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Midwifery practice and state regulation : a sociological perspective Burtch, Brian E. 1987

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MIDWIFERY PRACTICE AND STATE REGULATION A SOCIOLOGICAL PERSPECTIVE By BRIAN ERIC BURTCH B.A., Queen's University, 1972 MA., University of Toronto, 1978 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIRE-MENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES Department of Anthropology and Sociology, University of British Columbia We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA April 1987 ©Br ian Eric Burtch, 1987 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Anthropology and Sociology The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date 1. 1 9 8 7 r>F-Gn/R-n ABSTRACT Supervisor: Dr. R.S. Ratner Midwifery practice in Canada is anomalous in that, unlike other industrialized nations, a distinct legal status for nurse-midwives and community midwifery has yet to be established. Despite this constraint, community midwifery has survived the lack of institutional support for home births and legal prohibitions directed against it The manner of State regulation of midwives is a central issue in this study. It is shown that the State shapes the possibilities of midwifery in a contradictory manner, promoting midwifery on the one hand, and prosecuting and restricting midwifery practice on the other. A modified structuralist perspective on the State is developed with respect to midwifery. The Canadian State serves to limit possibilities for midwifery through various provincial enactments in quasi-criminal law, through the greater likelihood of criminal prosecution of midwives than physicians or nurses, and through funding of the established professions and hospitals. This thesis then, offers a critical examination of the anomalous occupational and legal status of Canadian midwives, using historical materials on the development of midwifery practice and cross-cultural data on the role of midwives in traditional cultures. It is argued that many of the reservations about community (lay) midwives are no longer applicable, and that the containment of nurse-midwives reflects an historical accommodation between the nursing and medical professions in Canada. This accommodation meets the need for highly-skilled obstetrical nurses or nurse-midwives within the tradition of physician dominance in health care. A major empirical focus of the study is a documentary analysis of birth records from community midwives, primarily in British Columbia and Ontario, between 1972 and 1986. Analysis of the data confirms that qualified community midwives, working under normal circumstances, manage births safely and with a minimum of interventions during labour and delivery, and during the prenatal and postpartum periods. Where comparisons with provincial i i and national populations are available, women attempting home birth under the care of a community midwife tend to have lower rates of forceps delivery, caesarean section, and episiotomy. These women are also likely to deliver their babies in positions other than the standard lithotomy position or prone position, and to have a lower incidence of perineal tears. Nevertheless, difficulties associated with the unregulated and often idiosyncratic situation of community midwives are underscored, particularly with regard to establishing guidelines for domiciliary midwifery. Data from the Low-Risk Clinic at Vancouver's Grace Hospital, together with reports on other nurse-midwifery programmmes, reinforce the claim that nurse-midwives can practice autonomously in providing prenatal care, assistance in labour and delivery, and postnatal care. The likelihood of realizing autonomous midwifery practice depends upon the particular agendas of the State, the structural interests of the professions, and the initiatives of midwives and health consumers who lobby for certification of safe alternatives in maternal and infant care. i i i TABLE OF CONTENTS ABSTRACT . ... ....... • 1 1 List- of Tables—.... v i i i ! ACKNOWLEIXJEMENTS ... . . . . — x I. INTRODUCTION .. .. 1 Preface: The Proper Person 1 Central Problem of the Research . 6 Scope of the Research . ..— 11 Ethical Considerations — 24 Significance of the Research . — 26 Midwifery, Medicine, and the State 27 II. STATE, HEALTH, AND JUSTICE . 31 Introduction — . . .. 31 Theoretical Approaches to the State 32 The State and Health Care . ...... 41 Law and the Regulation of Health Care . 47 The Midwifery Movement and the Canadian State 50 Unlawful Practice of Medicine: Quasi-Criminal Law 54 Criminal Prosecution of Birth Attendants 59 Inquests into Infant Deaths 63 Criminal Negligence and Physicians 64 Civil Suits against Birth Attendants . , . 65 Conclusion 66 HI. HISTORICAL AND CROSSCULTURAL PERSPECTIVES ... ..... 71 Introduction . ..... 71 Historical Perspectives on Midwifery 72 iv Midwifery in Europe ~ 72 Midwifery in Canada 77 Law and the Containment of Midwifery 82 ^^ ldv^ ifcry in the United St&tes »««»»»»»»«»»»«M»»»»»»»»»»»«»»»»»"«««»»««»*»»«"»«»»«"MM«»«»«««»»»««»«»«»M«»»»M»»»»*»»«»»«»»« 8S CROSS-CULTURAL Pl^SPECnVES ON MIDWIFERY ... 87 Variations in Infant Mortality Rates 89 Traditional Practices and Medicalization of Birth 92 Birth Practices in Western Countries 97 Midwifery in Japan and China . 98 Conclusion . . — . 99 IV. RESEARCH METHODS 102 Introduction: Studying Childbirth ...— 102 Research Design . 105 Literature Review 107 Sampling Procedures - . 109 Documentary Evidence . 117 Summary ........................................................... 120 V. COMMUNITY MIDWIFERY AND NURSE-MIDWIFERY « 124 Introduction ^ . 124 COMMUNITY MIDWIFERY PRACTICE IN CANADA ........... .—.............. 126 Midwifery Practice and the Course of Labour —.......—. 141 Delivery of the Infant . ... 145 Post-Partum Measures . — - — . 152 Safe Practice: Guidelines and Peer Review ....... ... ... 161 State Control and Resistance .. 164 NURSE-MIDWIFERY PRACTICE 169 Introduction , . .— 169 v Central Problems in Nurse-Midwifery 169 Home Birth and Midwifery Policy 174 Alternative Birth Centres . 176 Demonstration Projects: Canada and the U.S 178 Prestige and Professionalization 182 Midwifery Practice and Formal Authority . 183 VI. CRITICAL REFLECTIONS ON COMMUNITY MIDWIFERY . 191 Introduction » 191 "We and They": Oppositional Ideologies ... 192 "Midwife means to be with woman": Serving Mothers 193 Class Composition of Clients . . 195 Material Basis of Practice . . ........ 196 Formal Structure, Idiosyncratic Practice 197 Documentation of Midwifery Practice 199 Availability of Services . 200 Expanded Role of Nurse-Midwives and Hospitals 201 From community to bureaucracy? . 202 Summary . * . . 203 VH. CONCLUSIONS .. . ...... .... . . 204 Midwifery Initiatives and Conflicts 204 Self-Determination in Reproduction and Work 207 Promoting Midwifery, Prosecuting Midwives — 210 Further Research and Policy Development . 210 Birthing Centres and Women's Clinics 213 Conclusion . .... 215 Bibliography . 221 References Consulted, Not Cited 247 v i Appendix A: Glossary 265 Appendix B: Codesheet for home birth records 268 Appendix C: Letter of Consent 272 Appendix D: Interview Frame .. ... 273 Appendix E: Occupations of Home Birth Mothers and Fathers . ... 280 Appendix F: Delivery Positions: Attempted Home Births 283 v i i LIST OF TABLES Table Page 1 Average Income of Physicians and Other Taxpayers .— 20 2 Home Births by Province 111 3 Home Births by Year and Province 133 4 Ages of Home Birth Clients and Women Giving Birth in Canada 134 5 Gravida and Parity of Home Birth Clients . 135 6 Family Income: Home Birth Clients . 137 7 Previous Caesarean Section . ... . 138 8 Home Birth Mothers Diet . 139 9 Alcohol Use During Pregnancy . . 139 10 Smoking among Home Birth Mothers 140 11 Prenatal Visits by Community Midwives . 141 12 Rupture of Membranes: Attempted Home Births 142 13 Meconium Staining: Attempted Home Births 143 14 Use of Oxytocin in Attempted Home Births . ........... 144 15 Anaesthesia in Attempted Home Births ...... 144 16 Walking During Labour: Home Birth Clients 145 17 Place of Delivery . ............ 146 18 Delivery Positions: Attempted Home Births . .— 148 19 Type of Delivery: Attempted Home Births ..149 20 Episiotomies: Home Births and the Low-Risk Clinic .. ., 150 21 Perineal Tears: Home Births and the Low-Risk Qinic . . 151 22 Suctioning Techniques: Attempted Home Births 152 23 Apgar Scores: Infants Delivered at Home 153 24 Delivery of Placenta 154 25 Perinatal Mortality: Home Births. B C , and Canada . . 158 v i t i 26 Neonatal Mortality: Home Births, B.C., and Canada 159 27 Post-Partum Visits: Home Birth Clients 160 28 Mode of Delivery . 179 29 Demonstration Projects in the United States 179 i x ACKNOWLEDGEMENTS This research has developed through the efforts of many individuals. My Dissertation Committee provided constructive criticism and generous support over the years. I am grateful to my Thesis Advisor. Dr. Bob Ratner, for his perennial support and his useful criticisms of the manuscript. Dr. Helga Jacobson provided insightful observations on the research, and Dr. Neil Guppy was very helpful throughout the writing of the study. I am thankful for the materials and encouragement provided by other colleagues during the writing of this study. The Department of Anthropology and Sociology at U.B.C. provided computer resources and office space. The Alumni Association at U.B.C. provided a travel subsidy to facilitate the presentation of a Conference paper on midwifery in 1984. The School of Criminology, Simon Fraser University, provided ample computer support and the opportunity to teach during the final two years of completing the research. The efforts of research assistants Debbie Nickle and Maureen Gabriel in coding birth records, proofreading, and updating various tables are greatly appreciated. Data Entry Services at the University of British Columbia were a great resource for transposing codesheet data onto the computer system The efforts of the staff are gratefully acknowledged. I wish to thank the Social Sciences and Humanities Research Council of Canada for granting a Doctoral Fellowship during my first four years of doctoral studies. I am especially grateful to Jocelan Cory for her encouragement and for suggesting that I undertake this project on midwifery. The efforts of Carol Hird, Stan Howard, Cheryl Anderson, Gary Brown, Bruce Arnold, and many others are also acknowledged. The research was possible only through the interest and trust of many community midwives and nurse-midwives who discussed their practices and provided documentation. Most of all, I wish to thank the women whose births have been discussed herein. x CHAPTER I INTRODUCTION Preface: The Proper Person "Midwives were in demand among the settlers in Nova Scotia, for in 1755 a request came from Colonel Sutherland, in command at Lunenberg, for '...two proper persons to reside there as midwives at a salary of two pounds a year, as the inhabitants were losing so many of their children'...." 1 This request reflects the sense of propriety that had been vested in midwifery: that midwives must be of sound moral character, responsible and of service to women during childbirth and thereafter. Other documents attest to the importance of community midwives in coastal settlements in British Columbia and Newfoundland, on the Prairies, and in urban centres during the 18th and 19th centuries in Canada. J The central place of the community midwife in Canada has since changed dramatically. The status of the midwife as healer, neighbour, and mother has changed in two ways: first, the near-eradication of the lay midwife; and second, the development of professional nurse-midwives who are responsible in varying degrees for childbirth attendance. Once sought after as a resource for the State, community midwives have recently been subject to prosecution under criminal statutes or for quasi-criminal offences such as practicing medicine without a license. . Dramatic changes have also occurred within family structures and community organization in Canada and on a global scale. The family as the locus of childbirth and of childrearing has become diffuse, with institutions such as the hospital, the school, and childcare centres 1 Jan Gibbon and Mary Matthewson, Three Centuries of Canadian Nursing, Toronto, MacMillan, 1947, p. 237. 2 In colonial America midwives were well-regarded for their skills in managing births. Two writers mention how the Dutch West India Company paid for the passage of one midwife in 1630. See Margot Edwards and Mary Waldorf, Reclaiming Birth: History and Heroines of American Childbirth Reform, 1984, Trumansberg, The Crossing Press, p. 148. 1 taking more responsibility and control. The sense of community has also been altered, particularly in terms of a community of women. Historically, women formed communities of interest that included pregnancy, childbirth, and health care, and these communities thrived well into this century in some regions of Canada. 3 Kitzinger adds that midwives in peasant societies had high prestige and considerable power as their healing powers, childbirth attendants, and for presiding over the forces of fertility. 4 Structural changes in midwifery, families, and communities are brought forward in the discussion of Community Midwifery and Nurse-Midwifery in Chapter Five. At this point, it is important to define the central concept of midwifery and the implications of current definitions. There are a variety of definitions of midwifery and nurse-midwifery. A generic definition of midwifery includes anyone, male or female, who assists a woman in childbirth. This comprises certified nurse-midwives, lay midwives, neighbours and spouses who assist at birth, obstetricians, general practitioners, obstetrical nurses, and those compelled to assist at unexpected births such as police officers. A more restrictive definition of midwifery includes only female birth attendants. In this usage, "wife" (originally, "wyfe", or woman) and "woman" are linked. There is some debate over whether the term "midwife" includes all women who are present with the mother at birth, or only "...a woman by whose means the delivery is effected". 5 Another definition includes spouses. As set out below, the labouring woman is defined 3 Outport in villages in Newfoundland are one example of the importance of midwives and the community of women. See Cecilia Benoit, "Midwives and Healers: The Newfoundland Experience", Healthsharing, (1983), pp. 22-26. For a discussion of the weakening of female and community control over childbirth see Barbara Ehrenreich and Deidre English, Witches, Midwives and Nurses, 1973, Old Westbury, N.Y.: The Feminist Press; and Ann Oakley, "Wisewoman and Medicine Man: Changes in the Management of Childbirth" in Juliet Mitchell and Ann Oakley (eds.), The Rights and Wrongs of Women, 1976, Harmondsworth, Penguin, pp. 17-58. 4 Sheila Kitzinger, Women as Mothers, London, Fontana, 1978, pp. 125-126. 5 Oxford English Dictionary, 1979: p. 1792. 2 as a midwife (midwives are conventionally defined as separate from labouring women):6 "...the midwife is defined as any individual who, by choice, assists a woman in the process of delivering her baby, and who consciously assumes some degree of responsibility for the health and well-being of mother and child. This is the broadest possible definition, and includes trained nurse-midwives, traditional midwives or birth attendants in all cultures, as well as trained obstetricians. It also includes men and women who together decide to deliver their child at home. It excludes firemen, policemen, emergency service personnel and random individuals who fortuitously deliver an occasional baby as the result of idiosyncratic circumstances." This definition ironically combines the requirement that midwifery is a calling which embraces obstetrics and general practice with provision of midwifery status for occasional attendants such as spouses. A major issue is that some midwives would interpret midwifery training and practice as quite distinct from medical specialties and general practice. For them, this incorporation of midwifery and obstetrics is misleading since it obscures significant differences in practice and philosophy between midwives and other birth attendants. A Community Midwife may be defined as a birth attendant who regularly participates in labour and/or delivery without the protection accorded medical practitioners. Lay midwives do not have certification or official training. Some are self-taught, referring to available texts and other materials, often apprenticing with more experienced midwives. The term "community" midwife is becoming more commonplace: first, because "lay" midwife has a connotation of inferiority; and second, because many community midwives have nursing training, hospital experience, and so forth. Unlike the majority of practicing nurse-midwives, their practice in British Columbia is primarily out-of-hospital. This includes primary care prenatally and postnatally and assistance during labour and delivery. Community midwives may also provide birth control counselling, advice on breastfeeding, prenatal classes, and labour coaching in hospital. 6 Ann Kuckelman Cobb, "Incorporation and Change: The Case of the Midwife in the United States," Medical Anthropology, 1981, 5(1), p. 75 (italics added). 3 A Nurse-Midwife is a birth attendant who has completed nursing training, is registered with the local (national, State, provincial, where applicable) Nursing Association, and has completed additional midwifery training in an accredited programme. The sphere of practice of certified nurse-midwives (C.N.M.s) can be very broad. Nurse-midwifery may involve continuity of care beyond attendance at labour and delivery: 7 "(The certified nurse-midwife) might be employed by a hospital, by a medical center, by an affiliated community-based maternal and child health service, or by an obstetrician-midwife group practice. She manages the complete maternity care for mothers with an essentially normal course of pregnancy. She always functions with readily available medical consultation should any sudden medical complications arise. Today's modern midwife is prepared to function in all areas of [a] woman's health maintenance concerned with reproductive processes, including family planning and childbirth. Perinatal care and newborn health management are integral parts of midwifery practice." Lang's definition encapsulates several major themes concerning the redefinition of midwifery in contemporary medical care. First, the C.N.M. is usually not an independent practitioner, working out of her home or private office, for instance, but instead an employee or partner in a practice. An earlier report indicated that: "Nurse-midwives are never independent practitioners; they always function within the framework of a physician-directed health service". 8 This assumption of the subordination of nursing deserves critical scrutiny for it underestimates the role of the nursing profession in maternity and infant care. Chapter Five provides a theoretical framework for this discussion of the power of the nursing profession. A second theme is that non-medical personnel (such as lay midwives) are excluded from the CN.M.'s network of collaborating birth attendants. Third, the premise of "readily available" medical consultation obscures the very tangible conflicts between the sphere of practice of nurse-midwives and that of other birth attendants. 9 7 Dorthea Lang, "Modern Midwifery" in Dickason and Schult (eds.), Maternal and Infant Care, 1979, New York, McGraw-Hill. 8 Barry. S. Levy, Frederick S. Wilkinson, and William M. Marine, "Reducing neonatal mortality rate with nurse-midwives," American Journal of Obstetrics and Gynecology, 1971, 109(1), p. 51. 9 For a statement of the integral nature of nursing training to midwifery see Judith Bourne Rooks and Susan H. Fischman, "American Nurse-Midwifery Practice in 1976-1977: Reflections 4 The International Federation of Gynaecology and Obstetrics along with the International Confederation of Midwives established a widely-accepted description of midwifery that encompasses nurse-midwifery and other forms of midwifery. 1 0 "A midwife is a person who, having been regularly admitted to a midwifery education programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery. She must be able to give the necessary supervision, care and advice to women during pregnancy, labour and postpartum period, to conduct deliveries on her own responsibility and to care for the newborn and the infant This care includes preventive measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance and the execution of emergency services in the absence of medical help. She has an important task in health counselling and education, not only for her patients but also within the family and the community. The work should involve ante-natal education and preparation for parenthood and extends to certain areas of gynaecology, family planning and child care." These definitions of midwifery practice underscore the division of Canadian midwives into community midwifery or hospital-based, nurse-midwifery. Community midwives tend to be self-employed, to practice their skills outside of hospitals, to provide continuity of care throughout the pregnancy, labour and delivery, and the postpartum period. They also practice without the benefit of law and only recently have begun to develop a theoretical and clinical training programme in B.C. Nurse-midwives are not independent practitioners: they are usually employed in the capacity of obstetrical nurses, although some also serve in northern regions as outpost nurses. Since nurse-midwives operate on shifts within the hospital, they do not always remain with women from the time of admission to delivery, nor do they provide prenatal and postnatal care in the same, continuous manner as community midwives. Nurse-midwives are legal practitioners under the B.C. Registered Nurses' Act but as shall be '(cont'd) on 50 Years of Growth and Development," American Journal of Public Health, 70(9), p. 990. 1 0 J.M.L. Phaff et al., Midwives in Europe: Present and Future Education and Role of the Midwife in Council of Europe Member States and in Finland, 1975, Strasbourg, Council of Europe, p. 2 5 demonstrated, this legal status has been accompanied by the containment of nurse-midwifery skills within many obstetrical settings. Central Problem of the Research Much contemporary research on childbirth has been medically oriented, addressing obstetrical techniques and birth outcomes. This approach is closely allied with demonstrable improvements in the management of high-risk pregnancies and refined methods of treating newborns suffering from low birth weight, genetic deformities, fetal alcohol syndrome and the like. Technical discussions of prevention and treatment of mortality and morbidity are central to this literature, along with a growing interest in health promotion for expectant mothers and fetuses. Other approaches to childbirth present a less clinical or technical portrait of childbirth. For instance, there has been renewed interest in the history of birthing practices in North America and elsewhere, in cross-cultural variations in birth, in sociological studies of pregnancy and childbirth 1 1 and in the regulation of birth attendants by professional associations such as Colleges of Physicians and Surgeons and Nursing Colleges, as well as through direct involvement of the legal apparatus of the State. The central problem of this dissertation arises out of the renewed interest in midwifery and the growing interest in theories of the State. Specifically, the central problem is how the manner of State intervention in childbirth attendance in British Columbia has contributed to the outlaw or subordinate status of the midwifery profession, and whether midwives are competent caregivers for parturient mothers and children. The central thesis to be examined begins with the theoretical assumption that the State serves to maintain or extend patterns of domination and subordination. This encompasses patterns of male dominance over women (as 1 1 Ann Oakley, Women Confined: Towards a Sociology of Childbirth, 1980, New York, Schocken Books. 6 employees and patients) within the medical sphere, of professionals over non-professionals, and of routine interventions in childbirth over the more judicious use of childbirth technology. Specifically, State expansion via the regulation of childbirth, historically rooted in a legal monopoly of practice for male physicians and surgeons, was designed to protect the interests of the then-emergent, now dominant profession of medicine. The exclusion of non-medical practitioners by the intervention of the State thus enabled medical practices to develop with limited competition from "irregular" practitioners. 1 2 It is evident that this historical take-over of birth attendance, including the complicity of State officials with professional interests, remains largely intact today; i.e., with close to 100% of births in North America involving hospital-based deliveries supervised by medical personnel. 1 3 It is important, however, to critically assess the value of midwifery practice and to consider the benefits that have accrued through the development of maternity and infant services. To do otherwise is to oversimplify the complexity of the midwifery debate and the directions of future policies for midwifery education and practice. This study will examine the alleged occupational inferiority of midwives as birth attendants. If this allegation is disproven, then the existing legal encumbrances on consumer choice in childbirth and in women's freedom to attend births as an occupation must be recast as serving specific interests, not a putative general interest The specific apparatus of law within the contemporary Canadian State is considered. The thesis to be examined is that contemporary midwifery practice, whether undertaken by nurses trained in midwifery or by lay midwives, is substantially constrained by current legislation and legal practice. These constraints include the delineation of midwifery as an element of medical practice under the Medical Practioners Act in British Columbia. This has 1 2 This conflict in Ontario is traced in Lesley Biggs, "The Case of the Missing Midwives: A History of Midwifery in Ontario from 1795-1900", 1983, Ontario History, 75 (1), pp. 21-35. 1 3 Suzanne Arms, Immaculate Deception, 1977, New York, Bantam Books; Roger Tonkin, Child Health Profile: Birth Events and Infant Outcome, 1981, Vancouver, Hemlock Printers. 7 transformed midwifery from a local practice into an illegal act, thereby effectively transferring power from the midwives and their clients into the professional sphere of physicians and nurses. Other constraints include the corresponding powers of discipline and legal redress that physicians can employ against midwives for the quasi-criminal offence of "practicing medicine without a license", and the greater likelihood that legal officials - police and prosecutors -will initiate Criminal proceedings against non-medical birth attendants in the event of injury to the mother or child. One problematic aspect of this legal delineation is whether this monopoly status is in the public interest, A growing body of research is available in support of the argument that midwifery attendance is safe and appealing to parturient women. This finding is not fully established, partly due to methodological problems in the existing literature as well as contrary findings (i.e., where lay midwives appear to have greater rates of mortality and morbidity among their clients). Nevertheless, if midwifery attendance appears comparable to, or superior to, obstetrical attendance then the question remains: why is midwifery excluded or marginalized while the profession of medicine is entrenched? It will be suggested that the State maintains legal barriers to midwifery practice to support the professional interests of organized medicine, at the same time containing radical feminist initiatives, including demands for legal status extended to alternative practitioners. 1 4 The central problem investigated in this study is developed through a specific instance of "statism". Statism is defined as the transfer of activities from particular organizations in civil society to State regulation. 1 5 The concept of statism is synonymous with "statisization". 1 4 See Zillah Eisenstein, The Radical Future of Liberal Feminism, 1981, New York, Longman, p. 220. Midwifery is not wholly a "radical feminist" initiative. It does however stem from the feminist critique of patriarchy in law and health care. Radical associations have also been formed, for example, the Association of Radical Midwives. Other groups in England include the National Childbirth Trust and the Association for Improvements in the Maternity Service. See Caroline Flint, Sensitive Midwifery, 1986, London, Heinemann, pp. 238-240. 1 5 Arian Asher, "Health Care in Israel: Political and Administrative Aspects", International Political Science Review, 1981, 2 (1), pp. 43-56. Miliband speaks of the "vast inflation" of the power and activities of the State such that "...more than ever before men now live in 8 Panitch illustrates this expanded role of the State through State subsidization of political parties' expenditures and State influences on trade union activities. 1 6 This instance serves to illustrate the structural constraints on human action reinforced by the State. Nevertheless, it is anticipated that structuralist theorists of the State - Althusser and Poulantzas, for example -provide a theoretically incomplete framework. They fail to take into account instances of sustained, counter-hegemonic resistance to State control of social action. Structuralists question the separation between State agencies and non-State organizations favoured by Miliband, substituting a broader definition of the State. This connects formal State structures (the judiciary, the civil service, the police, the military, and so forth) connected with ideological structures: political parties, the Churches, trade unions, specific interest groups (including the Medical profession and related bodies). 1 7 The structuralist approach allows for distinct lines of authority between the professions, rival occupations, and State officials, as well as competing objectives among them. The initial encroachment of the State in permitting a monopoly status to medical practitioners in 19th century Canada was largely instrumentalist (serving the interests of members of a dominant class). It was also tied to patriarchical ideology by excluding, where possible, nonprofessionals (invariably women) from birth attendance. It has been established that the monopoly status of doctors in pioneer Canada was not enforceable in regions that did not have sufficient medical attendance. In such cases lay midwives were allowed to practice until medical and nursing personnel were present 1 8 "(cont'd) the shadow of the state". See Ralph Miliband, The State in Capitalist Society, London, Quartet Books, p. 1. 1 6 Leo Panitch, "The Role and Nature of the Canadian State" in L. Panitch (ed.), The Canadian State: Political Economy and Political Power, Toronto, University of Toronto Press, 1979, p. 10. 1 7 Ralph Miliband, op ciL; Nicos Poulantzas, Political Power and Social Classes, London, Verso, 1978. Miliband retains a greater distinction between the State and Civil Society, while recognizing the interaction of the two spheres. 1 8 See Biggs, op ciL, note 2; and Henry Sigerist, Saskatchewan Health Services Survey Commission, Report of the Commissioner, 1944, Regina, King's Printer. 9 The contemporary focus of this thesis, while linked with this instrumentalist framework, will address the complexity and vagaries of State enactments and occupational action through a "relative autonomy" theoretical framework. The modern State is not simply an instrument of a particular class or set of classes, nor is it a determined set of objective relations. Rather, the State maintains a degree of autonomy in initiating legal reforms and constraining the actions of dominant, privileged groupings. This feature, it is argued, reflects in part the vitality of struggles "from below". Attention is also directed to initiatives by State personnel that influence reforms in social justice and changes in criminal justice policies. 1 9 The central problem of State expansion into maternal and child care is the common ground against which a number of related sub-problems can be assessed. These sub-problems include the nature of accommodation to - or resistance against - State expansion. Resistance and accommodation are evident in the occupations of nurse-midwifery and community midwifery in British Columbia and elsewhere. Both occupations seem to manifest degrees of accommodation. Nurse-midwifery appears more allied with medical practitioners, while lay midwives challenge the hegemonic status of medical personnel in women's health care. It is hypothesized that these alliances affect the nature of midwifery practice. It is plausible that lay midwifery practice is associated with lower rates of intervention - episiotomy, medication, electronic monitoring, and so forth - than is nurse-midwifery practice. This differentiation is linked with structural pressures on nurse-midwives to defer to physicians during labour and delivery procedures, to utilize hospital equipment and personnel, and the like. This sub-problem is in turn linked with women's status and the State, especially the concept of patriarchy - e.g., the historical exclusion of women from participation in public life, the barring of women from medical education, 2 0 and the gradual dichotomy established between 1 9 See R.S. Ratner et al., "The Problem of Relative Autonomy and Criminal Justice in the Canadian State," in R.S. Ratner and J.L. McMullan (eds.), State Control: Criminal Justice Politics in Canada, 1987, Vancouver, University of British Columbia Press. 2 0 See Veronica Strong-Boag, "Canada's Women Doctors: Feminism Constrained" in Linda Kealey (ed.), A Not Unreasonable Claim: Women and Reform in Canada, 1880s -1920s, 1979, Toronto, The Women's Press, pp. 109-129. 10 men (as doctors) and women (as patients or as nurses, both subject to medical authority). 2 1 The major theoretical question addressed in this dissertation concerns power, particularly the political dimension of power whereby a group or groups vie to secure their interests or to establish a general interest Crucial to this thesis, then, is an articulation of the limitations of the dominant liberal conception of the State as pluralist, democratic, and quintessentially unbiased. Scope of the Research This study of midwifery in Canada addresses the contemporary debate on childbirth attendance and its regulation in a number of ways. First, a systematic search of the available literature on childbirth identifies the parameters of debate and discusses some of this literature regarding specific issues in contemporary maternity care. While there are omnibus approaches to specific aspects of maternity care - for instance, infant mortality and morbidity - few studies seek to integrate the detailed literature on obstetrical procedures and midwifery with the empirical and theoretical perspectives of social science. " Second, published studies of the history of midwifery and the advent of obstetrics is discussed to place contemporary debates in historical context Third, an empirical study of the practice of nurse-midwives and lay midwives in British Columbia will constitute an original contribution to our knowledge of childbirth attendance in a Canadian jurisdiction. 2 1 Judith Lorber, "Women and Medical Sociology: Invisible Professionals and Ubiquitous Patients" in Marcia Millman and Rosabeth Kanter (eds.), Another Voice: Feminist Perspectives on Social Life and Social Science, 1975, Garden City, Anchor Books, pp. 75-105. 2 2 Two exceptions are P. Anisef and P. Basson, "Institutionalization of a Profession: Comparison of British and American Midwifery", Sociology of Work and Occupations, 1979, 6(3), 353-372 and Gemot Bohme, "Midwifery as Science: An Essay on the Relation of Scientific and Everyday Knowledge", in Nico Stehr and Volker Meja (eds.), Society and Knowledge: Contemporary Perspectives in the Sociology of Knowledge, 1984, New Brunswick, Transaction Books, pp. 365-385. 11 Medical and nursing terminology is consolidated into a Glossary appendix (see Appendix A). Brief definitions of numerous terms are incorporated into this Glossary: placenta previa, Caesarean section, breech presentation, neonatal mortality, primagravida, and so forth. Reference is made throughout the text to specific research reports: e.g., recent overview articles on Caesarean section rates, studies of induction procedures and episiotomies, electronic fetal monitoring , and evaluation studies of nurse-midwifery and community midwifery. 2 3 Reference has also been made to standard Medical and Midwifery Dictionaries and Textbooks. 2 4 In addition, definitions of other terms such as infant and maternal morbidity and mortality, perinatal statistics, are provided in the text The empirical study is divided into three parts. The first is a comprehensive documentary analysis of birth records and charts pertaining to attempted home births with community midwives. The researcher asked all community midwives if they had compiled birth records or charts or had access to them. The researcher then requested access to these records to compare outcomes of midwifery attendance with obstetrical outcomes in this province. This documentary analysis provides crucial data on various aspects of birth attendance and birth outcomes in British Columbia. These findings are linked with the extant literature on birth attendance. Birth records and charts associated with births attended by certified nurse-midwives include documents linked with a midwifery demonstration project at the Grace Hospital in Vancouver between 1981 and 1984. Four nurse-midwives provided prenatal care, attendance at labour, and post-natal care for 61 women. This was the only demonstration project of its kind in Canada, although others have been reported in the 2 3 See Paul Placek and Selma Taffel, "Trends in Cesarean Section Rates for the United States, 1970-1978", 1980, Public Health Reports, 95(6), pp. 540-561; Carol Brendsel et al., "Episiotomy: Facts, Fictions, Figures, and Alternatives" in David Stewart and Lee Stewart (eds.), Compulsory Hospitalization or Freedom of Choice in Childbirth: Volume One, 1979, Marble Hill, NAPSAC, pp. 139-144; Student Nurses Association of Illinois, "Episiotomy as an American Phenomenon", Journal of Nurse Midwifery, 1979, 24(1), p. 31; Lewis Shenker et al., "Routine Electronic Monitoring of Fetal Heart Rate and Uterine Activity During Labor", Obstetrics and Gynecology, 1975, 46, pp. 185-189. 2 4 V. da Cruz, Bailliere's Midwives1 Dictionary (fifth edition), 1969, London, Bailliere Tindall and Cassell; M. Myles, Textbook for Midwives, 1975, Edinburgh, Churchill. 12 United States and other countries, and a second project has been implemented at the Grace Hospital in Vancouver. These two documentary analyses are combined with the third focus, information gleaned from in-depth interviews with samples of practicing nurse-midwives and community midwives, as well as other people concerned with maternity and infant care and pertinent legislation (defence attorneys and prosecutors, educators, consumer advocates). These three parts of the research study are integrated with the fundamental question of State expansion into birth attendance. Specifically, the results of the sociological approach -documentary analyses, interview data, State theories - are interpreted in conjunction with research reports by nurses, physicians, midwives, and health care researchers. The original research and the available literature are used to discuss how particular groups develop accounts of society and their contributions to a given society. Explanations which will be considered include the following: 1. the interest of professional organizations in ensuring a supply of patients and above-average income; 2. the division of work along gender-related lines as well as along class-related lines; 3. the use of legal prohibition to discourage midwifery practice; 4. the role of the judiciary in rationalizing State policies; 5. serious concerns about the safety of lay midwifery attendance and the need for formal regulation of birth attendance; 6. and the role of the judiciary in rationalizing State policies. 2 5 The implications of legal prohibition begins with a consideration of the historical precursor to modern campaigns against midwives, the persecution of midwives under State and Ecclesiastical auspices in North America and Europe. It is then extended into a review of recent case law dealing with prosecution of midwives under relevant legislation in British Columbia and other Canadian provinces. 2 5 For a discussion of the role of judges in rationalizing government policy see Roger Cotterrell, The Sociology of Law: An Introduction, 1984, Toronto, Butterworth, Chapter Seven. 13 This sequence of analysis will culminate in the application of this instance of State intervention in social and economic life (specifically, childbirth and the occupation of midwifery) to the continuing debate over the implications of State authority in advanced capitalist societies. It is expected that this instance of statism will illustrate features of the way in which structured patterns of authority and domination are mediated through the State apparatus in capitalist society. At the same time, it reveals the pressures for alternative approaches to childbirth and women's occupational freedom, the limited impact of these pressures on legislative enactments and professional policies (e.g., birthing practices), and the attempts of the State to contain these pressures through legal repression and ideological persuasion. The theoretical framework in which the above assumptions are explored involves the role of the State as "relatively autonomous" of specific interests of dominant groupings -such as organized medicine - as responsive to countervailing pressures, yet integral in the promotion of dominant interests as a whole. The debate over midwifery practice in British Columbia can be identified as a fundamental dispute about the desirability of granting midwives more independent, legal status as birth attendants. This debate highlights the contradiction between (1) the ostensible "general interest" served by professional birth attendance, and (2) the radical tenet that legal regulation primarily serves dominant class interests while undermining women's rights to self-determination as mothers and as birth attendants. Specifically, the outlawing or marginalization of lay midwives as well as the subordinate status of certified nurse-midwives reflects a consolidation of professional occupational interest that is largely intact despite challenges to its hegemonic status. 2 6 This consolidation of interest is made possible through legal sanctions that may be directed toward birth attendants "poaching" on the medical monopoly: first, through civil actions against midwives; and second, through criminal prosecution of midwives in the event of injury or death to mothers or newborns (while 2 6 Paul Starr, The Social Transformation of American Medicine, 1983, New York, Basic Books. 14 criminal prosecution is largely eschewed in instances of injury or death occurring in hospital-situated, professionally-attended births). These legal encumbrances on independent midwifery practice have been interpreted as protecting citizens from incompetent or dangerous birth attendants, and as a way of maintaining professional self-determination, status, and income. The B.C. College of Physicians and Surgeons has the statutory power to register doctors for the practice of medicine and to restrict the practice of medicine and midwifery by other birth attendants. An exception to this general rule involves outpost nurses working in areas that have few or no doctors; e.g., the Northwest Territories, the Yukon, and remote areas in the Provinces. Accordingly, the dominant method of birth attendance is for labour, delivery, and immediate post-delivery to be supervised by doctors, usually with the assistance of obstetrical nurses in maternity wings or maternity hospitals. There have been precedents in British Columbia whereby a person attending a birth has subsequently been convicted of practicing midwifery without a license: the conviction of Margaret Marsh in 1980 is a recent example. 2 7 There are nevertheless a number of problems with what appears to be a clear prohibition of midwifery practice and the dominant status of obstetrical personnel. First, the very definition of midwifery is not clearly set out in law. Second, despite the general legal prohibition, it has been estimated that there are up to 100 lay midwives attending births in British Columbia 2 8 and there have been recommendations to expand the role of the certified nurse-midwife with respect to hospital-situated births. 2 9 Third, this point is connected with the largely contradictory international phenomenon of what appears to be growing support for midwifery training, licensing, and practice on the one hand, and structural changes in 2 7 [Judge] Peter Millward, "Reasons for Judgement" Regina versus Marsh, 1980, Victoria, County Court of British Columbia. 2 8 See Andreas Schroeder, "Birthright", Today Magazine, October 4, 1980, pp.10-13. 2 9 Registered Nurses Association of British Columbia, "Policy Statement - Nurse Midwifery" 1979, [Typescript mimeo], 2 pp. 15 obstetrical practice that seek to eliminate midwifery or to "medicalize" it on the other.30 Fourth, the historical development of midwifery, the implementation of legal obligations to register births through Provincial Vital Statistics Acts, and the advent of physician-dominated childbirth in Canada, are not understandable through direct reference to case law and statute law alone. The legal status of midwifery in British Columbia is salient to this thesis since prosecution of midwives for alleged transgressions of section 203 of the Criminal Code of Canada, criminal negligence causing death, 3 1 has been undertaken in recent times in British Columbia and Nova Scotia. Moreover, the civil status of midwives in the provinces is the subject of lobbying on behalf of lay midwives and consumer advocates. The nature of midwifery practice, as argued in this thesis, is inseparable from the central problem of accounting for its legal regulation or prohibition in many North American jurisdictions. Arguments against establishing a legal footing for the practice of midwifery are almost invariably pitched on the basis that midwifery practice is unsafe, or not as safe as physicians' management of labour and delivery. Nevertheless, several short-term, demonstration projects in many countries have challenged this critique of midwives. 3 2 These demonstration projects are bolstered by longer-term midwifery services such as the Frontier Nursing Service 3 0 Robert Crawford, "Healthism and the Medicalization of Everyday Life", International Journal of Health Services, 1980, 10(3), pp. 365-388. An extended treatment of the myriad ways in which social issues have become the bailiwick of physicians is provided by Ivan Illich, "The Medicalization of Life" (Ch. 2), Limits to Medicine, 1977, Harmondworth, Penguin. 3 1 Paul Bourque, "Proof of the Cause of Death in a Prosecution for Criminal Negligence Causing Death", The Criminal Law Quarterly, 1980, 22(3), pp. 334-343. 3 2 Accounts of these projects are available in Doris Haire, "Improving the Outcome of Pregnancy Through Increased Utilization of Midwives", The Practicing Midwife, 1981 (summer); Barry Levy et al., "Reducing Neonatal Mortality Rate with Nurse-Midwives", American Journal of Obstetrics and Gynecology , 1971, 109(1), pp. 50-58; Anne Scupholme, "Nurse-Midwives and Physicians: A Team Approach to Obstetrical Care in a Perinatal Center", Journal of Nurse-Midwifery, 1982, 27(1), pp. 21-27; Richard Stewart and Linda Clark, "Nurse-midwifery Practice in an all-hospital Birthing Center: 2050 Births", Journal of Nurse-Midwifery, 1982, 27(3), pp. 21-26. 16 in Kentucky. 3 3 As set out in Chapter Five, some observers maintain that skilled midwives can lower rates of maternal morbidity and of operative delivery (i.e., anaesthesia, analgesia, forceps delivery, vacuum extraction, and Caesarean section). It is also important to consider how the midwifery movement emerges and is sustained. Information on patterns of recruitment and apprenticeship by lay midwives and nurse-midwives, on the practice of midwifery itself, data on why midwives may discontinue practice indefinitely or temporarily, and midwives' reflections on the optimal place of midwifery alongside obstetrical care is gathered through a semi-structured, interview frame. This information, which is linked theoretically with general works within the Sociology of Work and Occupations, especially those centering on women and the work-force, 3 4 will be applied directly to the central issue of the competency of midwives to attend births. If their competency or superiority is confirmed as hypothesized, this finding will challenge the rationale underlying the protected legal status of doctors in childbirth. This focus is useful inasmuch as midwives are overwhelmingly female. It is only recently that men have been admitted to midwifery training in Britain for example. Considering the near-segregation of work along gender lines historically, it is not surprising that in 1979, only four of the 24,000 midwives in Britain were men. 3 5 The theoretical linkage with work and occupations depends upon an understanding of the modern State. The assumption here is that historical and contemporary conflicts among birth attendants, as well as conflicts between these attendants and State officials, are best understood with reference to the movement of the State into this aspect of health care. By taking criminal action against lay midwives, by transferring licensing powers to medical and 3 3 Suzanne Arms, op cit 3 4 Helen Marieskind, Women in the Health System: Patients, Providers, and Programs, 1980, Toronto, C.V. Mosby; Susan Wilson, Women, the Family, and the Economy, 1986, Toronto, Prentice-Hall (second edition). 3 5 Leslie Plommer, "Male Midwives Meet Opposition in Britain", The Globe and Mail, February 15, 1979. 17 nursing Colleges, the State reinforces the dominance of medical attendance at birth while discouraging the growth of a more pluralistic birthing system. As will be outlined, however, there is evidence that State measures have contributed to maternal and infant safety and that this instrumentalist portrait of the State is not sufficient for understanding the complex struggles for reproductive freedom and safety of infants and mothers. The State and Health Care A common problem in sociological research is a tendency toward empiricism that divorces data from theory. 3 6 This promotes descriptive research and the pursuit of correlations without extensions into causal relationships among the variables under study. Reference to the available literature on health care and the State confirms that for the most part policy-oriented research has tended toward descriptive and atheoretical analyses in contrast to the growing, critical literature on the State and health care. 3 7 This study combines empirical research with a broader theoretical discussion of the State movement into Civil Society and the interests served by this movement The growing literature on the Sociology of the State includes preeminent liberal-pluralist theories of the State and society, structuralist theories that emphasize the play of objective forces autonomously from human agency, and a growing recognition of the functions served by the State in meeting demands of accumulation, legitimacy, and social control. Critical theories of the State have been generated by Marxist and neo-Marxist scholars, primarily in Europe. A central difficulty with this research is the limited attention given to health care issues. There have nevertheless been a number of recent articles and books addressing the pivotal role of the capitalist State in containing struggles surrounding health care services and 3 6 C. Wright Mills, The Sociological Imagination, 1959, Oxford, Oxford University Press. 3 7 For an overview see Andrew Twaddle, "From Medical Sociology to the Sociology of Health: Some Changing Concerns in the Sociological Study of Sickness and Treatment" in Tom Bottomore et al., Sociology: The State of the Art, 1982, London, Sage, pp.323-358. 18 social class, race, and gender.38 One major inadequacy in this work is the focus on theorizing at the expense of empirical work on particular "instances" of State regulation and struggles against such regulation. The study of State involvement in health care is applied through an evaluation of concrete instances of the intrusion of the State into childbirth. In many countries childbirth was a community event that was later regulated by ecclesiastical authorities. 3 9 With reference to birthing practices and State regulation in British Columbia, it is argued that the State's designation of birth as a medical matter has promoted a clientele for Canadian medical practitioners by eliminating competing practitioners such as lay midwives. Furthermore, the State's provision of massive expenditures for medical training, hospitals, supplies, medical insurance plans, and so forth has enabled physicians to consolidate their practices and augment their income relative to other wage-earners. Doctors' incomes in Canada have been over three times greater than the average income of other workers since the 1950s. 4 0 A clearer profile of Physicians' incomes is set out below in Table 1. State complicity in establishing medical attendance may in turn be linked with a number of motives: the importance of establishing a healthy work-force; the largely reciprocal interests of the professions and the. State in reinforcing patterns of hierarchy and obedience; and the need to redefine childbirth as a medical matter, dependent on technological interventions, in order to bolster demands for drug manufacture and obstetrical 3 8 For example, see Sander Kelman, "Toward the Political Economy of Health Care", Inquiry, 1971, 8(3), pp. 133-144; Colin Thunhurst, It Makes You Sick: The Politics of the NHS, 1982, London, Pluto Press. 3 9 For the history of municipal regulation of midwives in Germany see Thomas Benedek, "The Changing Relationship Between Midwives and Physicians During the Renaissance", Bulletin of the History of Medicine, 1977, 51(4), pp. 550-564. 4 0 CD. Naylor, "A Feeling of Deja Vu: The CMA and Health Insurance", The Canadian Forum, 1981, 60(708), p. 11. 19 Table 1: Average Income of Self-Employed Physicians, Dentists, Lawyers, and all Taxpayers in Canada Year Physicians Dentists 1951 9,975 6,287 1961 17,006 14,692 1971 39,555 27,862 1976 49,310 43,336 1981 66,722 60,139 1983 89,124 76,690 Source: Taxation Division, Department of Annual, various years. Lawyers All Taxpayers 10,214 3,149 15,718 4,348 25,828 7,237 44,858 13,319 53,123 15,415 61,457 17,333 Revenue, Canada, Taxation Statistics, equipment41 The thesis developed through the study of midwifery in British Columbia will go beyond the instrumentalist perspective denoted above. While there is merit in the political focus of instrumentalism, as an explanation of social and economic relations it requires modification with respect to the production and reproduction of class relations through struggle, including legal struggles. 4 2 The instance of midwifery in B.C. appears to reflect self-direction (in decision-making and recommendations) by legal officials (police, judges, prosecutors). This self-direction by officials is less apparent in civil actions under the British 4 1 For instance, Gough refers to "...Marx's own study of the British Factory Acts in the nineteenth century. He demonstrated how the Ten Hours Act and other factory legislation was the result of unremitting struggle by the working class against their exploitation, yet ultimately served the longer-term interests of capital by preventing the over-exploitation and exhaustion of the labour-force....". He also refers to the role of the 1906 Schools Act in improving the fitness of the working class. See Ian Gough, The Political Economy of the Welfare State, 1979, London, MacMillan, pp. 55 and 62. See also Magali Larson, The Rise of Professionalism: A Sociological Analysis, 1977, Berkeley, University of California Press. 4 2 Colin Sumner, "The Rule of law and Civil Rights in Contemporary Marxist Theory", Kapitalistate, 1981, #9, pp. 63-91. 20 Columbia Medical Practitioners Act, such as the charge of practicing medicine without a license. The protected, monopoly status of the medical profession is not at issue in such cases, and the Court generally has many precedents upholding findings against people practicing medicine (or midwifery) without a license. The self-direction of legal officials becomes more pronounced, however, when criminal law is invoked. This was evident in recent precedents whereby the prosecution of lay birth attendants under the Canadian Criminal Code or under criminal statutes in the United States was often unsuccessful, despite representations against the defendants by physicians. The point remains that the Canadian Courts have almost invariably upheld the legal monopoly of medical practitioners, including their prerogatives of restricting membership and of disciplining members for conduct disapproved by the College. The theoretical framework centres on the structuralist principle of the "relative autonomy" of State officials, including legal actors. Relative autonomy — a feature of State action in which the collective interests of capital are safeguarded against the interests of particular capitals — has been associated with various theories of the State, including instrumentalism and State Monopoly Capital theories. Nevertheless, such theories are incomplete in themselves, and require greater attention to the processes by which State enactments are reversed or modified through struggle, including legal struggles. The theoretical framework, therefore, moves beyond an instrumentalist approach in assessing the consolidation of obstetrics and general practice (and the near-elimination of the non-professional birth attendant) in the 18th and 19th centuries in Canada. It is suggested that the medical monopoly over childbirth has been challenged through consumer action and the women's movement in recent decades. These challenges in British Columbia include home births practices of community midwives, the expanded role of nurse-midwives in hospitals, and the acquittal of some non-professional birth attendants on criminal charges; and yet birth attendance as a whole remains largely structured in the interest of medical practitioners. 21 The autonomy of the State thus appears to be indeed relative to dominant interests. Given the ambit of State control via prohibitions of alternative practice and through enabling actions on the part of the State (billing through the Medical Services Plan, certification for midwifery instruction, and so forth), the role of the State in preserving patterns of occupational dominance is inseparable from the nature of midwifery practice and the legal forces that encumber it. The relative autonomy of the State, as a plausible sequel to what may have been the instrumentalist character of the Canadian State in the 19th century, thus implies State recognition of counterclaims along with claims from dominant groupings, as well as State action that intervenes against specific interests of these dominant groupings. This framework may be more applicable to the issue of midwifery regulation than purely instrumentalist explanations of health care or the established literature on professional dominance in health care that largely restricts analysis to interprofessional conflicts, with limited attention to historical antecedents or larger, economic factors. 4 3 Methodology As described in Chapter Four, several analytic techniques were applied in this study. Literature searches helped to establish the general parameters of discussion surrounding midwifery practice and regulation. In-depth interviews using a semi-structured interview frame were conducted with practicing midwives in British Columbia. The semi-structured aspect of interviews allows for disagreements and elaborations of general or specific questions culled from the literature review. The interview format permits probes of respondents' answers; the semi-structured format is suited to an exploratory study, especially since closed formats are typically not congruent with the range of respondents' answers. Third, documentary analysis of midwives' birth charts or records provides a reference-point for interviews, where possible, and affords a data base for statistical analysis for aggregate births during the study period. Again, the point is to collect data on the nature of midwifery practice, to compare lay midwifery 4 3 Eliot Friedson, Professional Dominance: The Social Structure of Medical Care, 1980, Chicago, Aldine. 22 practice with nurse-midwifery practice, and to contrast these practices with conventional obstetrical outcomes. The research design consists of a snowball sampling technique to outline the study sample. Snowball sampling is especially advantageous for this research. On the one hand, the practice of lay midwifery in British Columbia is essentially outlawed with few midwives advertising their practice; on the other hand, the available roster of Registered Nurses is not sufficiently sensitive to current practice to isolate currently practicing nurse-midwives. Reference to this Registry, membership lists of such organizations as the Midwives Association of B.C., and adjunctive sources of information will serve as a safeguard against overly skewed samples that may result from snowball sampling. Once the two primary samples - community midwives and nurse-midwives - were established, the next step was to contact midwives to request an interview. This was managed through an initial letter of contact which emphasized the importance of the research, assured confidentiality, and provided a brief outline of the researcher's interest in midwifery practice and its regulation. Community midwives from British Columbia and Ontario provided the bulk of birth-related data. Documents from Saskatchewan and Manitoba also were included in the analysis of birth records. The sample of practicing nurse-midwives was composed of two of the four nurse-midwives active in the Low-Risk Clinic at the Grace Hospital (61 clients between 1981 and 1984) as a core group of informants. Reference was then made to other certified nurse-midwives known to these four informants, along with a province-wide register of nursing specialties. The objective was to record features of midwifery practice so as to allow comparisons between midwife groupings and province-wide and nation-wide birth statistics. 23 The interview schedule also serves to obtain, where possible, documentary data regarding midwifery practice. Missing data were noted. The community midwives providing the records were asked to provide supplementary information where the documents were incomplete. Beyond noting how comparable the records are (between hospital and home attendants, and within both groupings), a key task was to document levels of intervention for overall births. Since few births had only one midwife in attendance, the statistical analysis dealt with births rather than outcomes associated with particular attendants. Additional sources of authority are derived from theoretical accounts of the State. A theoretical review of theories of the State with respect to the dominant ideology of liberal democratic pluralism and competing theories of the capitalist State - structuralism, instrumentalism, capital logic - is crucial to the (more restricted) analysis of nurse-midwifery and lay midwifery in this province. This review will take into account recent observations of a shift toward conservative ideology in Canadian politics, along with the continuing controversy over the functions and legitimacy of the State in advanced capitalist societies. The specific apparatus of legal authority is considered with respect to the regulation of health care and the professions in general. Ethical Considerations Research with human subjects is subject to ethical review, with the protection of subjects a primary consideration. This protection is secured in this study through the anonymity of all research subjects. Names are replaced by codes, and the researcher conceals the identities of people contributing to the research. Studies of midwifery in Canada are further complicated by their legal status. While midwifery is not expressly prohibited in Nova Scotia statutes, midwifery is clearly set out as within the bailiwick of medicine in British Columbia. Section 72 of the Medical Practitioners 24 Act thus stipulates that midwifery can only be legally practiced by members in good standing with the College of Physicians and Surgeons. This places a serious responsibility on the researcher. Knowing that community midwives who are being interviewed and who supply birth records are in violation of the Act, the researcher took a number of steps to avoid jeopardizing these midwives. Community midwives interviewed by the researcher were asked to speak in the third person rather than identifying themselves as birth attendants. This procedure was taken in case the researcher might be called as a witness to some future legal proceeding. While this was improbable - experts consulted on this matter believed that researchers were not subpoenaed for childbirth-related litigation - the protection of research subjects was paramount 4 4 If subpoenaed, the researcher could testify that no midwife directly identified their practice to him. As such, information supplied to the researcher via interviews could be interpreted as hearsay evidence and would likely be inadmissable under Canadian evidentiary rules. A similar precaution was taken with birth records provided by midwives. The researcher asked that these records not be identified as the property of any particular midwife and that discussion of missing data, clarification, and so forth not be tied to any midwife. A second precaution was that the interview tapes, notes, and transcripts were kept in a locked area. Third, upon completion of the study, the collected tapes would be destroyed.. Another ethical consideration that surfaces during the study is the accuracy of research. Where possible, the author recorded data as presented when compiling birth record variables; likewise, excerpts from interviews are presented verbatim or with ellipses to indicate missing words. Assertions by interview subjects were also critically examined and the comparison of 4 4 Under the Canada Evidence Act, the researcher-subject relationship is not privileged. Researchers can be ordered to divulge information. If a researcher refuses, a contempt of court order can result in incarceration for the researcher. See John Hagan, The Disreputable Pleasures: Crime and Deviance in Canada, 1984 (second edition), Toronto, McGraw-Hill. This situation has occurred in several American cities. 25 home birth statistics with hospital birth statistics was conducted systematically. In dealing with community midwives, nurse-midwives, lobbyists, physicians, the researcher adopted a helpful stance with respect to materials he had access to, sometimes alerting the interviewees about developments in other jurisdictions, pertinent research studies, and so forth. Significance of the Research This research addresses the safety of midwifery attendance, bringing together original data from several Canadian jurisdictions with published studies of birth outcomes in other regions. Proponents of midwifery certification, licensing, and training claim that midwifery attendance can augment conventional attendance by physicians in most births; moreover, in the minority of births that require specialized attendance due to complications, a transfer policy to obstetricians and obstetrical nurses can ensure the safety of mothers and infants. The evidence from the Canadian experience of midwifery practice, whether in institutions or at home, extends the generally favourable reputation midwives have established in other countries. As is demonstrated, the practices of nurse-midwives and community midwives have roughly comparable rates of infant mortality, and both groupings appear to have lower rates of obstetrical intervention (e.g., Caesarean section, forceps delivery, induction), especially the community midwives. 4 5 Nevertheless, there remain disquieting questions about adequate standards of care in some instances of community midwifery, and these will have to be addressed in formulating regulatory policies for midwifery. This study also provides findings that underscore the complexity of midwives' approaches to childbirth attendance. There are philosophical and policy differences within the midwifery movement, perhaps most dramatically with respect to the viability of out-of-hospital birthing, 4 5 It is important to note, however, that many high-risk pregnancies are managed in hospitals and the home birth clients may be a self-selected, healthier grouping. This issue will be developed further in Chapter Five. 26 and also surrounding the lay midwife versus nurse-midwife distinction. The theoretical implications of the study are connected with the longstanding debate over State regulation in general, and the regulation of women specifically. Midwifery practice is a crucible in which the freedom of women to birth as they wish, and of women to work freely as birth attendants, has been historically contained and continues to be challenged. This study thus excavates the nature of the challenge to midwives and their clients - the threat of legal prosecution, barriers to hospital practice and to independent billing under the Medical Services Plan, sanctions against physicians collaborating with community midwives, possible co-option of nurse-midwives, and pairs this with the kinds of solutions forged by midwives in British Columbia. As such, a quite intentional form of deviance 4 6 and political lobbying for legal recognition of midwives is examined in the context of civil disobedience. Midwifery. Medicine, and the State The following Chapters serve to develop the themes identified in this introduction. The theoretical discussion in the introductory Chapter shows how the nature of midwifery practice is not reducible to inter-professional conflicts, including ideological disagreements. Instead, the manner of State intervention in these conflicts, through legislation and subsidization, is critical in designating spheres of power in childbirth. The Canadian State is not presented as an instrument of wealthy, privileged interests, but as a structure that has a degree of autonomy in responding to broader interests. This is not to claim that the material basis of the State is unimportant, especially in maintaining patterns of economic inequality between men and women in health care. Chapter Three brings together historical and cross-cultural documentation to trace the development of midwifery in global perspective. The redefinition of childbirth as the bailiwick 4 6 Rose Weitz and Deborah Sullivan, "Virtuous Deviance and Identity Management Among Midwives" (no date), unpublished paper. 27 of physicians, the relocation of birth in hospital settings, technological advances in monitoring and influencing pregnancy, and the creation of the professional nurse and nurse-midwife are major themes in this Chapter. Claims that the incorporation of midwifery into the obstetrical team has been beneficial are questioned, including the assertion that obstetrical techniques (moreso than diet and hygiene) have dramatically reduced infant and maternal mortality. Another point is the great variation in birthing practices across (and within) cultures, as set against the often monistic premises of obstetrical training (e.g., restrictions on delivery positions, length of the second stage of labour, and increases in the rate of caesarean sections). Historical and cross-cultural perspectives are indispensable to understanding the current dynamics of midwifery practice and legal encumbrances on contemporary midwifery initiatives in Canada. In particular, birth as a community concern was recast as a monopoly of doctors - except where their powers were delegated to (outpost) nurses, for instance - and midwifery was redefined as an offence under various Medical Acts in the provinces and the Territories. The requirements for proving an offence under such legislation were narrowed, thereby facilitating prosecution for quasi-criminal offences. Moreover, criminal prosecution of Canadian midwives has become more commonplace during the past decade. Just as the movement of the State into civil life is brought forward as a theme in Chapter Two, so also has the State become involved in managing childbirth and related struggles. Chapter Four offers a detailed examination of the research methods adopted in studying midwifery. Midwifery records are often unavailable from the past, and many are no longer retrievable through oral histories. Accurate documentation of contemporary midwifery practices is essential. There are problems associated with the lack of standardized record-keeping among community midwives, although many variables are usually recorded as part of midwifery documentation. A major difficulty is securing access to records and the time required to code information and to verify or supplement the documentary analysis. Nevertheless, a combination 28 of statistical and non-statistical data was sought in this research. These studies are linked with in-depth interviews with midwives and others, together with reference to much of the world literature on midwifery regulation and practice. Chapter Five presents the major findings from the research. A statistical review of over 1,000 attempted home births in Canada is contrasted with nurse-midwifery initiatives and earlier studies of home births in the United States and Canada. The home birth study confirms the safety of attempted home deliveries relative to hospital deliveries, while raising the criticism that some neonatal deaths were avoidable if care had been provided in hospital. Rates of Caesarean section, episiotomy, induction and augmentation of labour, and perineal tears are lower, sometimes dramatically lower, than hospital outcomes. There is also a substantial diversity in delivery positions adopted by women giving birth at home. The praising of contemporary community midwifery often overlooks problems with some practices. There are instances where the midwife misses the birth or is unable to attend simultaneous labours. There is sometimes an "oppositional" ideology that decries heroic, invasive obstetrics while ironically substituting mystical properties to birth, possibly to the detriment of neonates and parents. The material basis for practice is also discussed in the context of an emergent profession (or calling) and the protectionism engendered by the struggle for midwifery. While the data on nurse-midwifery initiatives presented in this Chapter are less substantial, nurse-midwifery is an integral part of the research. The containment of nurse-midwifery within the hierarchy of doctor-nurse interactions is a central theme. The evidence to date indicates that nurse-midwives are quite capable of managing pregnancy and labour and delivery, but in Canada there has been a very limited sphere of practice for most trained nurse-midwives: most operate as obstetrical nurses, providing valuable assistance to mothers, but seldom are they permitted to practice independently or to assume responsibility at the time of delivery. Attempts to establish non-hospital settings have not yet 29 succeeded in major centres, and the home has become the dispersed site for independent (community) midwifery practice. Chapter Six, "Critical Reflections on Midwifery Practice", elaborates on concerns voiced about modem nurse-midwifery practice and community midwifery practice. These themes include the possibility of cooptation of nurses by the medical profession and hospital administration. For community midwives, serious concerns include variations in training and skill, willingness to transport mothers from home to hospital, and levels of prenatal and postnatal care, especially when the mother is transferred to hospital. These themes and related points are brought together in Chapter Seven. The theoretical implications of State control over liberties are redeveloped in the context of the data analysis and the recent prosecutions of midwives under Criminal and Quasi-Criminal statutes. Greater attention is given to future research possibilities regarding midwifery practice and to policy / development regarding the training, licensing, and discipline of midwives in Canada. The issue of control is central here: to what extent will midwives be self-determining? To what extent will State forces shape the nature of midwifery practice? 30 CHAPTER II STATE, HEALTH, AND JUSTICE Introduction The formal exclusion of independently practicing midwives was presented as a central concern in the introductory chapter. There are several possible explanations for this exclusion, among them the technical superiority and safety of the professions (medicine and nursing), sexism, and intolerance of ethnic minorities. 1 A common interpretation draws on the self-interest of the medical and nursing professions in protecting their income and status against rival health care workers. This chapter places the State as a central figure in the origin of the midwifery debate. It is also a central figure in mediating contemporary conflicts between community midwives, nurse midwives, other health care workers, and parents. The evolution of midwifery as a social movement is analytically inseparable from the manner of State intervention in British Columbia and other jurisdictions. In all Canadian jurisdictions the provincial and federal State sectors have been directly involved in the development of maternity and infant care. Medical insurance programmes, hospital construction, and medical education constitute major structural changes realized through the State. The monopoly practice accorded provincial Colleges of Physicians and Surgeons is a significant feature of legal power, while prosecutions under the federal Criminal Code underline the extensive State powers that can be brought against birth attendants in the event of damage to women or infants. Not only does the State wield these powers; it also is the site of lobbying efforts by midwives (and other health care practitioners) to secure a legal status. In 1 Some of the complaints against 19th century midwives in Canada have been tied with ethnic prejudices. See Suzann Buckley, "Ladies or Midwives? Efforts to Reduce Infant and Maternal Mortality" in Linda Kealey (ed.), A Not Unreasonable Claim: Women and Reform in Canada, 1880s - 1920s, 1979, Toronto, The Women's Press, pp. 131-149. Conversely, it can be argued that by virtue of its multicultural policy, the contemporary Canadian state promotes ethnic and cultural diversity. 31 short, legitimacy through the State is a central goal for many alternative health care practitioners, and their success or failure can reveal the manner of State regulation and the interests served by such regulation. In this chapter three main concepts will be defined and elaborated. The concept of the State will be drawn out with respect to various theoretical outlooks on State control; the concept of Health is directly relevant to the issue of midwifery and childbirth and is interconnected with major State expenditures and policies in health care; and the concept of Justice is applicable to the mandate of State authorities in regulating health care and permitting criminal and quasi-criminal prosecutions of birth attendants. Theoretical work on the State is complex, usually grouped within the three main political philosophies of conservatism, liberalism, and radicalism. Even within these philosophies substantial debates continue regarding the implications of State power. The conservative interpretation of the State will be outlined, followed by liberal and radical contributions to State theory. These theoretical approaches are then assessed against the phenomenon of midwifery practice and initiatives to legalize midwifery in British Columbia. Theoretical Approaches to the State Debate over the nature of the State, the manner of its growth, and implications of State influence on social and economic life illustrates a vital epistemological issue in sociology, and in science generally: whether human action is determined (and to what degree) by structures outside of individuals, or whether social life is altered through "human agency" (thought, consciousness) and is therefore not wholly or mostly determined by structures or forces external to the individual. Does the State emerge as a necessary force to ensure stability, does it emerge and survive as a means of domination by one group or set of groups over others, or does it reflect a contradictory mix Of forces and interests? State 32 policies with respect to midwives in B.C. will be interpreted in the latter sense: while defending special, powerful interests, there is a relative autonomy of the State from these interests in liberal democratic States. The nature and fate of midwives hinges in large measure on this degree of autonomy and the pressures brought to bear on State officials. The power of conservative philosophy is also evident in Western democracies, for example, the electoral successes of Conservative politicians in a number of Western countries, including Canada. England, and the United States. 2 Conservative approaches to the State highlight social order and the authority vested in the legal order. Order is paramount for without social, economic, and political stability, civil life becomes more war-like, industrial and cultural development is impaired, and life is jeopardized through domestic and international conflicts. Hobbes articulated this sense of a common interest in social order that is met through a strong central authority. Commerce, the arts, the very fibre of civilization were dependent on a social covenant between individual citizens and the State. 3 In 1652, in De Che Hobbes interpreted the State as a public power, a supreme political authority that was separate from the ruler (i.e., the Monarch) and the public. 4 A key issue with respect to State policy is the intolerance of minorities that has often been associated with conservatism. Discrimination in immigration policy, law enforcement, and work is more likely to appear under a conservative approach than a liberal State policy. J The Conservative approach is open to criticism for its emphasis on tradition and order, even 2 Ian Taylor, "The Law and Order Issue in the British general election and Canadian federal election of 1979; crime, populism and the state", Canadian Journal of Sociology, 1980, 5(3), pp. 285-311. 3 Thomas Hobbes, Leviathan, (orig. 1651), Harmondsworth, Penguin. A contemporary restatement of the State obligation to maintain order, even at the expense of justice, is set out in Ernest van den Haag, Punishing Criminals: Concerning an Old and very Painful Question, 1975, New York, Free Press. 4 See David Held, "Introduction: Central Perspectives on the Modern State" in David Held et al., States and Societies, 1983, Oxford, Martin Robertson, p. 2 5 See Paul Gordon, White Law: Racism in the Police, Courts and Prisons, 1983, London, Pluto Press for a critique of State discrimination in Britain from a civil liberties viewpoint. 33 in the absence of convincing evidence that far-reaching measures and powers are needed. The abstract value of the "general good" is likewise overemphasized, appearing often in generalizations about the Public or the General Will. Another criticism is the reliance on penalties and force as standard reactions to deviancy. Contemporary discussion about the capitalist State has been dominated by liberal pluralism principles. 6 Liberal perspectives on the State often involve the concept of pluralism and tolerance. It is significant that while liberal ideology emphasizes multiculturalism and diversity, it does not necessarily follow that racial or ethnic stratification is in fact reduced under a liberal State regime. 7 For some liberals this requires a reconciliation between substantive social inequality and formal guaranteed freedoms. This can take the path of abolishing aristocratic privileges, unchecked bureaucratic discretion, and racial and sexual supremacy. Programmes to reduce inequality in access to education and legal representation for people charged with crimes are emblematic of the liberal response to inequality. There is also an appreciation of spheres that are not rightfully controlled by the distributive powers of the State: kin relations and love are two examples. 8 The emphasis conservatives place on social order is leavened through liberalism. Social order is thus balanced against fundamental freedoms and the State is entrusted with protecting constitutional freedoms as well as meting out sanctions. The emphasis conservatives tend to place on public order and discipline is replaced with a clear delineation of private spheres by liberals. The value of these private spheres is consistent with the liberal emphasis on toleration and pluralism. The liberal tradition thus 6 Milton Mankoff, "Power in advanced Capitalist Society: A Review Essay on Recent Elitist and Marxist Criticisms of Pluralist Theory", 1970, Social Problems, 17(3), 418-430. 7 See Kenneth Bagnell, The Little Immigrants: The Orphans Who Came to Canada, 1980, Toronto, MacMillan. 8 See Michael Walzer, Spheres of Justice: A Defense of Pluralism and Equality, 1983, New York, Basic Books, p. xii. 34 favours limits to sovereignty while protecting various rights of citizens.9 Marxist theories of the State present a very different portrait Unlike the conservative sense of the legitimacy of the State or the liberal watchdog function with respect to excessive State powers, Marxist theories invariably reword the necessary powers of the state as forms of domination. The maxim of "The greatest good for the greatest number" is recast as the State actually serving the interests of the few while claiming to represent the Commonwealth. The Marxist theories are important with respect to health care, including midwifery attendance, since they incorporate differentials in illness and longevity, along with occupational stratification, in analyzing race, gender, and class. Major branches of Marxist and neo-Marxist theory include instrumentalism, structuralism, class conflict, and capital-logic. Instrumentalists claim that there is a direct correspondence of economic power and political rule such that the State is linked with a dominant class or set of classes. In a famous passage by Marx and Engels, the Executive of the modern State is portrayed as a committee for managing the common affairs of the bourgeoisie. 1 0 The State is thus conventionally defined as a system which comprises the government (e.g., federal, provincial, and municipal levels in Canada), the administration, the military and the police, the judiciary, sub-central governments, and parliamentary assemblies. 1 1 Empirical studies of instrumentalism thus focus on the class composition of those in State command positions and also on the differential implementation of sanctions through the State. 9 For a discussion of liberalism and liberal democracy see David Held, "Central Perspectives on the Modern State" in David Held et al.(eds.), States and Societies, 1983, Oxford, Martin Robertson, pp. 2-3. 1 0 Karl Marx and Freidrich Engels, The Communist Manifesto, 1979, London, Harmondsworth, p. 82. 1 1 Ralph Miliband, The State in Capitalist Society: The Analysis of the Western System of Power, 1973, London, Quartet, p. 50. 35 Instrumentalism has been widely criticized for oversimplifying economic and political developments in capitalist societies. A common criticism is that instrumentalism reduces the relation of State to civil society to actors' intentions, backgrounds, and affinities, thereby limiting the appreciation of structural influences. 1 2 This interpretation also fails to account for state interests in controlling its budget, in maintaining legitimacy (for electoral reasons), and the ability of state officials to initiate reforms in the interest of equity and justice. Nevertheless, instrumentalism provides an important emphasis on class struggles and the central role of the State apparatus in disguising and managing struggles. 1 3 Structuralist approaches to the State emphasize the total integration of power and domination in social and political life. Structuralists have also emphasized the play of structures external to the will of individuals. Foucault writes of the takeover of human consciousness by technologies of control in various sites - the factory, the schools, the military, and penal settings. In his words, bodies become "docile", and human action is increasingly monitored, measured, and controlled. 1 4 His work is especially important in reconceptualizing the joining of power as knowledge. The "clinical gaze" of medicine is especially pertinent to the midwifery debate. 1 5 For the power secured by physicians through scientific research and clinical practice and through monopolistic powers of practice under State auspices poses serious obstacles to others seeking official recognition as health care workers. 1 2 John McMullan and R.S. Ratner, "State, Labour, and Justice in British Columbia" in Thomas Fleming and Livy Visano (eds.), Deviant Designations, 1983, Toronto, Butterworths, pp. 5-36. 1 3 Charles Grau, "Whatever Happened to Politics? A Critique of Marxist Structuralist Accounts of State and Law" in Piers Beirne and Richard Quinney (eds.), Marxism and Law, 1982, San Francisco, Jossey-Bass, p. 207; Bob Jessop, The Capitalist State, 1982, London, Martin Robertson. 1 4 Michel Foucault, Discipline and Punish: The Birth of the Prison, 1979, New York, Pantheon. 1 5 Michel Foucault, The Birth of the Clinic, 1975, New York, Vintage. 36 This sense of a social totality that largely determines human action is clearly set out in the work of Poulantzas. He reconceptualized the State to include the schools, trade unions, media and other (ideological) apparatuses along with formal State (repressive) apparatuses. An abstract, complex structuralist approach was developed in which political struggles are properly directed against the State. The State serves as the "factor of cohesion" between various levels in constituting a given social formation. Thus, it is not sufficient to seek to transform civil society or to alter the mode of production without political struggles against the juridico-political superstructure of the State. The distinction between the private sphere of the family and the public sphere of the State is artificial according to Poulantzas. His position is that the State assigns the site of the family, that the family is largely unable to resist or evade this power of the State. 1 6 His approach is opposed to strict economic determinism or historicism, and yet the precise contours of structural determinism are not identified in his writing. 1 7 Structuralist-Marxists have been criticized on several grounds. For example, Poulantzas has been faulted for overemphasizing the power of political institutions, and Miliband has commented on the lack of data to develop and ultimately verify structuralist theory. 1 8 The need to bolster theorizing with careful empirical work has also been recognized by Marxists and their critics. Retrospective "explanations" of economic and political developments, and abstract theorizing without reference to a data base are not uncommon. Indeed, some writers point to the frequent clash between "essentialist" Marxist assumptions and the lack of empirical substantiation of .these assumptions. 1 5 1 6 Nicos Poulantzas, State, Power, Socialism, 1978, London, New Left Books, p. 66. 1 7 See Nicos Poulantzas, Political Power and Social Classes, 1973, London, New Left Books. 1 8 Bob Jessop, op tit,, pp. 181-191; Ralph Miliband, "The Problem of the Capitalist State" in Robin Blackburn (ed.), Ideology in Social Science, 1972, London, Fontana. 1 9 A brief discussion of this dichotomy is made by Nicos Mouzelis, "On the crisis of Marxist Theory", British Journal of Criminology, 1984, 35(1), 112-121. See also Ivan Jankovic, "Social Class and Imprisonment", in T. Piatt and P. Takagi (eds.), Punishment and Penal Discipline, 1980, Berkeley, Crime and Justice Associates, p. 104. 37 E.P. Thompson concludes that cultural forces limit the deployment of power and that attempts to use the legal apparatus are subject to reversals (e.g., jury acquittals) and due process safeguards. Thompson's writing has been directed against the reduction of human action to mere "vectors of ulterior structural determinations". As such, Thompson has affirmed the viability of historical understanding against the dismissive approaches of Hindness and Hirst, Althusser, and others. 2 0 His work combines an appreciation of resistance and human agency with a sober assessment of the increasing movement of the State into spheres that were either unregulated or weakly regulated by State authorities. The growth of technological surveillance and the punitiveness of policing policies in Britain, for instance, illustrate this Statist movement 2 1 Another theoretical approach closely allied with the cultural paradigm is the Gramscian outline of human agency. Human agency refers to the will and initiative of people and stands in contrast to the more deterministic theories of the State outlined above. 2 2 Gramsci coupled the elements of will and initiative with the historical development of the State and civil society. Ideological and political practices enable a dominant class (or class fraction) to maintain its hegemonic status so that dominated classes and groupings consent to oppression and exploitation 2 3 Accordingly, Gramsci emphasized the complexities of ideology, class, and law and the potential for counter-movements within the State superstructure. Gramsci also encouraged the role of "organic intellectuals" of the political left, skilled workers who would develop social and political policies. As such, this would bridge the distinction between 2 0 E.P. Thompson, Whigs and Hunters: The Origin of the Black Act, 1977, Harmondsworth, Penguin; E.P. Thompson, The Poverty of Theory and Other Essays, 1978, London, Merlin. A general outline of this cultural explanation is available in Michael Ignatieff, "State, Civil Society, and Total Institutions" in Michael Tonry and Norval Morris (eds.), Crime and Justice: An Annual Review of Research (Volume Three), 1981, Chicago, University of Chicago Press. 2 1 E.P. Thompson, "The Secret State", in David Held et al., (eds.) States and Societies, 1983, Oxford, Martin Robertson, p. 479. 2 2 Antonio Gramsci, Selections from the Prison Notebooks, 1971, London: London and Wishart 2 3 See Jessop, op ciL, note 12, p. 18. 38 intellectuals and manual workers. A synthesis of intellectualism and populism was favoured: 2 4 "...The intellectual's error consists in believing that one can know without understanding and even more without feeling and being impassioned (not only for knowledge in itself but also for the object of knowledge): in other words that the intellectual can be an intellectual (and not a pure pedant) if distinct and separate from the people-nation, that is, without feeling the elementary passions of the people, understanding them and therefore explaining and justifying them in the particular historical situations and connecting them dialectically to the laws of history and to a superior conception of the world, scientifically and historically elaborated...." For Gramsci, then, the potential of social movements was central in an understanding of State domination and strategies for realizing a Socialist State. State domination appears as a form of hegemony, the dominance of a "fundamental social group" over other, subordinated groups. This dominance is not achieved simply through threat and force: consent is secured ideologically by posing issues on a universal level rather than with reference to powerful groups. As Gramsci indicates, the State is an instrument which serves to shape civil society to the economic structure. There is also an appreciation of Civil Society as a source of political change. Even though there has been a statist tendency, the power of the State is limited by the resistance shown by various groupings. 2 5 These forms of resistance bring Gramsci's work directly into the debate between determinism (structure) and free will (human agency), since Gramsci, himself incarcerated as an enemy of the. people in Italy, was well aware of the structural forces that limit human action. Claus Offe has attempted to synthesize instrumentalism, relative autonomy, and structuralism. For Offe, the capitalist State is caught in the contradictions of a capitalist economy. Following O'Connor's approach, 2 6 Offe presents the contradiction between the 2 4 Gramsci, op cit, note 21, p. 418. Gramsci described the formal, bureaucratic method of intellectual work as "organic centralism". The nexus between intellectuals and the people is absent in this method. 2 5 Ibid., pp. 120-125. 2 6 John O'Connor, The Fiscal Crisis of the State, 1973, New York, St. Martin's. 39 State's interest in preserving accumulation and favouring private appropriation of resources, on the one hand, and the requirement that the State appear to be a neutral force operating in the general interest Just as the State depends on a vital private sector for its revenues, so also does the Capitalist State depend on legitimacy of the public. It is important to note that Offe does not agree with the instrumentalist tenet that the State is directly interlocked with capitalist interests; limits are set on the State by law and by pressures from "strategic groups" such as organized labour and oligopoly capitalists. 2 7 Difficulties are evident with Marxist and non-Marxist theories of the State. Perhaps most evident in the Poulantzas-Miliband debate, 2 8 there is a tendency for some writers to resist useful criticisms in developing their particular paradigms. A second difficulty involves the validity of claims. Many of the theoretical works do not include empirical evidence, remaining instead at the level of theorizing. Accordingly, there is no clear methodology for assessing how accurate these claims are nor is there a clear sense of refining hypotheses or statements. 2 9 Notwithstanding the parallel discourses within critical theoretical approaches to the State, the articulation of economism (whereby the mode of production shapes specific social and political activities), instrumentalism, structuralism, and culturalism has been useful in developing critical theory about the state. These issues are brought forward in the following section with respect to the nature of State regulation of health and health care. 2 7 See David Held and Joel Kreiger, "Accumulation, legitimation and the State: the ideas of Claus Offe and Jurgen Habermas" in David Held et al., (eds.) States and Societies, 1983, Oxford, Martin Robertson, pp. 487-497. 2 8 See Robin Blackburn, op cit, note 17. This debate dramatized the gulf between the largely empiricist approach adopted by Miliband and the theorizing of Poulantzas. 2 9 This criticism of Marxist abstraction and dialectical methodology is often associated with positivist epistemology. In The Disreputable Pleasures, 1984, Toronto, Prentice-Hall, John Hagan is critical of theoretical positions that are nonfalsifiable; that is, not subject to measures and standards of proof. See also Austin Turk, "Analyzing Official Deviance: For Nonpartisan Conflict Analyses in Criminology", in James Inciardi (ed.), Radical Criminology: The Coming Crises, 1980, Beverly Hills, Sage, pp. 78-91. 40 The State and Health Care The instrumentalist approach within health care emphasizes the benefits of State intrusion (statism) into civil society for dominant economic groupings. This benefit is evident in early legislation in Upper Canada. The Parker Act of 1865 gave physicians a licensing monopoly, including the power to regulate the supply of physicians and qualifications for the practice of medicine. In the twentieth century, with the advent of medical insurance, physicians were guaranteed payment for their services, usually about 90 percent of the profession's fee schedule. 3 0 Physicians' incomes in the United States are highest (on average) among the professions. Waitzkin associates this financial dominance with a monopoly control that is bolstered through State legislation. Ehrenreich and Ehrenreich add that the average income of doctors in the United States rose proportionately from about twice the average family income (in the 1920s and 1930s) to approximately four times the average family income in the United States. 3 1 The economic underpinnings of the relationships between the health care sector and the State have been developed through Marxian structural analyses. For example, Navarro has developed a theoretical framework in which health services are governed, for the most part, by considerations of political economy at regional, national, and international levels. 3 2 The contradiction between patients' needs and profit-orientation in health services is also developed by Waitzkin. He criticizes Coronary Care Units (CC.U.s) in the United States for their expense and inefficiency. These Units ostensibly serve the public interest through improved 3 0 Donald Swartz, "The Politics of Reform: Conflict and Accomodation in Canadian Health Policy", in Leo Panitch (ed.), The Canadian State, 1979, Toronto, University of Toronto Press, p. 328. 3 1 See Howard Waitzkin, The Second Sickness: Contradictions of Capitalist Health Care, 1983, New York, The Free Press, pp. 36-37; and Barbara Ehrenreich and John Ehrenreich, "Medicine and Social Control" in Ehrenreich and Ehrenreich (eds.), The Cultural Crisis of Modern Medicine, 1978, New York, Monthly Review Press, p. 57. 3 2 See Vicente Navarro, Medicine Under Capitalism, 1976, New York, Prodist; and V. Navarro, "The Political and Economic Determinants of Health and Health Care in Rural America", Inquiry, 13(2), 111-121. 41 emergency care for people suffering coronary illnesses. Waitzkin contends that C.CU.s in fact generate considerable profits for corporate interests, partly through State subsidies, without demonstrating their value in alleviating the suffering associated with coronary attacks. 3 3 A difficulty with this approach, however, is that it dismisses or minimizes authentic contributions to health and other benefits of health care services. 3 4 Waitzkin has built on this instance of the relationship of State to Capital. Working within O'Connor's theoretical framework, 3 5 Waitzkin indicates that the development of expensive medical technology and pharmaceutical commodities becomes profitable through State auspices. As health care in the United States has become increasingly commercialized, profits for corporations have been secured. Likewise, Waitzkin points to a public-private contradiction whereby the State is encouraged to subsidize the growth of private sector health care; for example, by diverting public funds to construction costs of private hospitals. Waitzkin is critical of the conflation of State and Civil Society as a unitary set of apparatuses. He extends Miliband's definition of the State beyond officialdom. 3 6 "..The state comprises the interconnected public institutions that act to preserve the capitalist economic system and the interests of the capitalist class. This definition includes the executive, legislative, and judicial branches of government; the military; and the criminal justice system - all of which hold varying degrees of coercive power. It also encompasses relatively noncoercive institutions within the educational, public welfare, and health-care systems. Through such noncoercive institutions, the state offers services or conveys ideologic messages that legitimate the capitalist system...." 3 7 3 3 Howard Waitzkin, "A Marxian Interpretation of the Growth and Development of Coronary Care Technology", American Journal of Public Health, 1979, 69(12), pp. 1260-1272. 3 4 See Nicky Hart, "Is Capitalism Bad for Your Health?", British Journal of Sociology, 1982, 33(3), pp. 435-443. 3 5 John O'Connor, The Fiscal Crisis of the State, 1973, New York, Saint Martin's Press. 3 6 Waitzkin, op ciL, note 30, p. 52. 3 7 Waitzkin, op ciL, note 30, p. 52. 42 Others have developed structuralist interpretations of State involvement in health care. In Renaud's exposition, 3 8 the capitalist mode of production constrains State solutions to such health-related issues as treatment, occupational health and safety, and environmental concerns. These constraints largely supersede the "volition" of individual health care workers, public officials, and the population at large. The dominant approach of expertise and health engineering draws together healing and consumption, in other words, a commodity approach to health care. This approach mistakenly treats diseases created by industrial development as natural phenomena. Ischemic heart diseases, various cancers, and mental and nervous disorders are examples of these diseases. This point is raised in Doyal 3 9 and developed with respect to carcinogens and co-carcinogens. 4 0 Renaud believes that medical knowledge operates within a paradigm of the "specific etiology" of diseases, with analysis centred on the cellular and biochemical diseases of the body. This approach promotes an overemphasis on individual responsibility for health and illness and obscures structural limitations on health care that are inherent in capitalist societies. 4 1 Foucault presented a structuralist interpretation of the "medical gaze", an epistemological and perceptual system that builds on categorization and classification of the subject 4 2 This alienation of environmental influences, of political economy, and health is promoted through the State, the legitimate problem-solver in advanced capitalist societies. Herein the State is cast in Marxian terms as the manager of crises, serving the general 3 8 Marc Renaud, "On the Structural Constraints to State Intervention in Health" in John Ehrenreich (ed.), The Cultural Crisis of Modern Medicine, 1978, New York, Monthly Review Press, pp. 101-120. 3 9 Lesley Doyal (with Imogen Pennel), The Political Economy of Health, 1981, Boston South End Press, pp. 24-25 4 0 Samuel Epstein, The Politics of Cancer, 1979, Garden City, Anchor Books. 4 1 The importance of social factors influencing health and illness is underscored in Ronald Labonte, "Good Health: Individual or Social?", The Canadian Forum, 1983, 63(727), pp. 10-13. 4 2 Michel Foucault, The Birth of the Clinic: An Archaelogy of Medical Perception, 1973, New York, Vintage. 43 interests of capital accumulation and maintaining social harmony, while presenting itself as a neutral agent This dualism is a central contradiction in State intervention in health care. For Renaud, this contradiction takes form in State reluctance to address work satisfaction and safety, a reluctance that is rooted in the commodified relationships of workers to work. 4 3 "...(The State) cannot question the basic factor that makes work unhealthy: the fact that workers largely are only commodities utilized for maximum output, efficiency, and profit It can only act on very limited, discrete, and easily identifiable working conditions." While promoting the interest of professionals with respect to more secure income and increments in earnings, State intervention in the form of hospital and medical insurance programmes also serves as a concession to working-class struggles for improved health care. 4 4 The most developed critical theoretical work on the State and health care begins from the premise that an understanding of current health care policies in advanced capitalist societies requires an historical perspective. Doyal 4 5 documents the worsened health of the populace in Britain during the transition from feudalism to early capitalism: long hours of work, restrictions on food production due to enclosure, poor sanitation and overcrowded habitats, accidents in factories, and the ubiquitous use of women, children, and men as labourers contributed to a general drop in the standard of health. She concludes that the orthodox perspective on medicine is largely empiricist, disease-oriented, and professional; this leads to minimal emphasis on social theory, non-organic sources of disease, and non-professional action in promoting health. The possibility of substantive allocation of resources is likewise minimized, while the focus of medical research and practice is on individual pathology and curative medical treatment Heroic medicine and high-technology 4 3 Renaud, op cit, note 35, p.115. 4 4 This concession to working-class interests in turn served to consolidate electoral victories for parties other than the CCF in provincial and federal Canadian elections. See Swartz, op cit, p. 335; Desmond Morton with Terry Copp, Working People, 1980, Ottawa, Deneau and Greenberg. 4 5 Doyal, op cit 44 approaches to illness coexist, reinforcing the medical sphere. For Doyal, high technology medicine and the dramatization of medical breakthroughs serve as "window-dressing" and support the existing system. 4 6 Doyal's analysis also emphasizes two imperatives: the production of commodities in the health sector, and the securing of authority relations. Authority relations are divided along lines of race, class, and gender. The importance of gender in health care is central to this understanding, especially as gender is associated with occupational stratification. The Women's Work Project examined data from 1970 gathered from New York City hospitals. They determined that between 75 and 85 percent of Lab Technicians, Licensed Practical Nurses, and manual services Aides were women, with 80 to 90 percent of the latter occupations comprised of non-white workers. 4 7 The structuring of occupations along gender lines is clear in other reports. In the professional and technical spheres in the United Kingdom only 12 percent of medical consultants in the 1970s were women. In 1982-1983, 99.8 percent of nurses in the United Kingdom and only 13.7 percent of physicians were women. 4 8 In their recent analysis of sexual stratification in the Canadian work-force, Phillips and Phillips write that two features of the work-force at the turn of the century are still evident: differentials in income (whereby women earn approximately 60 percent of men's wages, averaged for full-time work); and the concentration of women's paid employment in specific groupings. 4 5 The partial segregation of women into occupational groupings - in the health sector and other sectors - is thus linked with market forces. These forces in turn reinforce 4 6 Ibid., p.43. 4 7 Women's Work Project of the Union for Radical Political Economists, "USA - Women Health Workers", Women and Health, 1976, 1, (3), p. 19. 4 8 John Archer and Barbara Lloyd, Sex and Gender, 1985, Cambridge, Cambridge University Press, p. 225. 4 9 Paul Phillips and Erin Phillips, Women and Work: Inequality in the Labour Market, 1983, Toronto, James Lorimer. 45 patriarchial elements in the economy, although these relations of production in capitalist countries may also carry benefits: 5 0 "...the expansion of employment opportunities for women in these industries does improve conditions for women in the labor market In however limited a way, the availability of jobs in multinational and local export factories does allow women to leave the confines of the home, delay marriage and childbearing, increase their incomes and consumption levels, improve mobility, expand individual choice, and exercise personal independence...." The key to Doyal's analysis, then, is the dialectical relationship between domination and exploitation on the one hand, and changing patterns of health and health services on the other. Her analysis maintains a distinctly Marxian twist in its interpretation of advances in medicine and improved medical care as either: (1) concessions to the working class, thereby ameliorating developed class struggle; or (2) a service ultimately on behalf of a dominant class whereby the need for a healthier, more reliable work-force is achieved through health care programmes and the like. As noted earlier in this chapter, a criticism of Doyal's book — and indirectly of Marxian theories linking dialectical materialism and problems within capitalist economic systems — is that the arguments are structured to minimize or overlook health gains. Decreases in rates of infant mortality and increases in life expectancy of adults are two cases in point 5 1 Moreover, many of the problems associated with capitalist economies are present in socialist countries; for instance, smoking and cancer rates, infant mortality rates, and so forth. Hence, the possibility that capitalism has ushered in substantive gains in health is either not granted or is cast in terms of the interests of Capital rather than the populace. 5 0 See Linda Lim, "Capitalism, Imperialism, and Patriarchy: The Dilemma of Third-World Women Workers in Multinational Factories" in June Nash and Maria Fernandez-Kelly (eds.), Women, Men, and the International Division of Labor, 1983, Albany, State University of New York Press, p. 83. 5 1 These points are elaborated in a review of Doyal's book. See Nicky Hart, "Is Capitalism Bad for Your Health?", British Journal of Sociology, 1982, 33(3), 435-443. 46 Law and the Regulation of Health Care The specific appartatus of law is a critical factor in promoting and discouraging initiatives in health care. Subsidization of research and formal education are forms of promotion, while restricted access to (medical insurance) billing numbers and prosecution of practitioners serve to deter some workers or to limit their practices. Legal mechanisms are a pervasive and decisive force in the restructuring of health care, including maternity and infant care. Theoretical work on the sociology of law, as with State theory, is complex and often contradictory. Spitzer reviews the emerging theories of law that move beyond simple instrumentalism and economism. " Structuralism (exemplified by Althusser) and Culturalism (exemplified by E.P. Thompson) are the major, competing theories. Both attempt to redefine the nature of relationships between human actors, external structures, and law. A structuralist tenet is that although law is in some sense relatively automous, along with other superstructural features of society, the vectors of legal action are ultimately traced back to the economic system. The reformulation of this structuralist approach by Poulantzas involved a recognition of the role of law as an. apparatus that preserves "real rights" of dominated classes. These rights are embedded within a dominant ideology; consequently there is an overlap between justice and domination. Thompson's emphasis on cultural factors involves an appreciation of the interplay of superstructure and economic infrastructure, as well as a more fundamental critique of the formulation of infrastructure and superstructure. Law is conceived as more than an influence on the material base of society. It is an integral part of the material base. 3 3 " Steven Spitzer, "Marxist Perspectives in the Sociology of Law", Annual Review of Sociology, 1983, 9, pp. 103-124. 5 3 Ibid., p. 109. 47 The relationship between law and the state has thus undergone a contemporary reevaluation among Marxists and neo-Marxists. As Spitzer indicates, the shortcomings of legal economism and of structuralism have generated a more vital paradigm of law in which law is portrayed as created out of an "ideological pool" comprising beliefs, and assumptions from all social classes. In turn, the relatively autonomous role of the State - whereby the State is not governed by the will of a dominant class but preserves autonomous powers against direct interests of this class - • reflects the contradictory nature of legal ideology and the law as practice: 5 4 " ideology not only reinforces, enshrines, and legitimates the victories of the capitalist order, it also registers and presages its defeats.... the contradictory nature of law threatens to destroy the symmetry and closure of a Marxism that refuses to acknowledge its mediative and transitory character." Other radicals have also been concerned with the hidebound quality of Marxist orthodoxy. Some suggest that modern families can be a site in which progressive interactions can replace patriarchial ones, in which intimacy, cooperation, and child-rearing can exist within a feminist and socialist context 5 5 Eisenstein portrays the State as an agency containing radical alternatives, including radical feminism. 5 6 The State is structured such that it cannot allow women's equality with men. The "sexual ghetto" of lower-paid occupations is one instance of sexual stratification that the State - as employer and arbiter of social conflicts - perpetuates. Through the agency of law, the State mystifies what women are and what they do. It serves to constrain people's actual options. Yet it can establish "positive rights". In keeping with the 19th century feminist strategy of Elizabeth Cady Stanton, then, Eisenstein recognizes the political power of the State over women while endorsing struggles to secure the recognition of the 5 4 Ibid, p. 117. 5 5 Linda Gorden and Allen Hunter, "Sex, Family and the New Right: Anti-feminism as a Political Force", 1977/78, Radical America, 12 (1), p. 19. " Eisenstein, ibid., 1981, New York, Longman. 48 State. Other writers appreciate the role of pressure groups which maintain a critical focus on public policies. 5 7 In summary, liberalism and conservatism have largely shaped the development of health care practice in Canada. The current interest in cost-containment reflects the waning of liberal programmatic expansion. As such, the State has become more of a gatekeeper, monitoring expenditures and implementing cutbacks in services and layoffs of personnel. The economic underpinnings of this have been addressed through radical perspectives on the State and economy. Here, however, significant disagreements on State theory and political practice emerge within those viewing the State critically. The extent to which alternative health care systems can emerge alongside traditional ones is a cardinal issue. 5 8 Some have pointed to a cultural critique of organized medicine and high technology health care. Others see cultural reactions as flowing from structural features of the economy. Structuralism cannot be equated with predetermined relations, however, for a structuralist premise is that the State remains "relatively autonomous". The State is responsive to various sectors but nevertheless uses its semi-autonomous powers to secure the interests of powerful groupings, among them the medical profession. Theoretical and empirical studies of midwifery illustrate the nature of State intervention in restructuring health care occupations and suppressing the controversy over alternative maternity care. It will be argued that the State is not a neutral party in the controversy, but that it retains a level of relative autonomy from the contesting parties. 5 7 The value of these "ginger groups" (pressure groups) is articulated in Doris Lessing, "Prisons We Choose to Live In", The Canadian Forum, 1986, 65(754), p. 15. 5 8 See for example Donald E. Mills and Donald E. Larsen, "The Professionalization of Canadian Chiropractic" in D. Coburn et al, (eds.), Health and Canadian Society: Sociological Perspectives, 1986, Toronto, Fitzhenry and Whiteside, pp. 237-250. 49 The Midwifery Movement and the Canadian State Midwifery practice is a complex phenomenon in Canada and other industrialized societies. Legal regulation of birth attendance influences all forms of midwifery, but most dramatically community midwifery. Recent criminal trials have been launched against community midwives, and prosecutions for violations of provincial Medical Acts have also been undertaken. The historical depiction of midwives has been stereotypical: witch, harridan, meddlesome woman. 5 9 A closer look at contemporary midwives in B.C. indicates that they are not easily stereotyped: midwives vary in experience, professional training, and philosophies of birthing and politics. There are however several points of agreement among midwives. First, there seems to be a general agreement that pregnancy is not synonymous with illness. Morbid situations will develop, but birth can generally be managed skillfully and safely without current levels of obstetrical intervention (often recast as obstetrical interference). Second, it is recognized that the midwife can operate more autonomously than is currently provided under provincial law (which requires the direction of a physician, or his/her delegation of responsibility where applicable). The dependent status of midwives is thus generally seen as artificial. This perception is often linked with the economic interest of physicians in attending birth and the sense of control that some physicians (especially male physicians) prefer to employ over parturient patients and the nursing staff that assist doctors in childbirth care. 6 0 Third, women's right to be informed and to make decisions about maternity care is vital to the midwifery debate. Fourth, a sense of iatrogenic (physician-related damage) practice is often 5 9 See for example, Jean Donnison, Midwives and Medical Men: A History of Inter-professional Rivalries and Women's Rights, 1977, London, Heinemann; Joan Biggar, "When midwives were witches - white ones of course: A look at Maternity Care in the Middle Ages", Nursing Mirror and Midwives" Journal, 1972, 134(21), pp. 37-39. 6 0 Suzann Buckley, "Ladies or Midwives? Efforts to Reduce Infant and Maternal Mortality" in Linda Kealey (ed.), A Not Unreasonable Claim: Women and Reform in Canada, 1880s-1920s, 1979, Toronto, The Women's Press, pp. 131-149. 50 brought forward. Reliance on such procedures as the lithotomy (prone) delivery position, drugs to induce labour and to relieve pain, lack of continuity of care (throughout the prenatal period, labour, delivery, and postpartum), and the overarching ideology that birth is a medical event, are seen as contributing to substandard maternity care. Differences within the movement occur at various points. First, there is an ongoing debate over the importance of nursing training as prerequisite to midwifery training. Others favour direct entry into midwifery that incorporates some aspects of orthodox nursing curricula, while others maintain that formal criteria are not a necessary condition for midwifery practice. Second, there has been a movement toward establishing guidelines (or standards) for practice. Most midwives' associations have developed guidelines for practice. These guidelines may require that members do not manage breech presentations or twins at home, that women are to be transferred to hospital if their amniotic fluid is discoloured (this may be a sign of fetal distress) or if the fetal heart rate falls or rises sharply,and so forth. A few midwives believe that such contraindications to midwifery management are unnecessary controls on the midwife's judgement Another point of disagreement involves the necessity of midwives working with physicians and the delegation of ultimate responsibility for maternal and infant welfare to physicians. The traditional division of responsibility between nurses and physicians involves delegation of primary responsibility to the physician. 6 1 A counter-position is that midwives can work independently of physicians, at least in cases of uncomplicated deliveries. 6 2 The author's fieldwork on midwifery in British Columbia allows a few impressions on the sources of support for community midwives. First, community midwives are able to avail 6 1 For an example of this with respect to domiciliary births, see College of Nurses of Ontario, "Guidelines for Registered Nurses Providing Care to Individuals and Families Seeking Alternatives to Childbirth in a Hospital Setting", 1983, Toronto, College of Nurses of Ontario, (Typescript mimeo). 6 2 Vicki van Wagner, "The Current Politics of Midwifery in Ontario", Paper Presented at the 20th Annual Meetings of the Canadian Sociology and Anthropology Association, University of Guelph, 1984. 51 themselves of a variety of resources in conducting their work. There are legal resources available to them through legal advice, sometimes connected with litigation, and sometimes not. Likewise, there are legal defences available to midwife-defendants. As demonstrated by recent criminal prosecutions of the Halifax midwives and the birth attendant in Victoria (see below), these defences have been successfully employed against criminal charges. The various court-situated contests over midwifery and birth-related issues have been accompanied by some political support from opposition parties. In Ontario and British Columbia, for example, the provincial New Democratic Parties - through caucus or private member's bills - have supported the legalization of midwifery in their provinces 6 3 The National Action Status on the Committee of Women also passed a resolution in 1984 in support of midwifery legalization in Canada. 6 4 Second, many practicing midwives are aided by the material and emotional support of "significant others" - spouses, other midwives, neighbours, family members - which allows them to practice midwifery alongside other responsibilities of income, child care, and the like. Third, resources can be mobilized if a midwife is threatened with legal action. In one instance recounted to the author by a Lower Mainland midwife, the threat of prosecution for the unlawful practice of midwifery under the Medical Practitioners Act was not followed through, ostensibly because as a politicized midwife she was prepared to muster considerable support in defence of community midwifery. 6 5 Fourth, midwives do work in conjunction with sympathetic physicians and other personnel with respect to back-up and transfers of women into hospital. Fifth, midwives do utilize various forms of medical technology (oxygen for rescuscitation, sutures for tears) and a variety of communications devices (the ordinary telephone, message recorders, "beepers") to 6 3 Dave Cooke, "Government Should Recognize Midwifery", N.D.P. News, December 4,1984, p. 30; Robert Stephens, "Ontario midwives merit legal status, NDPer says", The Globe and Mail, March 16, 1984, p. 4. 6 4 Lois Sweet, "Midwives are Battling for their Freedom", The Toronto Star, April 8, 1985, p. CI. " This episode is outlined in Chapter Five. See also Brian Burtch, "Community Midwifery and State Measures", Contemporary Crises, 1987 (in press). 52 contact other midwives, clients, and so forth. Community midwives have also developed the resource of media exposure, through letter-writing campaigns to newspapers and contributions to such periodicals as The Maternal Health News . Increased income is another resource. Fee increases for birth attendance are especially important in light of the relatively low incomes generated by community midwifery and the economic strain on family earnings. Apparently, the "service" orientation of the mid-1970s has been succeeded by higher fees (approximately $600 for prenatal, labour and delivery, and postnatal care). These resources must be placed in a larger context of midwifery containment Community midwives are liable to quasi-criminal prosecution for the unlawful practice of midwifery, they are occasionally faced with the real possibility of criminal prosecution, their personal incomes are far below that of physicians and below that of obstetrical nurses working full-time. Nurse-midwives face constraints in existing law and the policy position of their College and the College of Physicians and Surgeons. Recent initiatives to practice midwifery on a more autonomous footing required the unpaid involvement of nursing professionals on the Low Risk Clinic in Vancouver. There has also been a reluctance to recognize midwives as midwives (since midwifery is seen as a physician's monopoly under current legislation); at one point recently there was an unsuccessful attempt to define trained midwives as "primary care perinatal nurses". The practice of midwifery is, for the most part, both constrained and facilitated through its legal status. A key element in the involvement of the State - through its legal powers -in what was previously a localized, neighbourhood event in North America, has been the assumption that midwifery practice is intrinsically more hazardous than physicians' attendance. A related assumption is that midwives require supervision by physicians, although legislation such as the 1902 Midwives' Act in England has established a basis for self-regulation by midwives to a considerable degree. A second assumption is that legal constraints on midwives 53 emerge from a public consensus on the appropriateness of restricted birth practices. Unlawful Practice of Medicine: Quasi-Criminal Law The customary assistance of women in childbirth has generally been replaced by a professional monopoly on birth attendance. In 19th century Ontario, for instance, the right to practice midwifery (independently of physic or surgery) was eventually restricted to medical practioners. 6 7 Enforcement was problematic at this time due to the limited number of doctors and the lack of doctors in what was then a predominantly rural region. Nevertheless, section 49 of the Ontario Medical Act held that: 6 8 "It shall not be lawful for any person not registered to practise medicine, surgery or midwifery for hire, gain, or hope of reward, and if any person not registered pursuant to this Act, for hire, gain or hope of reward practices or professes to practice medicine, surgery or midwifery, or advertises to give advice in medicine, surgery, or midwifery, he shall, upon summary conviction thereof before any Justice of the Peace, for every such offence, pay a penalty not exceeding $100 nor less than $25." An important qualification at this point in legal regulation was that the alleged illegal practices must encroach on medical practice, and that isolated episodes would not sustain a conviction. As Garrow, J.A. indicated: 6 9 "The thing practised must, to be illegal, be an invasion of similar things taught and practised by the regular practitioner, otherwise it does not affect the monopoly, and is outside the statute. And it must be practised as the regular practitioner would do it -that is, for gain, and after diagnosis and advice. And it must be more than a mere isolated instance, which is sufficient to prove a 'practise'". 6 6 There is little evidence that women are largely favourable to the elimination of midwifery services or great limitations on midwifery practice. See for example Peter Howitz and Jytte Ussing, "(Delivery at Home or at an Institution? An Analysis of the preferences of 5,240 Danish women concerning the place of delivery)", Ugeskrift For Laeger, 1978, 140(26), pp. 1569-1573. 6 7 The takeover of birth attendance was not so one-dimensional. The right of women to practice midwifery without a license was recognized in the First legislation passed in Upper Canada. See Biggs, op ciL 6 8 Biggs, op ciL 6 9 Re Ontario Medical AcL 1906, p. 513. 54 The obligation to prove more than a single act had been upheld in a number of precedents. The conviction of a Toronto midwife under section 49 of the Ontario Medical Act was reversed on appeal. The Appeal Court found that the Crown had not established that the midwife had practised medicine on more than one occasion, and further that she had not always received financial gain through her actions. 7 0 The necessity to prove that financial gain was received and that the illegal practice of medicine occurred repeatedly was crucial in the acquittal of another accused person. 7 1 The judge held: "Before an accused person can be convicted of falsely pretending to heal the sick, it is necessary that it be shown that the accused was in the habit of so pretending, or at least that there had been continuous treatment, the principle being the same as practising medicine for gain or hope of reward. An isolated case is not sufficient to secure a conviction". A subsequent decision by Justice Simmons confirmed that a single act does not constitute the practise of medicine or a trade. 7 2 Nonetheless, as the State has deliberated over birth-related law, this criterion for an offence has been broadened. In Ontario, the common law rule that "practice" implied repetition of the offending act was altered. A single act was deemed sufficient to establish the practice of medicine. Nevertheless, the prosecution of midwives was not always successful. One criminal conviction of a midwife in the Northwest Territories was quashed on appeal. The Court held that section 60 of the Medical Profession Ordinance did not include "midwifery" as a form of practice to be covered along with "medicine" and "surgery". Since section 60 had been composed with reference to the earlier Ontario Medical Act - which prohibited midwifery, medical, and surgical practice by unregistered persons - the Court reversed the conviction. 7 3 7 0 Regina v. Whelan, (1900) 4 Canadian Criminal Cases, p. 277 [Ontario]. 7 1 Regina v. Armstrong, (1911) 18 Canadian Criminal Cases, p. 72 [Saskatchewan]. 7 2 Regina v. Cruickshanks 6 Western Weekly Reports, 1914, p. 524; Alberta Law Reports, 92; 23 Canadian Criminal Cases p. 23; 16 Dominion Law Reports, 536 [Court of Appeal]. 7 3 Regina v. Rondeau, 5 Territories Law Reports, pp. 478-483. 55 Legal prohibitions on the practice of medicine thus serve to protect unregistered practitioners to a degree. In another case, an orderly accused of practising midwifery and with practising medicine, both for "hope of reward", was acquitted on both counts. The court held that the accused orderly had assisted a woman following delivery when no doctor was available to her; that is, he acted under emergency circumstances and did not attempt to charge for his attendance. On the second count, although the accused had on two occasions filled in blank prescription forms, taken patients' temperatures, and given instructions as to treatment, there was no proof of payment or a request for payment by the orderly. 7 4 The corollary is also true: persons practising medicine on more than one occasion and seeking payment for their advice could be convicted. 7 5 About two decades later, in a case heard in Saskatchewan, Justice Trant declared that the rights of unregistered practitioners are limited and sharply defined. They must not offer diagnosis, give advice, or prescribe medicines. 7 6 The practice of midwifery in British Columbia is legally protected as the bailiwick of medical practitioners. Section 72 of the British Columbia Medical Practitioners Act stipulates that: "(1) A person who practices or offers to practice medicine while not registered or while suspended from practice under this Act commits an offence. (2) For the purposes of and without restricting the generality of subsection (1), a person practices medicine who... (d) prescribes or administers a treatment or performs surgery, midwifery or an operation or manipulation, or supplies or applies an apparatus or appliance for the cure, treatment or prevention of a human disease, ailment, deformity, defect or injury.... [emphasis added]". 7 4 Regina v. Ornavowski 1, Western Weekly Reports, (1941), p. 103 (Saskatchewan). 7 5 Provincial Medical Board v. Bond (1890), 22 N.S.R. 153 (C.A.). The County Court decided in favour of the defendant following a charge under the Medicine and Surgery Act of 1884. The defendant had treated people with plaster and given advice on the use of poultices for people suffering from tumours and cancer. On appeal, however, the initial judgement was reversed: a penalty of $20 for one day's practicing and court costs were imposed on the defendant. 7 6 Regina v. Raffenberg 12 Western Law Reports (1909), p. 419. 56 Again, it is important to note that alternative practitioners may be acquitted on charges of unregistered practice of medicine. In Wong the court held that the art of acupuncture was not recognized as a branch of medicine by the Alberta College of Physicians and Surgeons. Moreover, acupuncture was not taught in North American medical education. 7 7 A later conviction of an acupuncturist in B.C. occurred despite the reasoning in Wong. It was held that the defendant had violated the B.C. Medical Practitioners Act. Under section 83 of the Medical Practitioners Act, the minimum penalty for a first offence of practicing medicine or midwifery is $100 or imprisonment (section 87). It is set at $300 or imprisonment for a second conviction, and imprisonment for a third or subsequent conviction. It must be kept in mind that the court has the power to dismiss charges against defendants when the information is insufficient. In one instance where a defendant was charged under the British Columbia Medical Act the information alleging the unlawful practice of medicine was quashed since it failed to set forth the act or acts constituting the alleged offences and failed to name the persons with whom the defendant was alleged to have unlawfully practised medicine 7 8 Under section 73 there are several exceptions to the broad ambit of medical practice set out under section 72. The following practitioners do not practice unlawfully while registered under their respective Acts: chiropractors, dentists, naturopaths, optometrists, pharmacists, podiatrists, psychologists, nurses, and dental technicians. Orthoptic technicians, physiotherapists, and dieticians may also be exempt from section 72. The legal standing of these practitioners, and their self-regulation through professional associations reinforces, qualifies the purely instrumentalist approach to medicine as an elite profession that is able to monopolize health services. Emergency procedures are permitted under the Health Emergency Act. Domestic administration of family remedies is permitted, and religious practitioners "...who 7 7 Regina v. Wong (1979) 6 Western Weekly Reports (Provincial Court), p. 163. 