Many things are said to entice midwives into becoming part of the medical/government/pharmaceutical system. Some compelling arguments that I have been presented with include:
1. Midwives can feminize and change the system from within. We’ll take our herbs, homeopathics and loving care into the hospitals and everyone will see the healing power of midwifery.
2. If we become licensed/regulated, etc., we can work for the very poor who are now unable to access midwifery care.
3. We will be equal colleagues with physicians and will gain their respect. Then, if we need their services, our clients will be treated better and have continuity of midwifery care. We will also be more respected in the community.
These are lofty and tempting goals, especially for women who have chosen a career that is marginalized and abused in Western society. The problem is that these enticements have never been shown to actually come to fruition even years after legalization in government-funded or endorsed practice schemes.
Here in Canada, midwifery has been brought under a government umbrella in four provinces in the last 15 years. What we have seen is:
1. Instead of midwifery softening the “system,” the system has hardened midwives. One example of this regards elective induction.
Prior to regulation, midwives were an alternative for women who were threatened with induction of the birth process at 42 weeks gestation. Immediately after regulation in January, 1998, in the province of British Columbia (BC), midwives began stripping the membranes of homebirth clients at 41 weeks gestational age. The midwives were under threat that their clients would lose the opportunity to have a homebirth. Why? Physicians let midwives know that if they didn’t do things the same way as the doctors, they would not maintain their hospital privileges. When the midwives became regulated, they were told by the government that they would be “autonomous.” However, written into the regulatory legislation is a clause that requires midwifery clients to be seen by a physician before three months of pregnancy.
In addition, each midwife is required to have hospital privileges. Who gives out hospital privileges? Physicians, of course . It was a case of the whale swallowing the minnow. Midwifery can never be autonomous when midwives need doctors to survive and doctors don’t need midwives for their survival. Believing otherwise is simply wishful thinking.
From 1998 to 2005, women in BC were stripped, induced and pushed into the birth process by their registered midwives because the scientific evidence (Cochrane database) showed that was the best management. This aggressive treatment had not been seen previous to 1998 when BC midwives were working independently and underground. Then, in 2002, Dr. Philip Hall of Manitoba published new evidence in the British Journal of Obstetrics and Gynecology regarding the induction of birth at 41 weeks gestational age. The article, entitled “Nonsensus Consensus,” revealed flaws in the large study that was published in 1992 upon which the induction epidemic was based. Midwives in the province of BC had been inducing women with all the horrible results of that (including one homebirth death after membrane stripping) based on erroneous “scientific evidence.”
Government funded midwives in B.C. were no longer thinking for themselves. They were no longer doing what women have done to and for others back to the beginning of time. Even now, with the evidence overturned, the policy of the BC College of Midwives is to “offer” induction at 41 weeks gestational age but not “push” it until 43 weeks. This demonstrates how insidious the medical pressure is on government regulated midwives.
2. Midwifery is accessed by women who are smart and economically secure, not poor women. Poor women, for the most part, don’t seem to find out that they could have had a midwife until it’s too late in their pregnancies to obtain one of the limited number of placements. Regulated midwives, few in number, are all booked and the number of clients they can take on is capped (government-mandated), so they do little or no outreach to promote their services to marginalized groups.
3. Although midwives in Canada were enticed by the notion that the abusive patriarchy of big medicine would begin to treat them nicely if they did everything by the medical book, this has not happened. The relationship between doctors and midwives is analogous to a family that has an abusive father and many daughters. Some of the daughters will try to get nearer to Dad in the hope that he will change one day and appreciate all their efforts. Other daughters will move as far away from Dad as possible in order to escape the tyranny. For the ones who stay close, the game is endless and Dad never changes. The abuse may take on different forms and come in new disguises but it is always there because, ultimately, the lie is that the daughters’ job is to somehow parent the insane parent.
With midwifery and “big medicine,” the lie is that obstetrics is scientific, sane and humane. Remember, modern North American obstetrics wiped out breastfeeding, cut episiotomies routinely for 50 years, uses ultrasound routinely, invented the epidural, started the induction and cesarean epidemics, damaged babies with thalidomide and DES, etc., etc., etc. The role of “big medicine” is to get babies out of women’s bodies efficiently, timely and with as large an economic return as possible. Childbirth does not fit nicely into this context. Birth requires a great deal of time and patience to unfold in a healthy way. This dichotomy of structure is the big flaw that permeates the medical birth system. To think that midwifery can change this from within is to relegate midwives to a life of endless frustration.
We can draw an analogy by comparing the medical birth system to the government education system. The lie in the education system is that a seven-year-old is a broken eight-year-old who needs to be fixed. A real educator in that system will never be able to do his/her work. He/she will have to create an alternative school or support home-schoolers in order to get any job satisfaction and make a difference in the world. Within a system based on a false premise, one can only become frustrated and bitter. This is what has happened to midwives in the province of BC. Midwives are reluctant to apply to work here in B.C. Many registered midwives are continually in-fighting and changing partners and others are off on stress leave and complain of burn-out.
When the medical birth patriarchy is criticized, midwives are quick to point out the existence of very woman-friendly doctors and nurses who do a wonderful job within the existing system. This is well and good but doesn’t take away from the fact that the entire system is flawed and failing. The classic measure of how well an obstetric system is working is the cesarean rate. That rate is constantly creeping higher despite all the good intentions of the “good guys” in the system. That creeping cesarean rate is the “canary in the coal mine,” letting all practitioners know that the end cannot justify the means any longer.
Wanting to be respected and admired is only human. As midwifery strengthens its professional framework, this respect will naturally emerge. Midwifery needs strong, outspoken, autonomous women to articulate a vision of birth with dignity for all women. Unfortunately, such voices tend to belong to women who are “outside the system.” Once women are in a legalized system, they are silenced. They can be coerced to give unnecessary pharmaceuticals to women and babies (oxytocin, erythromicin, vitamin K) and they become good corporate citizens. The real respect and admiration that comes from knowing that you are true to yourself is missing. This can be a terrible price to pay for a piece of paper and a guaranteed pay cheque.
Midwifery is growing and expanding and, as medicine gets worse, more families are opting out of the hospital birth illusion. We see more and more families choosing to give birth unassisted by medical professionals. We’re seeing more celebrities choosing homebirth. The research studies show overwhelmingly that homebirth is safer, more satisfying and less painful than hospital birth. One need not look far for the evidence that midwifery care produces less trauma to mother and baby than physician care.
Since women can give birth by themselves, the right of each woman to choose where, when and with whom she gives birth is the fundamental principle on which any healthy midwifery model is built. Thwarting the growth of the midwifery movement by making it more and more difficult for new midwives to get training and to launch their practices is ridiculous. Instead of constantly knocking the woman off the ladder on the rung below us, we need to reach down and give her a hand up. Training of the new generation is one of the strong suits of the medical profession and midwives would be wise to emulate that desire to multiply colleagues. The future of midwifery rests in the young women who are now working as doulas. This educated group of women is emerging as the midwives of tomorrow and they need all the support and nurturing that practicing midwives can give them so they can be ready to take up the challenge. When midwives focus their time and energy on training the next generation and quit trying to join the dinosaurs that are on their way to extinction, we will find power, respect and joy in our work.
Gloria Lemay was the 2002 Recipient of the Women’s Voice Award, the 2004 Recipient of Waterbirth International’s “Mothers and Midwives” Award, an Advisory Board Member of the International Cesarean Awareness Network (ICAN) and a Contributing Editor for Midwifery Today Magazine.
For more reading on the politics of licensing/registering midwives see: