In December of 2016, I wrote an essay for Nursing Clio called Nurse-Midwives are With Women, Walking a Middle Path to a Safe and Rewarding Birth. In the piece, I advocated that all women be given the option of delivering with hospital-based nurse-midwives, whose evidence-based practice results in safe births and, in some settings, significantly lower rates of interventions such as cesarean section. I only recently, quite belatedly, realized that OB-GYN Amy Tuteur had responded on her blog to my essay. She offered a belittling (and inaccurate) representation of my position on hospital-based nurse-midwifery, specifically invoking the specter of “white privilege.” Why? As far as I can see, it was an attempt to shut me down with highly-charged language that was intended to shame me and alienate those likely to be my allies.
In a different political environment, I would not bother to re-open a stale debate. But given the state of our current political and social discourse, I think it is important to call out Tuteur’s inappropriate use of an important concept.
Tuteur claims that nurse-midwifery could only possibly be appealing to middle-class white women such as myself, who she believes are inordinately attached to the idea that women might value a low-intervention birth experience, and therefore, when I advocate that nurse-midwives be available to all pregnant and birthing women who want them, I am cluelessly advocating from a position of white privilege.
As I explained in the essay, nurse-midwifery was originally developed to serve lower-income women who could not afford physicians’ fees. Midwives continue to disproportionately serve low-income rural and inner-city women, many of whom have difficulty accessing care otherwise. The Institute of Medicine has emphasized the relevance of nurse-midwives for improving outcomes among low-income women, and highlighted nurse-midwifery practices such as the Family Health and Birth Center in Washington, D.C. that caters to a primarily low-income clientele and is dedicated to reducing racial and class differentials in birth outcomes.
Middle-class women may be the loudest advocates for midwifery care, simply because they have the most access to public forums such as this one. And midwives certainly do serve middle-class women too. But they are by no means only good for middle-class women. Some elements of midwifery care, such as a substantially lower rate of cesarean section and better psychosocial support during pregnancy, may be particularly valuable to low-income women, who care for themselves and their families in considerably more complex and demanding situations with substantially less financial and social support than most middle-class women.
All women should be able to choose their birth practitioners, whether they choose obstetricians or midwives, and all women should have access to the psychosocial, medical, and surgical care they need. This means that all women should be able to get care from both midwives and obstetricians, as their preferences and medical needs indicate.
Tuteur will never accept evidence that any form of midwifery is safe. She is completely committed, at least publicly, to advocating for OB-GYNs at every birth, and no evidence of nurse-midwifery’s safety will ever be enough for her. That means that, at least as long as the evidence available to me supports the safety of nurse-midwife care for low-risk women, we will have to agree to disagree about the role of nurse-midwives.
The language with which we disagree, however, matters too, and I do not accept Tuteur’s mis-use of the critical terminology of “white privilege.” Specious arguments based on claims about white privilege are pernicious because they weaken and discredit the concept. We urgently need to accurately and perceptively identify the workings of white privilege. We will have trouble dismantling it if we let it be used as a vague and convenient slogan to indiscriminately smear opponents.