7 8 See Regina v. Kripps (1977) 4 British Columbia, Law Reports, (Provincial Court) 364. 57 practise the religious tenets of their church without pretending a knowledge of medicine or surgery" are exempted under section 74 of the Act Liabilities associated with childbirth become even more complex when one considers the liabilities of parents. In the United States the parents' duty of care has traditionally begun with the birth of the child: there has been no obligation on the part of the mother, for instance, to seek medical assistance prior to the birth of a child. Nevertheless, there appears to be a shift in legal opinion whereby "parental" failure to obtain medical care in circumstances where such care is clearly warranted ought to be culpable. 7 9 Parental liability is also at issue with respect to responsibility surrounding midwifery attendance in jursidictions where it is illegal. One midwife stated that the choice of a birth setting - and, by extension, the choice of birth attendants - is the responsibility of the expectant mother. 8 0 A number of prenatal documents examined by the researcher also contained a waiver, signed by the mother (and father, where applicable), which did not hold the midwife legally responsible. Members of the Freemont Birth Clinic linked their philosophy of parental responsibility and decision-making with a non-hierarchial approach to birth management: 8 1 "Working as a team throughout pregnancy and labor, prospective parents and workers all share in the responsibility for the situation. The woman who is pregnant or in labor, and her support people, are the ones who ultimately make the decisions about what to do, how to proceed. Especially because we're not certified in any way, we're concerned that people analyze their level of comfort working with us. We encourage people to educate themselves as much as possible, consult the statistics we have kept, ask us lots of questions, talk to others who have experienced obstetrical care in other settings, and to make conscious decisions to really think about what they want and to make intelligent judgements". 7 9 For a review of American litigation on this point see George Annas, "Legal Aspects of Homebirths and Other Childbirth Alternatives", in David Stewart and Lee Stewart (eds.), Safe Alternatives in Childbirth, 1977, Chapel Hill, NAPSAC, p. 180. 8 0 Sandra Klein, A Childbirth Manual, 1980, Victoria, British Columbia (Typescript mimeo). 8 1 Freemont Birth Collective, "Lay Midwifery - Still an 'Illegal' Profession", Women and Health, 1977, 2 (3), pp. 19-27. 58 On another level, legal actions are conventionally brought against the birth attendant, not the expectant mother. This locus of responsibility avoids a direct confrontation with parental rights, at the same time locating the legal conflict as essentially a property dispute pertaining to occupational licensure. Legal protections for unborn children have also been strengthened. In Canada and in other industrialized countries the unborn child has been vested with certain rights. As mentioned below, the Marsh case in British Columbia included a decision that a child at term — but not expelled from the mother — was a person and entitled to protection. As the "human status" of the infant has been secured, 8 2 there appears to be a rise in litigation in the event of injury or death to fetuses or infants. The conjuncture of medical knowledge and legal protection of medical practice is best suited to the structural motif of power. The mechanics of touch, palpation, measuring, and viewing of the pregnant woman or fetus have become centred in hospital-based obstetrics, and other forms of practice have been largely excluded. Professional interests are thus protected, even as there has been some erosion of the monopoly status of physicians under quasi-criminal statutes. Criminal Prosecution of Birth Attendants The Canadian Criminal Code stipulates that criminal negligence occurs when a person, either through commission or omission, shows wanton or reckless disregard for the lives or safety of other persons. The omission or commission must be associated with something that is his or her duty to do. Section 203, "Causing Death By Criminal Negligence", states: 8 3 "Every one who by criminal negligence causes death to another person is guilty of an indictable offence and is liable to imprisonment for life." 8 2 See Dana Raphael, "Matresence, Becoming a Mother, a 'New/Old' Rite de Passage" in D. Raphael (ed.), Being Female, op cit., p. 67. 83 Martin's Annual Criminal Code, Toronto, Carswell, 1984, p. 212. 59 The criminal prosecution of midwives, while less prevalent than civil actions launched against midwives, is nonetheless crucial to an understanding of legal encumbrances on midwives: criminal prosecution carries the possibility of severe dispositions, including life imprisonment in Canada in cases involving criminal negligence causing death. 8 4 Criminal actions against midwives have increased as home birth has become more prominent since the mid-1970s. The three recent cases outlined below involve an ex-physician and two midwives. No other reported cases of criminal prosecution of non-physician birth attendants were found in the search of legal cases or cases cited by the trial lawyers. Regina versus Marsh (1979) A major trial concerning home birth attendance in British Columbia is the prosecution and acquittal of a spiritual healer (and former doctor) on a charge of criminal negligence causing death. In Marsh an infant death was attributed to cerebral haemorrhage due to a tear in the tentorium of the skull. This tear was in turn associated with malpresentation of the fetus at term. 8 5 The legal actions which followed this infant death were two-fold. First, a charge of criminal negligence causing death was laid against the birth attendant, a former physician who had been dropped from the rolls of the College of Physicians and Surgeons of British Columbia. Second, following her acquittal of the above charge, a quasi-criminal charge of Practicing Medicine Without a License - a contravention of the British Columbia Medical Practitioners Act was successfully brought against the defendant 8 6 In his "Reasons for Judgement" Judge Millward concluded: 8 7 8 4 The three main classifications of criminal negligence in Canada are criminal negligence causing death (section 203), bodily harm (section 204), and in the operation of a motor vehicle (section 206). See Paul Bourque, "Proof of the Cause of Death in a Prosecution for Criminal Negligence Causing Death", The Criminal Law Quarterly, 1980, 22 (3), pp. 334-343. 8 5 Regina v. Marsh (1979) 8 6 Greg Mclntyre, "Midwives Ask for Sanction of Law", The Province, February 18, 1983. 8 7 Peter Millward, "Reasons for Judgement", Regina v. Marsh 1980, Victoria, County Court of British Columbia. 60 "...Mrs. Marsh first became aware of the unusual and dangerous position of the child when the first foot appeared. By then, the evidence clearly shows it was too late to save the child from the injury that it suffered, or at least on the evidence, it is most unlikely, given the situation, that is a lack of skilled personnel present, the distance in time and space from the hospital, and the lack of any previous arrangements having been made ...On that finding, and with reference to the acts or omissions of Mrs. Marsh from the point in time when the foot first emerged, there cannot be a finding of criminal negligence causing death arising out of those acts or omissions, and accordingly, if any criminal liability is to be attached, it must be found in her acts or omissions prior to that point in time.... a most important point, in my view, is that there is no evidence whatever of any doubt, in the mind of Mrs. Marsh as to the position of the child at that point Accordingly, while Mrs. Marsh may have been incompetent, yet I am faced with the evidence of eminent authorities called both by the Crown and by the Defence, to the effect that even the most expert and experienced practitioners do make mistakes from time to time in detecting the position of fetuses in circumstances similar to those which were obtained here. I am faced with that clear evidence and a total lack of any positive evidence of a wanton or willful disregard. I am unable to conclude that any act or omission of Mrs. Marsh, prior to the emergence of the foot was indeed negligent, and certainly I am unable to conclude that it was criminally negligent" A key decision in the Marsh trial involved whether an infant at term, but not yet expelled from the mother, could be deemed a "person" for purposes of the Criminal Code. In an earlier case, 8 8 an award for the loss of a child not born alive was denied. In the judgement, a human being was described as an entity which has proceeded completely out of the mother's body. 8 9 In Marsh, Judge Millward held that a fetus at term, but not yet expelled, could be considered as a person for purposes of the Criminal Code. 9 0 "The essential nature of the organism, that is the fetus, is not changed by the fact of birth, and to hold that prebirth criminal negligence causing death of a fetus immediately after birth is an indictable offence, while similar negligence causing death immediately before delivery is not criminal, is not a conclusion that accords well with the concept that the State has a duty to protect unborn children and to preserve their 8 8 Lavoie v. Cite de Riviere-du-Loup et Autre (1955) C.S. 452 (1955) (Quebec S.C.). 8 9 Glanville Williams also spoke of the "conditional legal personality" of the unborn child, and that claims of defendants for negligence injuring unborn children crystallize after the child-plaintiff is born alive. See Alec Samuels, "Injuries to Unborn Children", Alberta Law Review, 1974, 12, p. 266. 9 0 Reasons for Judgement of His Honour Judge Millward, Regina v. Margaret Lillian Marsh, County Court of Vancouver Island, November 7, 1979, pp. 14-15 (trial transcript). 61 opportunities to be born and to enjoy the rights and obligations normally incident to the status of human kind." Regina versus Carpenter et al. (1983) Since the 1980 decision in Marsh, three midwives faced criminal prosecution in Halifax. The three defendants, were charged with criminal negligence causing bodily harm on January 27, 1983 following the transfer of an infant to hospital. This charge was later raised to criminal negligence causing death in the summer of 1983, a few weeks after the infant's life support system was disconnected. At the preliminary inquiry to determine whether the defendants would be brought to trial, Judge Gunn decided that the women would not be brought to trial due to lack of evidence. Witnesses at the preliminary inquiry made three key observations: first, that the infant suffered a hemorrhage to the portion of her brain that governed breathing; second, that this injury was not attributable to the midwives' care; and third, that similar injuries have been noted among babies delivered in hospital settings under medical care. 9 1 Regina versus Lemay and Sullivan (1986) Two Vancouver midwives were charged with criminal negligence causing death, assault, and other charges following the death of a baby girl on May 3, 1985 in Vancouver. These charges followed the transfer of a mother and unborn child to hospital following an attempted delivery of a shoulder dystocia. This situation in which the oblique diameter of the pelvic inlet is smaller than the bisacromial diameter - is regarded as an "obstetric emergency" along with other forms of dystocia. 9 2 9 1 Alternative Birth Crisis Coalition, "News Analysis - Canada: Midwives on Trial", ABCC News, 1984, 111 (3), pp. 3-4. 9 2 See Jensen et al., op cit, pp. 492 and 505. 62 As expected, the parents were reported to be supportive of the attending midwives. 9 3 In contrast to other cases, however, the two midwife-defendants were found guilty on the charge of criminal negligence causing death. The midwives were ordered to perform community service, to refrain from attending births, and to be on probation for two years. Expert witnesses called by the Crown were critical of their management of the birth, and the trial judge encouraged greater regulation of midwifery practice in British Columbia. Inquests into Infant Deaths The McLaughlin-Harris Inquest (1984) The death of Daniel McLaughlin-Harris in October 1984 in Toronto, Ontario was followed by a provincial inquest into the infant's death. Two midwives had attended the mother in labour at a Toronto Island residence. The baby was born asphyxiated and transported to The Hospital for Sick Children by one of the midwives. The inquest dealt with the viability of midwifery as an independent profession, along with the causes of the infant's death. The Coroner's jury made several recommendations to alter the status of midwifery in Ontario. First, it was recommended that the Ontario Health Disciplines Act be rewritten to specify what constitutes midwifery practice and strict penalties for illegal practice be provided for practice outside the Act Second, that midwifery should be undertaken as a specialty practice under the College of Nurses of Ontario; after .five years, an independent College of midwives should be established. Third, that midwifery training should be set at international standards and taught at accredited post-secondary institutions. It would require at least two years' midwifery training and a year of general nursing. Fourth, that licenced midwives should be given hospital privileges in maternity wards. Fifth, that the Ontario Health Insurance Plan 9 3 Sullivan-LeMay Legal Action Fund, "Bulletin and Trial Update", Vancouver, B.C., September 1986. 63 coverage should be available for midwives and that malpractice insurance should be compulsory'. Sixth, that birthing centres should be established in hospitals. Seventh, that the option of home birth attendance should be available within the Ontario health care system. Finally, that the College of Physicians and Surgeons should establish safety standards for home births. Doctors should be free from censure by their colleagues if they attend home births. 9 4 Criminal Negligence and Physicians Canadian case law reveals few instances in which charges of criminal negligence causing death have been brought against doctors attending births. There are cases involving illegal abortions, for example, but a search of Canadian legal periodical indexes, and discussion with trial lawyers, did not yield many instances of physicians tried for birth-related criminal matters. In Simard the conviction of a physician for criminal negligence was quashed on appeal to the Quebec Court of Queen's Bench. The newborn child died of a cerebral haemorrhage a few days following delivery by forceps. Nevertheless, the Appeal Judges clearly felt that the facts of the case did not warrant the jury finding of guilt. These facts included the wish of the mother to not be delivered in a hospital but rather at a clinic, her failure to follow Dr. Simard's suggestion of an X-ray for suspected cephalo-pelvic disproportion, and the mother's departure from the birth setting against the doctor's advice. The Court also accepted expert testimony vindicating the use of chloroform and forceps and rejected contrary opinion on this point 9 5 9 4 Anne Besharaw, "Jury recommends legalization, recognition of midwifery in Ontario", The Canadian Nurse, September 1985, p. 11. 9 5 Simard v. The Queen 43 Criminal Reports (Canada), 1964, pp. 70-82. It seems that deaths of infants in hospital or clinic settings with attendance by medical or nursing personnel are generally followed by internal hospital reviews. In some instances physicians may lose their hospital privileges or be struck from the College rolls. In few cases, however, are physicians 64 A subsequent case in which a physician was convicted of criminal negligence causing death arose out of the death of a child. The young boy had been put on a very low protein diet for treatment of a skin condition. The boy lost weight and died in hospital due to gross malnutrition. In dismissing an Appeal by the accused, the principle of competency required by law was reaffirmed: 9 6 "In enacting s. 187, Parliament has imposed a legal duty upon every one who undertakes to administer medical treatment. Included in that legal duty is to have 'reasonable knowledge' in doing so. The essence of that 'reasonable knowledge' was that a physician (which Rogers was) should have foreseen the harmful consequences of depriving the child of proteins and calories in the circumstances. Regardless of his personal theories, Rogers was under a duty to have that foresight It was, therefore, irrelevant for the jury to consider Rogers' own belief that his diet was a beneficial treatment" Civil Suits against Birth Attendants Malpractice suits against physicians are proportionately smaller (on a per capita basis) in Canada than in the United States. While 20,000 malpractice suits were launched in the United States in one year, only 200 to 300 were initiated in Canada. 9 7 Another author, using data from the Canadian Medical Protective Association, reported that between 1966 and 1970 the number of monetary settlements against its members averaged 18 per year; in 1971, only 22 monetary settlements resulted from 131 writs against its members. 9 8 In a 1981 case following hypoxia of an infant in a Vancouver hospital, a provincial Supreme Court Justice ordered payment of unspecified damages to the family. The nursing "(cont'd) faced with criminal charges. 9 6 Regina v. Rogers, (1968) 4 Canadian Criminal Cases, p. 299. 9 7 David Coburn, "Patients' Rights: A New Deal in Health Care", The Canadian Forum, 1980, 60 (699), p. 14. 9 8 Ronald Maclsaac, "Negligence Actions Against Medical Doctors", Chitt/s Law Journal, 1976, 24 (6), p. 204. 65 care afforded the mother was deemed below the expected standard of care and the attending physician failed to establish the progress of labour before prescribing pain killers. Lack of suctioning equipment in the emergency bundle and the absence of attending staff for a 30-minute period while the woman plaintiff was in labour were other factors in the decision. 9 9 Coburn suggests that judges in Canada are generally sympathetic to physicians because of a common status. 1 0 0 This notion of class affinity is developed further with respect to the British judiciary and the Canadian judiciary. 1 0 1 At the same time, there is little evidence of civil suits launched against community midwives by their "clients". It is noteworthy, however, that as American nurse-midwives have become established as professionals in institutional (hospital and clinic) settings, they are now increasingly subject to malpractice actions. 1 0 2 Conclusion There is ample evidence that dominant groups invoke their powers to exclude competing groups. The State is central to these exclusory attempts. It has the power to criminalize behaviour, to adjudicate civil matters, and to direct its financial resources to specific groups. 1 0 3 Hospital-based birth attendance is either directed by physicians or, less commonly, responsibility may be delegated to nursing personnel. Physicians' incomes (on average) remain well above average incomes for North Americans, while as a rule midwives' incomes are 9 9 "Grace Hospital, doctor faulted in baby's birth", The Vancouver Sun, April 7, 1981, pp. A1-A2. 1 0 0 Coburn, op ciL 1 0 1 See Miliband, op ciL; and Dennis Olsen, The State Elite, 1980, Toronto, McClelland and StewarL 1 0 2 Gail Sinquefield, "A Malpractice Dilemma: Defining Standards of Care for Certified Nurse-Midwives", Journal of Nurse- Midwifery, 1983, 28 (4), pp. 1-2. 1 0 3 For a critique of Parkin's theories of exclusory tactics see Anthony Giddens, Profiles and Critiques in Social Theory, 1982, Berkeley, University of California Press. 66 markedly lower, especially with respect to community midwifery. Concern has also been expressed over patriarchy in law, 1 0 4 not only in the struggle for the legalization of midwifery, but also in the regulation of other conflicts surrounding human reproduction. 1 Community midwifery in British Columbia and other regions is a concrete instance of resistance to medical dominance in managing childbirth and providing prenatal and postnatal care. As noted above, attempts to use the courts to prosecute midwives under the Criminal Code have not always been successful. Even quasi-judicial hearings such as Coroners' inquests do not automatically reinforce the authority of medical control over birth: two recent coroners' inquiries in Ontario recommended legal recognition of midwives and the establishment of a provincial School of Midwifery. 1 0 6 Legal struggles and the continuing dominance of physician authority in Canadian maternity care touch directly on the criticism of Western legal ideology for the adherence to formal, abstract equality of citizens despite substantive inequalities before the law. 1 0 7 Some socialist writers, while acknowledging the role of law in perpetuating inequality, have favoured the use of law as a form of political struggle. 1 0 8 In the health sector, some have favoured 1 0 4 Patriarchy has been defined as "...a specific organization of the family and society, in which heads of families controlled not only the reproductive labor, but also the production of all family members". See Gorden and Hunter, op cit., p. 12. 1 0 5 See Shelley A.M. Gavigan, "The Criminal Sanction as it relates to human reproduction", Journal of Legal History, 1984, 5(1), pp. 20-43. 1 0 6 Ontario Association of Midwives and the Nurse Midwives Association of Ontario, Brief on Midwifery Care in Ontario, 1983, Toronto, Ontario; Brief submitted to the Health Disciplines Review Committee [Typescript mimeo]. As indicated above, these constraints have been challenged by more autonomous midwifery projects in hospital and domiciliary settings, and there are contradictory decisions in criminal and quasi-criminal actions against birth attendants. 1 0 7 Isaac Balbus, "Commodity Form and Legal Form: An Essay on the 'Relative Autonomy' of Law", Law and Society Review, 1978, 2, pp. 571-588. 