By Raymond G. DeVries and Rebeca Barroso

Forthcoming in H. Marland and A. Rafferty, What is to be done with the midwife? Midwife debates, 1890-1990, London, Routledge, 1996. Quote by permission only and with proper citation.

It was a strange sight, even by the standards of a large American hospital. Here, among the world's most advanced obstetric technology - electronic monitors, infusers, ultrasound devices and well-appointed surgical suites - a woman was giving birth on the floor.

The labouring women was Hmong, a recent immigrant from Laos. She arrived at the hospital by ambulance, sent by her relatives who claimed she was not in labor, just 'overdue.' Neither she nor her partner spoke English. While the nurse-midwife was reviewing her scant prenatal records, she quietly left her bed and began squatting on the floor. As she squatted, her waters broke. The attending nurse-midwife hurriedly placed some "sterile" linen under the woman and joined her in a squatting position. Within minutes, a healthy baby boy slipped into the hands of the midwife.

The odd image of a squatting woman giving birth surrounded by the gleaming, modern equipment of an American maternity ward is an apt metaphor for midwifery's problematic relationship with technology. Can midwifery, with its low-technology, non- interventive tradition, find a place in an environment where competence is equated with the use of the latest, high-technology devices? In deciding how to respond to the new technologies of birth, midwives face a troublesome dilemma: if they adopt the instruments of modern medicine, they risk sacrificing their distinctive tradition; if they cling to their tradition, they are marginalized as anachronistic, quaint, or perhaps, dangerous practitioners.

The importance of machines to modern obstetrics is illustrated in the conclusion of this story, as told by the nurse-midwife: I handed the baby to the nurses as soon as I clamped and cut the cord. I had no safe place to put him while I helped the mother move from the slippery floor. For the next five to ten minutes I was busy finishing the birth of the placenta and checking on blood loss. It seemed just a few minutes before the nurse brought the baby back, dried and wrapped in a warm blanket. When it was all over, I felt good that I attended this birth in a way that respected the culture of the mother. A few hours later when I was doing the required paper work, I was shocked to see a note in the baby's records: '10 cc clear gastric fluid per aspiration.' They had taken this perfectly healthy, vigorous baby and [using suction] emptied his stomach!

Because there was no medical indication for this procedure, the midwife concluded that the nurses felt an overwhelming, but irrational, need 'to use the equipment.' Low-technology midwifery had to be baptized by high
technology medicine.1

The re-creation of health care professions

The dilemma of 'midwives among the machines,' is, in fact, a special case of a problem faced by all health care professions. As the world around them changes, health care professions must adapt, they must 'recreate' themselves.

The sources of change in health care practice are varied. The need for professional 're-creation' is often the result of change coming from within the profession itself. As a profession develops new technology and new techniques, practitioners must adjust, changing routines and discarding old theories, making room for the latest professional knowledge. Who now, for example, purges and bleeds their patients?

But change in technique is not the only source of change originating within the profession. Decisions regarding the organization of a profession also bring about change. Professions consciously recreate themselves when they develop new educational programmes, create new areas of specialization, or reallocate tasks among occupational groups. These same decisions can also set in motion processes with unintended, sometimes negative, consequences for that self-same profession. Starr offers an eloquent description of this, showing how the professional autonomy secured by American physicians early in this century eventually (and ironically) lead to the 'corporatization' of health care, forcing doctors to adjust to a new, corporately controlled environment.2

Less obvious, but no less important sources of professional re-creation are changes in society and culture. Included among the many influences exerted on medicine by society are changes in the economy and in the political environment, the reorganization of health care financing, and demographic shifts such as baby booms, aging populations, and increased urbanization. Health care systems must also adjust to shifts in cultural ideas about gender, family, work, science, and religion. Notice, for example, the way
health care changed in response to new cultural conceptions of gender: the gender balance in medical occupations has been altered, there is a new concern with the treatment of women as patients, and medical research has been re-focused to include women.

A new, or recreated, medical practice is best seen as the result of a combination of factors. The increasing popularity of walk-in medical clinics in the United States offers a case in point. 'Immediate-care centers' are franchised and intended for quick-stop care for minor problems, earning them the name 'Doc- in-the-boxes' (a pun on the name of a well known 'drive-through' restaurant, 'Jack-in-the-box'). Their appearance and rapid proliferation can be attributed to: the corporatization of health care (a corporate strategy to increase profit), changing residential patterns (large suburban tracts offer an ideal 'market' for these clinics), and the desire of physicians for more reasonable work hours deriving from new attitudes about work and family.3

All health care professions are influenced by these changes, but not all are equally free to recreate themselves. Some, more than others, must labour in an environment where their 'social capital' is limited. A profession's history and consequent cultural authority determine the freedom it has to shape its place in the medical marketplace. Professions with greater prestige, greater income, and greater power are more free to influence political, organizational, and cultural processes. Professions like nursing, established as an adjunct to the profession of physicians, find their position controlled by those with more 'social capital.'4 Professions closely connected to a tradition, like midwifery and homeopathy, find their ability to adjust and recreate themselves limited by that tradition. In the following pages, we examine the ways in which midwifery has chosen, and is choosing, to recreate itself. We begin by recasting the history of midwifery as a continuing effort of midwives to recreate the profession in light of
its tradition, its position vis ˆ vis physicians, and developments in society. Next we look at the strategies of re-creation used by midwives on both organizational and individual levels. In order to highlight the socially situated nature of professional re-creation, we use data from both the United States and the Netherlands. We conclude by reviewing the factors that impede the midwives' task of recreating themselves, focusing on the idea of 'risk' and its place in the medical division of labour.

Recreating midwifery

The history of midwifery in the United States and the Netherlands has been told by many.5 These histories, like the earlier chapters in this anthology, are a rich source of information about the evolving relationships among health occupations. The details of midwifery's history vary by location and time period, but in each chronicle we find midwives recreating themselves, or being recreated by others, as the conditions around them, and in their profession, changed.

Reviewing these histories, we find certain events common to the re-creation of midwifery in all industrializing societies: the development of the machinery of obstetrics - from forceps to the most recent techniques of prenatal testing - the rise of hospitals, an increasing faith in science, and changing demographic patterns. Nearly all histories of midwives assert that midwifery forceps gave a technological edge to male birth attendants. The initial response of midwives was to denounce the new technology, to
assert the superiority of the 'hands-off' tradition of midwifery. Elizabeth Nihell, an eighteenth century English midwife, equated the tools used to assist at birth with military weapons: ' . . . those instruments, those weapons of death, would one not imagine that the art of midwifery was an art militaire?'6 Those sympathetic to midwifery's tradition of a patient and natural approach to birth point out that forceps ushered in a new, meddlesome midwifery.'

But not all midwives were content to recreate themselves as an alternative to interventionist obstetrics. Marland points out that a significant number of midwives in the Netherlands sought the right to use forceps. She cites an address delivered in 1910, signed by over 300 Dutch midwives, that claimed the use of forceps and the right to suture were 'vital to the well-being of their occupation and their clients' (emphasis added).7

Although midwives failed to gain access to tools of modern obstetrics, the attempt by midwives to bring the technology of medicine to the tradition of midwifery must be seen as a prudent strategy to preserve and extend their profession. The centralization of care (and 'scientific' technology) in hospitals and increasing public faith in science threatened to eliminate
independent midwifery. Physicians, competitors of midwives, easily capitalized on new public attitudes to paint midwives as old-fashioned, unscientific, and dangerous.8

In the United States, midwifery suffered further as a result of two important demographic changes: declining immigration and decreasing family size. Reduced numbers of new immigrants diminished the social contexts that supported the traditions and customs brought from the 'old country.' immigrants wanted to become 'American' and the 'American' thing to do was to
use a hospital for birth with a physician in attendance. For immigrant families with many children the desire for a hospital birth was often limited by the ability to pay, but as families became smaller hospital confinement became a luxury most could afford. Lacking an effective organization, American midwives could not respond to changing preferences of clients.

During the latter half of the twentieth century, midwifery has faced increasing pressure to change, to accommodate to the new obstetrics. The social and political position of midwives offered little room to recreate their profession in a way that would extend, or even preserve, their independence. They did not have the resources - in terms of political influence, public confidence in their 'scientific' competence, or support from hospitals and other medical organizations - to compete with obstetrics.
Given these limited resources, midwives in most industrializing nations were forced to recreate themselves as assistants to obstetric specialists. In the United States this meant creating an alliance with the established (though subordinate) profession of nursing and seeking work in medically under-served areas. In many European nations midwives became 'extensions' of doctors, the so-called 'lengthened arm' of obstetricians. As the term implies, midwives found legitimacy by working under the direct supervision
of another profession, subordinating their tradition to the ever 'new,' promising, modern approach of medicine. Even in the Netherlands, where an autonomous profession of midwifery survived, the political and cultural power of midwives was no match for that of doctors. Elements of Dutch culture and the Dutch medical system supported the tradition of midwifery, but without the protection of influential gynecologists/obstetricians, it is likely that Dutch midwifery would look much like midwifery in other
industrialized nations.9

The 'assimilationist' strategy of re-creation chosen by midwives threatened to extinguish the separate tradition of midwifery. In effect, midwives were exchanging their own tradition for the tradition of medicine or nursing. But the 1960s created a detour on the path to extinction. Societal and cultural change in the form of the feminist movement and a new and vigorous questioning of technology gave midwives the opportunity to emphasize their distinct tradition, to recreate themselves as separate from medicine.

In the light of this new cultural atmosphere midwives could renew their identity as a 'low-tech, high-touch,' women-centred occupation. The very image that weakened the profession earlier in the century, now gave them a
niche in the medical marketplace. Midwives found further support for their profession during the 1980s and 1990s as governments and health care organizations sought to control the costs of medical care. In this environment midwives asserted themselves as more 'cost-effective,' extending their appeal beyond new cultural ideas about women and technology to
economic concerns of policy makers and health care administrators.

Strategies of re-creation

The changed cultural attitudes of the 1960s and the economic realities of the 1980s and 1990s allowed midwives to maintain a foothold in modern medical systems. But the future of the profession remains unclear. To the extent that it promises to manage risk and to reduce pain, the machinery of modern obstetrics has wide appeal. Midwives face the difficult task of finding a way of recreating midwifery that preserves the distinctiveness of the profession while remaining up-to-date in obstetric techniques.

The strategies used by midwives to respond to this unmanageable situation fall into two categories: 1) organizational strategies, efforts taken by, or on behalf of, midwife organizations, efforts to preserve a place for the profession in the medical marketplace, and, 2) individual strategies, efforts by individual midwives to establish and protect the distinct practice of midwifery. These strategies of re-creation, be they organizational or individual, are influenced by social context, a fact that becomes clear in the contrast between the situations of midwives in the Netherlands and the United States.

Organizational strategies: recreating the profession of midwifery The United States

Midwives in the United States, quite commonly used at the turn of the century, were pressed nearly to extinction in the years between the two world wars. Factors mentioned above - increasing faith in science and medicine, changed patterns of immigration and decreasing family size - reduced the popularity of midwifery, as did the 'midwife debates' that took place in the second and third decades of the century. These 'debates' were not, in fact, debates at all. They are better described as diatribes by physicians against midwives. Capitalizing on new attitudes, midwives were portrayed as untrained, incompetent and dangerous, the cause of high infant and maternal mortality.10

If, in the face of these conditions, the practice of midwifery was to survive in the United States, an organizational strategy was needed. It was not enough for individual midwives to practice the tradition of midwifery, as many 'granny-midwives' in the southern part of the country were doing,11 the profession needed to find a way to secure a place for that practice in
the changing medical system. The strategy chosen was to ally with the established profession of nursing, adding midwifery training (often secured in England) to certification in nursing. Through the work of Mary Breckenridge and the Frontier Nursing Service in Kentucky, and later the Maternity Center Association in New York City *(with its own training programme), midwifery claimed a legitimate place in American medicine. In 1955, nurse-midwives took a further step to defend the interests of their profession by establishing the American College of Nurse-Midwifery (ACNM,
now the American College of Nurse-Midwives).

Two of the most important tasks of the ACNM were the creation of a nationally recognized programme of certification and obtaining licensure in all states and jurisdictions. The 'recognized place' of midwifery remained limited, however, with the newly (re)created profession serving poor women on the rural and urban fringes of society.12 Table 1 shows that up through
the 1970s midwifery played an increasingly limited role in maternity care. The flame of midwifery was not completely extinguished in the United States, but by 1970 midwives were attending less than one-half of one per cent of births there, and the percentage of births outside of medical settings fell to less than one.

____________________________________________________________________________________
Table 1

Distribution of live births by place of delivery and attendant, 1940 - 1992,
United States (in per cent)

_________________________________________________________________________________

YEAR Place of delivery Attendant

Hospital Not in hospital* Physician Midwife Other

1940 55.8 44.2 90.8 8.7 0.6

1945 78.8 21.1 93.5 6.1 0.3

1950 88.0 12.0 95.1 4.5 0.4

1955 94.4 5.6 96.9 2.9 0.3

1960 96.6 3.4 97.8 2.0 0.2

1965 97.4 2.6 98.3 1.5 0.3

1970 99.4 0.6 99.5 0.4 0.1

1975 99.1 0.9 98.8 0.9 0.3

1980 99.0 1.0 97.4 1.7 0.8

1985 99.0 1.0 96.7 2.7 0.6

1990 98.9 1.1 95.3 3.9 0.8

1991 98.9 1.1 94.8 4.4 0.8

1992 98.9 1.1 94.5 4.9 0.6
________________________________________________________________________
 

*Includes free standing birth centers
 
 

Sources: U.S. Department of Health and Human Service Vital Statistics of the
United States, Vol. 1 - Natality, Hyattsville, MD, U.S. Department of Health
and Human Services, 1993; National Center for Health Statistics, 'Advance
report of final natality statistics, 1990', Monthly Vital Statistics Report,
1993, vol. 41, no. 9, supplement; National Center for Health Statistics,
'Advance report of final natality statistics, 1991', Monthly Vital
Statistics Report, 1993, vol. 42, no. 3, supplement; National Center for
Health Statistics, 'Advance report of final natality statistics, 1992',
Monthly Vital Statistics Report, 1994, vol. 43, no. 5, supplement.

_______________________________________________________________________________

How did American midwifery respond to the social and cultural changes of the 1960s? This opportunity to recreate and reaffirm midwifery as separate from the tradition of medicine lead to a curious bifurcation of midwifery in the United States. The tenor of the times was a natural source of support for midwifery, but many would-be clients and supporters of midwifery saw nurse- midwifery as a 'sell-out,' too much a part of the 'system.' Thus was born an American version of the direct-entry midwife: variously called the lay midwife, the empirical midwife, or, most recently, the traditional midwife.

The rhetoric of traditional midwifery, as suggested by the name itself, stressed the need to recreate midwifery in its true image, forswearing any connection with 'medicine.' Traditional midwives saw themselves as being a genuine response to a new generation of clients with a healthy distrust of technology and believed that hospital-based nurse-midwives 'co-opted' women, promising a midwife birth but doing regular obstetrics.13 To avoid being co-opted themselves, traditional midwives rejected formal training in favour of apprenticeship and self-education. Textbooks written by physicians were acceptable, but the medical socialization that attended training programmes for nurses, midwives, and physicians was to be avoided. Traditional midwives continue to favour home birth, herbal remedies, and simple, non- medical solutions to problems of labour. As might be expected, the training and
competence of these women was (and remains) uneven.

Traditional midwifery flourished among the 1960s and 1970s counter-culture. In keeping with the counter-cultural spirit of 'do your own thing,' hierarchical organization, legal regulations, and alliances with existing medical organizations were avoided. Lacking any formal organization, it is difficult to speak of an 'organizational strategy' of traditional midwives of the 60s and early 70s. In resisting the 'medical establishment,' some traditional midwives did ally themselves with an odd collection of marginal health practices from reflexology, to aromatherapy and iridology, thus keeping them at the margins of mainstream health care. On the other hand, it is possible to see these midwives as part of a larger consumer-based 'alternative birth movement' in the United States that is often given credit for the creation of alternative birth settings inside and outside of hospitals.14

Increasing resistance from physicians, in the form of legal actions and unwillingness to provide medical back-up, caused traditional midwives to begin organizing in the hope of gaining legal recognition. In the late 1970s, several state associations of traditional midwives were created, many of which approached state legislatures with licensing legislation. These attempts to gain legitimacy through licensure were largely unsuccessful and today the laws governing the practices of traditional midwives remain a
hodgepodge of difficult-to-interpret rules and regulations.15 In most states traditional midwives remain outside the existing medical system, with no access to hospitals and strained relationships with physicians and nurse-midwives. Repeated failures of state organizations to gain licensure and increased prosecution of non-nurse midwives for violation of medical
practice acts, led to the creation, in 1982, of a new, national organization, the Midwives' Alliance of North America (MANA). The founders of MANA saw it not just as an organization of traditional midwives, but as an opportunity to promote the profession by connecting with other, more established midwives. Membership was open to all midwives, be they nurse-midwives or traditional midwives, and efforts were made to connect with midwife organizations in other countries and with the International Confederation of Midwives (ICM). Seeing the need for a publicly recognized 'standard of care,' and in keeping with the non-medical approach of traditional midwifery, MANA created, in 1989, a certification programme for non-nurses, the North American Registry of Midwives (NARM). According to MANA, 'the test serves as a tool to determine whether entry level knowledge
has been achieved, and it assists in fostering reciprocity between local jurisdictions.'16

Because they had recreated midwifery in two different ways, it proved difficult for MANA and ACNM to work together. Each claimed to represent the true tradition of midwifery in the United States.17 But by the early 1990s, the organizations saw the need to join forces and formed the 'Interorganizational Workgroup' (IWG). The IWG produced, in 1993, a statement on 'Midwifery Certification in the United States,' that allows for the certification of two types of midwives: the 'Certified Midwife,' and the
'Certified Nurse-Midwife.'18

The dialogue between nurse and traditional midwives has also increased as a result of the movement of many traditional midwives into nurse-midwifery in the 80s and 90s. One of the more important reasons for a traditional midwife to become a nurse-midwife is the desire for a steady and reasonable income. In the early 90s, the average annual income of a nurse-midwife was $55,000, while for most traditional midwives it was nearly impossible to earn a living.19 In the words of one traditional midwife, 'my work is an expensive hobby.'

For their part, nurse-midwives used the favourable cultural climate of the 60s and 70s to expand their position, locating themselves between the extremes of obstetrician-controlled, high- technology birth and 'do-it-yourself,' no-technology home birth. Seeking to claim this middle ground, they simultaneously emphasized the tradition of midwifery 'with woman' and their connection with the latest and best hospital technology. Note the language used by one nurse-midwife to describe her profession: 'a
certified nurse-midwife . . . is a specialist with obstetrical nursing experience and graduate training in midwifery. . . she [also] has the
attitudes and approaches of the age-old profession. . . that. . . women today are seeking.'20 During the 1970s, nurse-midwives expanded their training programmes, seeking cultural credibility by locating them in university settings, associating with schools of medicine or schools of nursing.21

In an effort to increase the supply, and hence the visibility, of nurse-midwifery, the profession is experimenting with new methods of education. The best known of these programmes is the Community-Based Nurse-Midwifery Education Program (CNEP) run by the organization that pioneered nurse-midwifery, the Frontier Nursing Service. CNEP students spend only short period at the facility in Kentucky, finishing their training via self-directed study, regular communication with professors via a computer network, and a residency with a nurse-midwife service in their home community.

A different sort of organizational strategy for the re- creation of midwifery is the establishment of new institutions for the management of birth. The 'free-standing birth center' (FSBC) is particularly suited to the autonomous practice of midwifery. Such centres are structurally and administratively separate from hospitals, equipped for management of low-risk births. Staffed, in most cases, by nurse-midwives, FSBCs have arrangements for 'back-up' with local hospitals. By separating their sphere from the sphere of specialist physicians, midwives are given more latitude for practice. As explained by one nurse- midwife:

The birth center nurse-midwife is constantly reminded that, while the birth center is a place for the practice of midwifery, the hospital is the place for the practice of medicine. In the birth center the whole system is
designed to nurture the practice of midwifery. In the hospital, medical practice is the norm, midwifery is 'different' and thus much more of a struggle . . . It is simply easier to practice midwifery in a birth center.22

Physicians are not especially supportive of FSBCs, but, because they reduce costs, they are increasingly popular with health insurance companies.23 Convinced that the future of midwifery lies in the creation of new settings for birth controlled by nurse-midwives, a CNEP instructor requires all students to develop a detailed plan for the creation of a free-standing birth center in their communities.

Faced with the extinction of their profession the organizational strategies of re-creation used by American midwives have included: 1) alliance with an existing profession, 2) the creation of programmes to train and certify the competency of midwives, 3) the establishment of organizations to represent the interest of midwives, and 4) the creation of new forms of delivering maternity care. We will consider the wisdom and success of these strategies after reviewing the situation in the Netherlands. However, at this point we can note modest gains for American midwives at the organizational level. Referring back to table 1, we see that the changes that began in the 1960s, on a cultural and social level and among midwives, resulted in a small but steady increase in their share of maternity care after 1970.24

The Netherlands

The situation of midwives in the Netherlands is unique in the world. Dutch midwives and the maternity care system of which they are fundamental part are often held up as a model for other countries.25 The two features of the Dutch system that attract most attention are the high percentage of home births and, the autonomous status of midwives. Midwives are part of the primary care system of the Netherlands, the so-called 'first line.' As such, they have the authority to decide which women can remain in the first line - giving birth at home or having a 'polyclinic' short-stay, birth - and which must see a specialist. This is quite the opposite of the situation typical in other countries, where specialists make the decision about the appropriate level of care.

The historical conditions that produced the existing system in the Netherlands are well described by van Lieburg and Marland26. Hingstman27 suggests there are four 'pillars' on which the Dutch maternity care system rests:

1) the 'protected' position of the midwife, whose profession was defined and protected in the 1865 'Act on the Practice of Medicine,' and who was given 'primacy' - healthy mothers are only reimbursed for midwife care - in the health insurance law;

2) a generally accepted screening system for high-risk pregnancies, standardized criteria that define as clearly as is possible the conditions requiring referral to a specialist;

3) a well-organized maternity home care system, that allows continuity of care in home births; and

4) the sociocultural environment in the Netherlands that regards pregnancy and childbirth as normal physiological processes.

In comparison to midwives in the United States it would seem that Dutch midwives have no pressing need to recreate their profession. Table 2 shows that, while there has been a substantial decline in home birth, midwives are providing for a stable and large proportion of the nation's births. Nonetheless, in the face of shifting social and cultural conditions midwives in the Netherlands are concerned to preserve their position. The organizational strategies used by Dutch midwives include efforts to become more 'scientific,' actively supporting features of the culture and the health care system favourable to midwifery, seeking reforms that will protect the profession, and finding new ways of delivering care.

Table 2

Distribution of live births by place of delivery and attendant, 1940 - 1992, the Netherlands (in per cent)

____________________________________________________________________________

YEAR Place of delivery Attendant*

Hospital** Home Physician Midwife
 

1940 n/a n/a 51.3 47.7

1945 n/a n/a 62.8 36.1

1950 n/a n/a 58.1 41.1

1955 23.9 76.1 58.5 40.9

1960 27.4 72.6 63.0 36.6

1965 31.5 68.5 64.2 35.3

1970 46.7 57.3 62.7 36.7

1975 55.6 44.4 59.9 38.6

1980 64.6 35.4 59.7 39.4

1985 63.4 36.6 57.8 41.7

1990 67.9 32.1 53.9 44.1

1992 68.5 31.5 53.1 45.8

________________________________________________________________________ ________________

n/a: not available.

*Excludes births with shared responsibility and cases where attendant is unknown.

**Includes, starting in 1970, 'polyclinic' (i.e. short-stay) hospital births.

Source: Centraal Bureau voor de Statistiek, 1899-1989: Negentig jaren
statistiek in tijdreeksen, 's-Gravenhage, CBS Publikaties, 1989; Centraal
Bureau voor de Statistiek, Geborenen naar aard verloskundige hulp en plaats
van geboorte, Voorburg, CBS, 1990, 1992.

________________________________________________________________________________

Although home birth remains popular in the Netherlands, more clients are choosing to give birth in the 'polyclinic.' Polyclinic births are short-stay hospital births attended by midwives or general practitioners. They are favored by parents who wish to have 'alles bij de hand' (everything, i.e., medical equipment, on hand). Midwives supervise the majority of these births, but the trend is troubling because it reflects a growing faith in obstetric technology and because, in the polyclinic, not only do midwives feel less free to exercise their profession, but there is a higher rate of transfer to specialist care.28 On an organizational level, midwives have
responded to this trend in two ways: first, to become more 'scientific,' that is, to pattern themselves after 'scientific' medical professions, and second, to reinvigorate public confidence in home birth.

Recognizing the power of science in modern society, midwives face the challenge of becoming more 'scientific' without necessarily becoming more technological. One strategy to accomplish this is to distinguish 'physiological' (normal) birth from 'pathological' birth. Thus separated, midwives can use scientific methods to study normal pregnancy and birth and
claim jurisdiction as experts in physiological birth. Science is used to assess technology itself, examining its appropriate and inappropriate uses.
In an effort to expand the 'scientific' competence of midwives, a fourth year was added to the education of midwives entering school in 1993, a significant portion of which is dedicated to training in scientific research methods. Carefully conducted, scientific studies not only enhance the image of a profession, but yield information useful to the promotion of the profession. Recognizing this, the Dutch Organization of Midwives (Nederlandse Organisatie van Verloskundigen, NOV) encourages its members to
cooperate in studies of the quality of care. This cooperation was rewarded by favourable results in a recent comparative study of polyclinic and home birth. The study concluded that home birth was at least as safe as polyclinic birth for first-time mothers, and safer for women who already had one child.29 This study became the centrepiece of a public campaign to encourage home birth entitled, 'een goede keuze bevalt beter,' - a play on words, meaning both, 'a good choice births better,' and 'a good choice
brings a more pleases result.' The campaign was intended to encourage more women to choose home birth by showing the rationality of this cultural ideal. According to the NOV, the campaign was intended to reach pregnant women, their partners, and other influential relatives, as well as midwives and other caregivers; information about the safety and desirability of home
birth was given by means of brochures, press releases, a nationwide telephone information line, and visits to groups of midwives, nurses, and physicians.30

Because Dutch health care is organized differently from that in the United States,31 midwives, through their national organization, have a voice in the creation of policy affecting their profession.32 This voice has been used to protect the 'indications list' that defines the work terrain of midwives, to secure a reduction in the average number of births expected of each midwife - in the hope of reducing 'burn-out' and attrition of midwives - and to generate support for research projects promoting the practice of midwifery.
The government, concerned with the costs of health care, is inclined to support midwives and home birth because research consistently demonstrates that they reduce costs while providing compatible, or better, outcomes than clinical births attended by physicians.33

But even Dutch midwives, with their favoured position and new orientation toward science, are handicapped by their tradition. This is most visible, of course, in questions related to the use of technology. The tradition of midwifery suggests the practice should avoid technology and promote the confidence of women in their ability to give birth without assistance from machines. But Dutch midwives are also a medical profession, with the freedom to use certain medical procedures.34 Questions naturally arise: why not
promote more polyclinic births? After all, centralizing care means less travel, greater ease in attending births, more assistance from nurses and support staff. Why not use ultrasonography routinely? Sending women elsewhere for a sonogramme increases the chance that they will stay under the care of specialists and makes the profession appear 'old- fashioned.'35 The consequent debates over whether new technology should or should not be employed weaken the image of the profession in the eyes of a public
convinced of the value of technology. By way of contrast, the more eclectic and experimental tradition of physicians allows them to 'own' new technology. They may discuss its appropriate and inappropriate uses, but they never suggest that technology itself is undesirable.

Like their American counterparts, midwives in the Netherlands are also experimenting with new methods of delivering care. The best-known effort in this regard is the 'Geboortecentrum'(birth centre) in Amsterdam. It is not a centre where birth occurs - midwives already have a great deal of autonomy in home births and polyclinic births - it is rather a centre that collects
all the various services related to pregnancy and birth under one roof: a prenatal clinic, pregnancy and post-partum courses, a bureau to arrange post-partum care, once-a-week consultations with an obstetrician, a shop with articles for pregnancy and birth, and a clinic for care of the newborn. The idea is to strengthen the position of the midwife, putting her in control of various services associated with birth, keeping women in the 'first- line.' Here too, the tradition of midwifery becomes an obstacle, with some midwives complaining that this type of centre results in the improper commercialization of the profession.36

What works, what does not

We can now review the organizational strategies used by midwives to adapt their profession to changing circumstances. Do these strategies recreate the profession in a way that insures its existence and preserves its identity?

The comparison of Dutch and American midwifery reveals a striking difference in the strength of the voice midwives have in policy-making. Like midwives in the United States, Dutch midwives must compete against the prestige and
power of physicians, but in the Netherlands midwives have a legitimate place in the government bureaucracy that controls health care, allowing them to influence decisions about the place of midwifery in the health care system.

Some strategies work to guarantee a place for the profession, but threaten to alter the profession so radically that it remains distinct in name only. The affiliation with nursing in the United States is an example of this. The uncritical acceptance of medical technology will bring similar results. A number of Dutch midwives are resisting the trend towards polyclinic births for this reason. They claim that polyclinic births are not merely 'transplanted' home births, but are the first step in a technological transformation of the profession.37

Some strategies are neutral, essential for the profession but not vehicles for transforming or extending midwifery. Included here are decisions to create midwife organizations. These organizations are necessary to give midwifery a voice, but the strength of that voice is dependent on social and cultural context. In the United States, the presence of two (more or less) competing organizations hindered the effective re-creation of midwifery.

The decision of traditional midwives in the United States to avoid official organization and to identify with a variety of marginal health practices dissipated professional strength. This radical strategy was seen as a corrective to the medicalization of nurse-midwifery, but it allowed established medical professions to discredit both traditional and nurse-midwifery as dangerous and strange.

Most promising are strategies that strengthen the structural position of midwives and work to create supporting cultural ideas. The 'birth center' idea, in its manifestation in the United States and in the Netherlands, is a strategy of this sort. It gives the profession more autonomy while making it attractive to policy makers and clients. As more clients use these services, cultural ideas are transformed in a way that favours the profession. In both countries midwives have created national organizations to promote birth
centres, the National Association of Childbirth Centers in the United States, and the Vereniging Geboortecentrum Nederland (Association of Dutch birth centres), in the Netherlands.

As important as these organizational strategies are, they form only a part of the recreation of midwifery. It is the everyday practices of midwives where the tradition is given life. Midwife organizations might preserve the profession, but the profession loses its meaning if the practices of midwives become indistinguishable from physicians. Thus we turn to strategies employed by midwives as individuals to find a way to practice midwifery among the machines of obstetrics.

Individual strategies: recreating the practice of midwifery The United States

In the United States it is nurse-midwives who are called upon to find individual strategies for recreating the profession. Traditional midwives, existing outside the mainstream medical system, are free to practice as they please. The organizational strategies of nurse-midwives have earned them a place in a 'medical' environment where they must find ways to remain midwives and not become 'physician extenders.' This is especially difficult when working in a hospital surrounded by medical technology, much of which appears to simplify the work of midwifery. For example, when a labour is proceeding slowly, the tradition of midwifery might suggest that a woman walk around or lay in a warm bath. But in a hospital this is difficult to arrange. It is much more efficient to administer a drug to speed labour.

Given this situation, midwives who wish to remain faithful to the tradition of midwifery must find ways to overcome the limitations of their surroundings including: a lack of knowledge, lack of access to proper equipment or facilities, and limits created by hospital policy.

As the machinery of obstetrics becomes more prevalent, new knowledgereplaces old knowledge. For example, knowledge of how to deliver a breech birth vaginally is all but lost in the United States where a breech presentation is almost always an indication for caesarean section. The gradual obsolescence of the fetoscope is another example of lost knowledge. The 'doptone,' which uses sonar technology to amplify sounds from the uterus, is a much easier way to find fetal heart tones and to allow them to be heard by the expectant parent(s). But some midwives argue that the fetoscope (or wooden 'tooter'), the traditional tool of the profession, is
the better instrument. Without electronic amplification it is possible to find the point where the heart tones are the clearest and loudest, allowing the precise position of the child to be identified. Furthermore, the fetoscope brings the midwife much closer to the woman, allowing the caregiver to assess level of relaxation, skin tone, and overall condition. Midwives in training who wish to learn the proper use of the fetoscope find that their teachers have lost the ability to use one. The response is self-education or association with an 'old- fashioned' midwife, but midwives who gain this knowledge encounter a second problem: difficulty finding fetoscopes on hospital obstetric wards.38

Lack of equipment and facilities is a serious constraint on the continued practice of midwifery. A warm bath is a preferred way to promote relaxation and thus stimulate labour, but in many hospitals there are no bathtubs. A midwife reports similar problems with items needed to use traditional techniques for supporting and relaxing the perineum. In her hospital, all women having an epidural must give birth in a delivery room under sterile conditions, making it impossible to use poultices and oils to minimize perineal pain and prevent lacerations. The midwife's response is to improvise: using available sterile pads, doing a 'clean catch' of a
lubricant into a sterile cup in order to allow it to be used in the sterile environment, looking for hot water in labor rooms.

Hospital policy is another constraint on the practice of midwifery. Many hospitals in the United States have a policy, set by their department of anaesthesia, prohibiting obstetric patients from receiving anything by mouth after admission. The rationale for the policy is the rare danger of aspiration with the use of general anesthesia. Midwives, believing in the necessity of adequate hydration and nourishment, are forced to find a way around such policies. A simple solution used by some midwives, is to deny admission to a labouring women until she has had something to eat and drink.

These individual strategies are, in fact, strategies of subversion. As such, they show the power of medical technology. Because the task of reforming the structure of medicine and the culture that supports it is so overwhelming, the best midwives can do is to find ways to work within medical settings without comprising the ideas and values of their profession. In fact, many midwives find subversion too difficult or too costly (in terms of their relationships with colleagues) and hence they simply follow the medical
protocols.39 In the Netherlands, where the context is different, midwives are able to devise different strategies.

The Netherlands

Given their legitimate place in the 'first line' of Dutch health care, midwives have less need to subvert the system. Their position as
'gatekeepers' in the first line gives individual midwives the power to defend the practice of midwifery. When a women first suspects or knows she is pregnant, her first visit is to the midwife or the general practitioner. A specialist can not be seen except by referral from the first line. This gives midwives a great deal of power over the behaviour of specialists. Midwives tell of situations where a local gynaecologist is treating women poorly, or discouraging women, sent for consultations, from having a home birth. The response is to simply cease sending women to this specialist. Eventually, the specialist will call and ask what might be done to once again receive referrals. This strategy works best in areas where several hospitals exist and compete for clients; but even midwives in rural areas report travelling extra distances to avoid unwanted practices in a local hospital.

Dutch midwives do, however, feel an increasing need to subvert culture. As more women choose polyclinic births, seeking the safety of medical technology, midwives are becoming more active in promoting home birth. Not just organizationally, as discussed above, but also in individual practices midwives seek to encourage women to remain at home for birth. Many midwiveswill ask women choosing a polyclinic birth to explain their choice. In so doing midwives are protecting (and promoting) a cultural value that says home birth is the preferred choice, all other choices must be explained.40 Women who persist in their desire for a polyclinic birth are advised that when contractions start they can choose to remain at home; when labour begins some midwives will visit the home, reminding the woman and her partner that it is possible to simply stay home.

But why encourage home birth? Is it not possible to practice midwifery in a Dutch hospital? It is true that Dutch midwives exercise a great deal of autonomy in the hospital, but many midwives believe that the peaceful, familiar setting of the home is one of the tools of traditional midwifery. In the hospital you can not tell an over-wrought partner to go and make some coffee, in the hospital the labouring women feels less at ease, less in control, she is not free to walk about. And, as in the American situation, so simple a thing as a bathtub is often unavailable.

Conclusion: midwives, machines, and the 'risks' of birth Not all efforts to recreate midwifery are equally successful. Our review of the situation of midwives in the Netherlands and in the United States makes it clear that the structural position of midwifery affects the possibilities for re-creation. Individual strategies of re-creation can be little more than subversive or marginal if the profession has not secured a legitimate and autonomous place in the health care system. Midwives interested in preserving a place for a
distinctive profession, one that is not simply the 'lengthened arm' of physicians, must work toward gaining structural legitimacy. And in order to gain this legitimate place, there must be an effort to recreate and reinforce cultural ideas that support midwives. Thus, free standing birth centers will not gain great success in the United States unless women (re)gain trust in their ability to give birth without the assistance of the technology of obstetrics. Thus we are brought back to the image of midwives
among the machines. The response of midwives to the machines of obstetrics, from forceps to ultrasonography, has been uncertain. For good reason. If midwives shun obstetric technology they seem out-of-date. In an expos* of nurse-midwives in public hospitals in New York City, midwives at one hospital were faulted for having a Caesarean Section rate of 12.9 percent, far below the city average of 23.1 percent.41 In a technological culture it is unthinkable to not use the latest technology; this is one reason many midwives in the Netherlands were anxious to bring ultrasonography into their practices. But if midwives adopt obstetric technology, they set in motion a process that changes their profession so drastically that it becomes
subsumed by, or indistinguishable from, obstetrics.42

Why do the machines of obstetrics have this effect on midwifery? It is because these machines expand the notion of risk and increase uncertainty. Ultrasonography and other means of prenatal diagnosis turn every pregnancy into a risky pregnancy, supporting the idea of many American obstetricians that 'a pregnancy is low risk only in hindsight.' Because the technology is
available, women are forced to make a choice: should it be used or not? Their choice is often influenced by their placement in a 'risk group,' thus, normal pregnancy ceases to exist and uncertainty over the outcome of pregnancy grows. The wealth of information produced by the technology of obstetrics also increases uncertainty.43 Electronic fetal monitors, for example, produce an unending stream of data, all of which is subject to different interpretations, each leading to a different clinical decision.44 Increasing risk and uncertainty means one of two things for a midwife: either she, as an expert in normal birth, is no longer needed, or she must
become more technological.

What is to be done with the midwife? The question itself suggests the subordinate, passive position of her profession, a position controlled by cultural and social factors. It is true that midwives have little control over societal and cultural forces: support and resistance often come unbidden. But a profession that understands the way these forces work is better equipped to work with them, to influence them, to turn the question around: What should the midwife do?

___________________________________________________________________________________
Rebeca Barroso was a traditional midwife for 20 years, after which she completed her education as a Certified Nurse-Midwife at the Frontier School of Midwifery and Family Nursing. She received her MSN from Case Western Reserve University and is currently practicing as a CNM in Minnesota.

Raymond de Vries is an associate professor of sociology at St. Olaf College in Northfield, Minnesota. He has a Ph. D. in sociology (University of California, Davis). Among his publications is Making Midwives Legal: Childbirth, Medicine and the Law (Ohio State University Press, 1996). Most recently he spent a year in the Netherlands, at the Netherlands Institute for Health Care Research (NIVEL), studying the Dutch system of maternity care.

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Endnotes

1. R. Davis-Floyd, Birth as an American Rite of Passage, Berkeley, University of California Press, 1992, provides an in- depth analysis of ritual uses of technology in modern obstetrics. 2. P. Starr, The Social Transformation of American Medicine, New York, Basic Books, 1982.

3. See E. F. Merritt, 'Family and the medical profession: conflicting claims', Journal of the American Medical Association, 1993, vol. 270, p. 1606 ff.

4. See, for example, Celia Davies, Gender and the Professional Predicament of Nursing, Buckingham, Open University Press, 1995. 5. See, for example, F. Kobrin, 'The American midwife controversy: A crisis of professionalization', Bulletin of the History of Medicine, 1966, vol. 40, pp. 350-63; J. Donnison, Midwives and Medical Men, London, Heinemann, 1977; J. Litoff, American Midwives: 1860 to the Present, Westport, CT, Greenwood Press, 1978; J. Litoff, The American Midwife Debate, Westport, CT, Greenwood Press, 1986; W. Arney, Power and the Profession of Obstetrics, Chicago, University of Chicago Press, 1982; J. Leavitt, Brought to Bed: Childbearing in America, 1750-1950, New York, Oxford University Press, 1986; M. van Lieburg and H. Marland, 'Midwife regulation, education, and practice in the Netherlands during the nineteenth century', Medical History, 1989, vol. 33, pp. 296-317;
I. Loudon, Death in childbirth: an international study of maternal care and maternal mortality 1800- 1950, Oxford, Clarendon, 1992;  Vroedvrouwen: beeld and beroep, Wageningen, Wageningen Academic Press, 1992; H. Marland (trans. and ed.), 'Mother and Child Were Saved': The Memoirs (1693-1740) of the Frisian Midwife Catharina Schrader, Amsterdam, Rodopi, 1987; H. Marland (ed.), The Art of Midwifery: Early Modern Midwives in Europe, London, Routledge, 1993.

6. Quoted in J. Aveling, English Midwives, Their History and Prospects, 1872, reprinted 1977, New York, AMS Press, pp. 122-3.

7. See H. Marland, 'Questions of competence: the midwife debate in the Netherlands in the early twentieth century', Medical History, 1995, vol. 39, pp. 317-37, on p. 328.

8. See Kobrin, 'Midwife controversy', and R. Wertz and D. Wertz, Lying In: A History of Childbirth in America, Expanded edition, New York, Free Press, 1989.

9. See J. Klomp, De jaren zestig: De vroedvrouwen bijna verdwenen, leve de vroedvrouw, Bilthoven, Catharina Schrader Stitching, 1994.

10. See N. Devitt, 'How doctors conspired to eliminate the midwife even though the scientific data support midwifery', in D. Stewart and L. Stewart (eds), Compulsory Hospitalization: Freedom of Choice in Childbirth?, Marble Hill, MO, NAPSAC, 1979, pp. 345- 70. See also Wertz and Wertz, Lying In, and Litoff, The American Midwife Debate.

11. For more on 'granny-midwives' see Onnie Lee Logan, Motherwit: An Alabama midwife's story, New York, Plume, 1989.

12. See P. Langton, 'Competing occupational ideologies, identities, and the practice of nurse-midwifery', Current Research in Occupations and Professions, 1991, vol. 6, pp. 149- 77.

13. See R. DeVries, 'The alternative birth center: option or cooptation?', Women and Health, 1980, vol. 5, pp. 47-60. 14. See J. Mathews and K. Zadak, 'The alternative birth movement in the United States: History and current status', Women and Health, 1991, vol. 17, pp. 39-56.

15. See I. Butter and B. Kay, 'State laws and the practice of lay midwifery', American Journal of Public Health, 1988, vol. 78, pp. 1161-9; and R. DeVries, Regulating Birth: Midwives, Medicine and the Law, Philadelphia, Temple University Press, 1985. See also P. Tjaden, 'Midwifery in Colorado: a case study in the politics of professionalization', Qualitative Sociology, 1978, vol. 10, pp. 29-45, and G. Giacoia, 'Lay Midwives in Oklahoma', Journal of the Oklahoma State Medical Association, 1991, vol. 84, pp. 160-2. 16. From, 'The North American Registry of Midwives,' Newton, KS, MANA, n.d. 17. See J. Rooks, 'The context of nurse-midwifery in the 1980s: Our relationships with medicine, nursing, lay-midwives, consumers and health care economists', Journal of Nurse-Midwifery, 1983, vol. 28, pp. 3-8.

18. See Women's Institute for Childbearing Policy (WICP), Childbearing Policy Within a National Health Program: An Evolving Consensus for New Directions, Boston, WICP, 1994; and Langton, 'Competing occupational ideologies'.

19. D. Korte, 'Midwives on trial', Mothering, 1995, vol. 76, pp. 52-63.

20. B. Brennan and J. Heilman, The Complete Book of Midwifery, New York, Dutton, 1977, p. xi.

21. See K. Whitfill and H. Varney Burst, 'ACNM-Accredited Nurse- Midwifery Education Programs', Journal of Nurse-Midwifery, 1993, vol. 38, pp. 216-27.

22. S. Stapleton, 'The pleasures and perils of hospital privileges for birth center nurse-midwives', NACC News, March/April 1995, pp. 6-7, emphasis in original.

23. See Mathews and Zadak, 'The alternative birth movement', and E. Annandale, 'Dimensions of patient control in a free-standing birth center', Social Science and Medicine, 1987, vol. 25, pp. 1235-48.

24. See also E. DeClercq, 'The transformation of American midwifery: 1975 to 1988', American Journal of Public Health, 1992, vol. 82, pp. 680-84.

25. See, for example, M. Mehl Madrona and L. Mehl Madrona, 'The future of midwifery in the United States', NAPSAC News, 1993, vol. 18, pp. 1-32, and G. Chamberlain and N. Patel (eds), The Future of Maternity Services, London, RCOG Press, 1994. 26. Van Lieburg and Marland, 'Midwife regulation, education, and practice', and Marland, 'Questions of competence'.

27. L. Hingstman, 'Primary care obstetrics and perinatal health in the Netherlands', Journal of Nurse-Midwifery, 1994, vol. 39, pp. 379-86.

28. T. Wiegers and G. Berghs, " Bevallen . . . thuis of poliklinisch?', Tijdschrift voor Verloskundigen, 1994, vol. 19, pp. 266-76.

29. Ibid.

30. The proceedings of the conference are summarized by M. Amelink and C. van Leent, 'Een goede keuze bevalt beter', Tijdschrift voor Verloskundigen, 1994 vol. 19, pp. 343-46. 31. A complete description of the Dutch health care system can not be given here. For more information see, L. Graig, Health of Nations, (2nd ed.), Washington, DC, Congressional Quarterly, 1993, pp. 115-28.

32. For a description of the relationship between Dutch midwives and the government, see E. Van Teilingen and L. van der Hulst, 'Midwifery in the Netherlands: more than a semi-profession?', in T. Johnson, G. Larkin, and M. Saks (eds), Health Professions and the State in Europe, London, Routledge, 1995, pp. 179-186 . 33. A study by G. Berghs and E. Spanjaards, De normale
zwangerschap: bevalling and beleid, Nijmegen, University of Nijmegen, 1988, has been important in this regard. No differences were found in the outcomes of births to low-risk women under the care of midwives, general practitioners and specialists, except that those under specialist care had more interventions.

34. The Dutch government classifies midwifery as a "medical" occupation, separating it from "paramedical" occupations such as physical therapy and exercise therapy.

35. See C. van Leent, 'Pret-echo', Tijdschrift voor Verloskundigen, 1992, vol. 17, pp. 405-6, and J. Wladimiroff, 'Prenatale diagnostiek van aangeboren afwijkingen met behulp van echoscopie', Tijdschrift voor Verloskundigen, 1993, vol. 18, pp. 357-60.

36. See E. de Miranda, 'Het geboortecentrum in Amsterdam', Tijdschrift voor Verloskundigen, 1992, vol. 17, pp. 393-94; and B. Smulders, 'Twee jaar Geboortecentrum Amsterdam: een discussiestuk', Tijdschrift voor Verloskundigen, 1994, vol. 19, pp. 81-6.

37. See, for example, A. Schoon, 'De 'keuzevrijheid' voor de plaats van de bevalling', Tijdschrift voor Verloskundigen, 1995, vol. 20, pp. 182-7.

38. An article by R. Barroso and R. DeVries, 'Fetoscope use among nurse-midwives', is in preparation.

39. See Stapleton, 'The pleasures and perils'.

40. In the United States women requesting a home birth must explain their decision since the default choice is hospital birth.

41. D. Baquet and J. Fritsch, 'New York's public hospitals fail and babies are the victims', The New York Times, 1995, vol. 144, March 5, 6, 7, pp. 1ff. See also N. Kraus, 'Mismanaged journalism: responsible reporting in peril at the New York Times', Journal of Nurse-Midwifery, 1995, vol. 40, pp. 304-12. 42. A. Jacobson, 'Are we losing the art of midwifery?', Journal of Nurse-Midwifery, 1993, vol. 38, pp. 168-9.

43. See M. Sandelowski, 'Toward a theory of technology dependency', Nursing Outlook, 1993, vol. 41, pp. 36-42. 44. See A. Grant, 'Monitoring the fetus during labour', in I. Chalmers, M. Enkin and M. Keirse (eds), Effective Care in Pregnancy and Childbirth, vol. 2, Oxford, Oxford University Press, 1989, pp. 846-82.
 
 

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