criticisms ‘well the US and the UK are structured differently than the Netherlands! We can’t say our homebirths would be as safe as their’s!’ okay fine, maybe make that additional safety requirements? Maybe? Why is this so terrible?)

sandvick

Reblogged this on DailyHistory.org and commented:
Over the past 100 years, babies have gone from being born at home to hospitals. This transformation from “social home births” to “medicalized labor” has changed the traditional role of midwives as shepherds of a natural process to “highly-educated medical practitioners.” Even though midwives have been co-opted by modern medicine, they have been at the vanguard of reconnecting birth to its more traditional roots in the home. Jordan Taitel describes the dual role midwives have adopted in an article for Nursing Clio.

David Harley

There is an almost inevitable tendency to romanticize the birthing room of the past. Those of us who have written about it deployed the concept of “women’s culture”. When we discovered that that there was a ritual of childbirth and a space which largely excluded men, we used to neglect the differences of class or status among the women present.

They were not necessarily women whom the mother-to-be would have chosen. There was often friction between them and the midwife, who wanted to assert her authority regardless of the status of the other women. The midwife had very different interests from those of the other women present. Her reputation was at stake, especially in a difficult birth. Diaries and letters record contests over when to call a surgeon, and the midwife is often blamed for being too vigorously interventionist, in the event of a bad outcome. “Haling” is the word seen over and over again, after the event. Women’s letters about a forthcoming birth often focus on the man-midwife’s gentle hands.

When we discuss pre-modern childbirth, “women” is a false universal. The duchess and the dairymaid did not have have the same interests. And even a roomful of social equals was not likely to be devoid of interpersonal tension. Regardless of the perceived death rate, the relative privacy of a home birth attended by a surgeon and the husband might well be preferred to the days of a roomful of women, endlessly eating and drinking at the household’s expense. We see a whole different set of problems arising when local midwives were (and still are, in some countries) being replaced by midwives with metropolitan training.

A Patchwork of Care: Midwifery in Canada

[…] and social conditions.  The history of midwifery in Canada is similar to the rise and fall of midwifery in the United States and Europe.  For years women gave birth at home surrounded by female relatives and neighbours, […]

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