1 0 8 If midwifery is taken as one instance of a "rights struggle", then struggles for such rights as the right to abortion, prisoners' rights, redress of racial and sexual discrimination, and so forth are to be encouraged. The importance of such "rights struggles" and the democratization of the State have been articulated in maternity care, by many socialist writers. See for example: Colin Sumner, "The Rule of Law and Civil Rights in Contemporary Marxist Theory", Kapitalistate, #9, pp. 63-91; Piers Beirne and Robert Sharlet (eds.), 67 "democratic relativism" as a means of protecting unorthodox forms of medicine and healing, thereby permitting comparisons of the various forms of health care. 1 0 9 These struggles in maternity care should not overshadow the continuing protection of professional attendance and medical dominance in the Canadian context and elsewhere. A key consideration is to determine when midwifery practice is demonstrably as safe as (or safer than) conventional physician-managed, deliveries and when it may be more hazardous. This issue is addressed directly in Chapter Five. A related point concerns the role of the State in promoting or containing midwifery initiatives. Laws that largely buttress the professional dominance of obstetricians and general practitioners are one case in point By vesting policing powers with the Medical Colleges, and through the occasional prosecution of alternative practitioners, the implementation of safe, pluralistic maternity care services remains greatly constrained. The constraints on midwifery practice should not however overshadow the role of the midwifery and nursing professions in various countries in lobbying for recognition and resources. As set out in the discussion of nurse-midwifery and community midwifery, support has emerged from within the state and within the professions for implementation of midwifery services. Reconceptualizing midwifery as governed by the State also requires greater attention to the resources provided through the State. One of the difficulties with the oppositional ideology that appears among some community midwives is the bold line drawn between natural childbirth and obstetrical intervention, between spiritualism and science, and between home and hospital. The machinery of the State can be seen as emerging from popular concerns over safety and welfare, not simply from the logic of capital or the interests of specific professions. 108(cont'd) Pashukanis: Selected Writings on Marxism and Law, 1980, London, Academic Press. 1 0 9 Paul Feyerabend, "Democracy, Elitism, and Scientific Method", Inquiry, 1980, 23 (1), pp. 3-18. Implementation of pluralism has not been secured in Western public policy. See Kenneth McRae, "The Plural Society and the Western Political Tradition", Canadian Journal of Political Science, 1979, 12 (4), pp. 675-689. 68 The instrumentalist portrait of the State is further qualified by the requirements of due process and procedural rules. A variety of enactments including the Charter of Rights and Freedoms can and have been used to offset the potentially absolute powers of the State. Relevant to an understanding midwifery practice, the law of evidence and judicial rulings have generally not been helpful in prosecuting community midwives for criminal negligence causing death. Also, despite the hegemonic powers exercised by the State and the professions, the midwifery movement continues a tradition of collective self-help and opposition to professional control in health care. The State may attempt to "colonize all forms of existence" 1 1 0 but this attempt is not wholly successful. Chapter Three provides additional information on diversity of childbirth practices, including the status of midwives in global perspective. An important dimension that connects State theory with cross-cultural and historical materials is the need for specificity. Within liberal democracies there are countries such as Canada which have promoted an outiaw status for midwives, while other democracies have supported direct entry training of midwives and a broader sphere of practice for trained midwives active in Canadian hospitals. The theme of the relative autonomy of the State, evident in clashes within the Canadian courts and within legislatures, and also evident in this global perspective, captures the structuralists' premise that the State is used to contain initiatives from relatively powerless groups. This containment objective is nonetheless subject to change, and the sources of change emerge not only in Civil Society but within the very framework of the State. This is an apt theme in the Canadian context: whereas the monopoly status of medicine in childbirth reflects an instrumentalist perspective, there is evidence that the medical thrall is diminishing in North America as other health professions demand legal status. 1 1 1 1 1 0 Stuart Ewan, "Charlie Manson arid the Family: Authoritarianism and the Bourgeois Conception of 'Utopia': Some Thoughts on Charlie Manson and the Fantasy of the Id", Working Paper in Cultural Studies, Centre for Contemporary Cultural Studies, Birmingham, 1972, Volume 3, pp. 33-45. 1 1 1 David Starr, "Medicine and the Waning of Professional Sovereignty", Daedalus, 1978, 107(1), 175-193; David Coburn et al., "Medical Dominance in Canada in Historical 69 These modern conflicts surrounding monopolistic professional powers, safety of infants and mothers, and women's right to choose the place of birth and birth attendants, become understandable when two dimensions are considered: First, the historical dimension of control over childbirth; and second, cross-cultural variations in birthing practices, particularly in the role played by midwives. Chapter Three elaborates on these points, and the pivotal role of the State in shaping the directions of midwifery practice. m(cont'd) Perspective: The Rise and Fall of Medicine?", International Journal of Health Services, 1983, 13(3), 407-432. 70 CHAPTER III HISTORICAL AND CROSSCULTURAL PERSPECTIVES "Then the king of Egypt said to the Hebrew midwives, one of whom was named Shiph'rah and the other Pu'ah, 'When you serve as midwife to the Hebrew women, and see them upon the birthstool, if it is a son you shall kill him; but if it is a daughter, she shall live.' But the midwives feared God, and did not do as the king of Egypt commanded them, but let the male children live." Exodus, Chapter 1:15-16 "...And if there is a single piece of wisdom that has more humanity in it than any other it is this: befriend the womb." 1 Introduction Thousands of years have elapsed between the biblical account of the midwives' defiance of Herod and current conflicts over the State and midwifery. This chapter provides an overview of major developments in the evolution of midwifery worldwide. Two broad sections are included: first, the historical development of formalized midwifery practice in England, Continental Europe, the United States, and Canada; and second, crosscultural variations in midwifery and birthing customs. In virtually all cultures women have been responsible for assisting births, and birth attendance has involved the presence of kin and neighbours. Birth was thus a localized event, a community event in a sense. The advent of professionalized midwifery - in the wider framework of technological advances, centralization of maternity services, and formal bureaucratic structures - is a relatively recent transformation of the context of birth. 1 Hugh Hood, Reservoir Ravine, 1985, Toronto, General Publishing, p. 195. 71 Historical Perspectives on Midwifery "...there is an underside to every age about which history does not often speak, because history is written from the records left by the privileged. We learn about politics from the political leaders, about economics from the entrepreneurs, about slavery from the planatation owners, about the thinking of an age from its intellectual elite." 2 Midwifery in Europe The evolution of midwifery in Europe reflects technological advances in the medical sciences and the changing patterns of control through the professions and the influence of the State. These structural changes have contributed to the eclipsing of the traditional midwife by physicians, and their replacement by the nursing and nurse-midwife professions. As feminist writers have documented, this inclusion into what was, historically, a women's sphere, has produced the incorporation of women into maternity care. This incorporation means that reproduction is usually mediated and controlled by an elite of primarily male physicians. 3 Bohme traces four phases in the social history of European midwives. 4 The first phase, solidary aid, is traced to the very early days of mankind. Knowledge of childbirth was gained through personal experience of childbirth: giving birth was a necessary aspect of becoming a midwife. The concept of solidary aid underlines the communal involvement of women assisting other women during labour, delivery, and the post-partum period. The second phase is that of office. The ecclesiastical administration of life in the Middle Ages was extended to childbirth. Midwives were appointed and licensed by the Church so as to ensure 2 Howard Zinn, The Politics of History, 1970, Boston, Beacon Press, p. 102. 3 Ann Oakley, Women Confined: Towards a Sociology of Childbirth, 1980, New York, Schocken, pp. 8-10. 4 Gemot Bohme, "Midwifery as Science: An Essay on the Relation between Scientific and Everyday Knowledge," in Nico Stehr and Volker Meja (eds.), Society and Knowledge: Contemporary Perspectives in the Sociology of Knowledge, 1984, New Brunswick, Transaction Books, pp. 365-385. 72 that the moral character of birth attendants befitted the office. Attempts to thwart abortions, substitutions (i.e., changelings), and infanticide were made, paternity was established by midwives, and newborns were baptised by midwives. Midwives could not profit by their work. As Bohme puts it, the office of midwife sought "poor but honest" practitioners. 5 The third phase, traditional profession marked the transition from an assigned office to a clearer conflict between midwives and male physicians at the beginning of the eighteenth century. Surgeons and barber-surgeons, once restricted to performing Caesarean sections or extracting stillborn babies (or babies who could be removed otherwise), asserted their superiority via innovations such as the forceps and anaesthesia. The exclusion of women from the Universities and the development of Gynecology and Surgery further reduced the province of the appointed midwife. 6 The status of midwifery as a modern profession, self-regulating and licensed, now predominates in Europe. Specialized training of midwives, local and international Associations, and the conjuncture of theoretical and practical midwifery characterize this contemporary phase of midwifery. There has been a considerable literature on the historical development of midwifery in Britain. This section relies substantially on Donnison's comprehensive review of lay midwifery and the rivalries that ensued with the growth of professionalized medicine and nursing. 7 Midwives in the Middle Ages were likely to be middle aged, married women who had given birth. Personal experience was seen as an important qualification. The customary practice of lay midwifery was altered dramatically with the advent of surgeon's guilds in the thirteenth century. Surgeons were designated as the appropriate birth attendants for births in which natural delivery was not possible. Fifteenth century English 5 Ibid., p. 375. 6 Ibid., pp. 375-377. 7 Jean Donnison, Midwives and Medical Men: A History of Inter-Professional Rivalries and Women's Rights, 1977, New York, Schocken. 73 midwives were vilified as agents of the Devil but were not subjected to the Inquisitorial punishments to the same degree as midwives in Continental Europe. 8 Episcopal licensing was a form of midwifery regulation that influenced birth attendance. As noted earlier, midwives were to be of good moral character and they were obliged to see that babies were christened in accordance with Church doctrine. The licensing of physicians was vested in Church authorities in England in 1511, while the informal regulation of midwives by the Church was legalized in 1512. Power over birth attendants, particularly midwives, was thus transferred from the community and the parish and centralized at the Bishops' level in the Church hierarchy. 9 The combined weight of traditional community customs and of Church regulation was eventually offset by the growing power of the nation-State in England. This expansion can be linked with European political philosophy, and especially Liberalism, in which the mediating role of the State in human affairs was acknowledged. In Germany concerns were expressed about illiteracy and superstition among midwives, along with damages to infants and mothers by such practices as manually removing the placenta and incorrect cutting of the infant's frenum, the small ligament controlling the movement of the tongue. 1 0 These concerns led to formal regulations specifying the responsibilities of midwives and physicians in Germany. One of the ironies of late 15th century and early 16th century urban ordinances in Germany was that midwives were 8 Donnison, op ciL, p. 4. See Nacham Ben-Yehuda, "The European Witch-Craze of the 14th to 17th Centuries: A Sociologist's Perspective", American Journal of Sociology, 86, 1-31. 9 See William Ray Arney, Power and the Profession of Obstetrics, 1982, Chicago, University of Chicago Press, p. 22. Midwives were hindered by Church proscriptions on their conduct and by the lack of an internationally recognized knowledge base. This limited knowledge base contributed to the limited powers of community midwives in resisting the growth of scientific obstetrics developed in France and adapted in Britain. See ibid., pp. 21-29. 1 0 For a general critique of the motif of European lay midwives as respectful of the natural course of childbirth see Edward Shorter, A History of Women's Bodies, Toronto, University of Toronto Press, 1982(??). 74 required to summon physicians for advice or direct assistance in complicated deliveries.11 Control of German midwives was often more direct Witch-hunting resulted in the executions of thousands of midwives, and it appears that those without an affiliation with a male were especially vulnerable to witch hunts. 1 2 The critique of lay midwives was also present in France. As Theophile Roussel indicated in 1874, many birth practices of the day were seen as unenlightened, and the menace of untrained midwives was decried: 1 3 "Notwithstanding the disinterested counsel of physicians and enlightened persons, the force of habit, the brutish stubborness of the peasants, and the foolish advice of the midwives maintain practices that are fatal to children whose health needs are poorly attended to...." In France the government also established midwifery instruction at the Hotel Dieu Hospital in Paris. Donnison concludes that government intervention was to the benefit of French and German midwives. Government-subsidized instruction was however lacking in England in the eighteenth century and charitable institutions were not greatly involved in promoting improved midwifery practice. 1 4 The growth of State authority served to mediate the growing rivalry between traditional, female midwives and the men-midwives who aspired 1 1 It is noteworthy that earlier regulations required midwives to consult with other midwives when complications arose. Nevertheless, by the beginning of the 17th century midwifery had become an inferior occupation while the status of physicians had increased. Control was not simply by men over women: at this time, male physicians and surgeons were forbidden to examine female genitalia. See Thomas G. Benedek, "The Changing Relationship Between Midwives and Physicians During the Renaissance", Bulletin of the History of Medicine, 1977, 51(4), pp. 550-564. 1 2 See H.C. Erik Midelfort, Witch Hunting in South Western Germany: The Social and Intellectual Foundations, 1972, Stanford, Stanford University Press; and the discussion of his work in Mary Daly, Gyn/Ecology: The Metaethics of Radical Feminism, 1978, Boston, The Beacon Press, pp. 184-185. 1 3 Cited in Jacques Donzelot, The Policing of Families, 1979, New York, Pantheon, pp. 30-31. 1 4 Donnison, op cit, pp. 18, 40-41. She notes on p. 21 that by the 1720s men-midwives were becoming more prominent in uncomplicated deliveries as well as abnormal deliveries. 75 to attend a greater proportion of births. Midwives and medical practitioners were vilified and satirized, and appeals were made to government for recognition of the superior skills of either profession. Midwives in Europe were denounced as witches and thousands of midwives and female healers were executed. 1 5 Yet this vilification campaign was not without its critics. Some opposed the encroachment of men-midwives in birth on grounds of modesty as well as the unnatural methodologies and inferior skills of male attendants. In A Treatise on the Art of Midwifery (1760), Elizabeth Nihell also criticized the lower pay available to women attendants relative to men. 1 6 The Midwives Act of 1902 followed the efforts of the Midwives' Institute and its supporters to gain legal recogniton and a protected status in law. This was not, however, an autonomous status. This Act subjected the midwives to local authorities. It also provided broader grounds for de-registration on grounds of professional misconduct The private lives of midwives were open to scrutiny. Essentially, midwives were not self-regulating since the role of the medical profession was dominant in midwife-related matters. 1 7 The Midwives Act of 1936 reflected concerns over the falling birth rate in England and the likelihood of war. Local authorities were to secure salaried, full-time midwifery services adequate to the citizenry. This Act also promoted the development of professional midwifery: unqualified midwives were banned from attending birth in any capacity. 1 8 The amended Midwives Act of 1951 continued the stipulation that the Board could strike off midwives for conduct unrelated to their work that brought the profession into disrepute. 1 9 1 5 Doreen Nagy, "Obstetrical Forceps: Symbols of Power and Professionalism in Victorian Britain", Nexus, 1983-1984, 3(1-2), 98-103. Obstetrical forceps were refined and by the 1860s were used more frequently by doctors. Nagy concludes that forceps served not only a beneficial clinical purpose, but also had a symbolic value in establishing midwifery as a branch of medicine. 1 6 See Arney, op cit, pp. 30-31. 1 7 See Donnison, op cit, pp. 174-175. 1 8 Donnison, ibid., p. 191. 1 9 Donnison, ibid., p. 183. 76 2 0 Midwifery in Canada The historical study of midwifery in Canada suffers from the elitist view outlined by Zinn. In Canada, historical approaches have favoured a Whig version of history written "from above" and not from a working-class perspective. Biographical accounts of eminent physicians and chronicling of dramatic medical advances are featured in this Antiquarian approach, while accounts by working-class people are absent or minimal. 2 1 For Nellie McClung, those who did "the work of the world" were not written about by historians. 2 2 There is however a renewed interest in Marxist historiography and critical interpretations in Canadian history. 2 3 This stems from the interest of several prominent social historians in writing history "from below"; that is, from the viewpoint of working people who have for the most part been neglected in historical accounts. 2 4 Women's accounts have also been "hidden from history" in 2 0 Some have indicated that the greater institutionalization of midwifery in Britain - relative to the United States - hinges in part on the lack of regulation of midwifery in colonial America, and the failure to establish midwifery as a centrally-controlled institution in the face of opposition by organized medicine. See P. Anisef and P. Basson, "Institutionalization of a Profession - Comparison of British and American Midwifery", Sociology of Work and Occupations, 1979, 6(3), 353-372. 2 1 The Antiquarian approach tends to avoid or minimize contributions of non-medical practitioners as well as external factors influencing health care. S.E.D. Shorn, "Antiquarians and Amateurs: Reflections on the Writing of Medical History in Canada", in S.E.D. Shortt (ed.), Medicine in Canadian Society: Historical Perspectives, 1981, Montreal, McGill-Queen's Press, pp. 1-17. Shortt notes that compensatory historical work on working class history has been limited. 2 2 See Nellie McClung, Clearing in the West, Toronto, Thomas Allen, 1935. 2 3 For instance, the tradition of paternalistic authority relations in Upper Canada between 1800 and 1850 was influenced by working-class resistance and negotiations between dominant group members and subordinates. Bryan Palmer, Working Class Experience: The Rise and Reconstitution of Canadian Labour, 1800-1980, 1983, Toronto, Butterworth, p. 18. See also Desmond Morton with Terry Copp, Working People: An Illustrated History of Canadian Labour, 1980, Ottawa, Deneau and Greenberg. 2 4 Peter Burke, in Raphael Samuel (ed.), People's History and Socialist Theory, 1981, London, Routledge and Kegan Paul, pp. 370-373. See also E.P. Thompson's social historical approach 77 many respects. 2 5 The historical assessment of Canadian midwives is alternately hindered and developed through these Antiquarian and radical approaches. It is hindered by the palpable lack of records and documents of lay midwifery in frontier and post-frontier eras. Lay midwives in Canada rarely kept systematic records. Moreover, available records from Ukrainian, Scandinavian, Acadian, and Quebecoise midwives do not appear to have been translated into English. The lack of written records has also been observed in historical accounts of lay midwifery in the United States. 2 6 As with other scholars who have delved into hospital practices in 19th century Canada, for instance, historical records of lay midwives are often incomplete or absent 2 7 Historical writing on Canadian midwives has thus been limited, although there is a renewed interest in excavating documentary materials related to lay midwives and the nurse-midwives who succeeded them. It is clear that lay midwives were the primary birth attendants in colonial Canada. Lay midwives in pre-Confederation Canada were often affiliated with specific immigrant groups. 2 8 Cameron provides a fictional account of native Indians attending a white woman in labour, 2 9 Historical accounts have confirmed that native midwives assisted settlers in the colony of "(cont'd) in The Making of the English Working Class, 1968, Harmondsworth, Penguin. 2 5 Sheila Rowbotham, Hidden From History, 1973, London, Pluto Press. 2 6 Jane Donegan, op cit., pp. 3-4, 20. 2 7 S.E.D. Shorn, "The Hospital in the Nineteenth Century", Journal of Canadian Studies, 1983, 18(4), 3-14. A 19th century Nova Scotia midwife's records were restricted to the date of birth and the name of the mother. See Jane Hamilton Sorley, ""Five Islands, N.S., midwife" (Records of births attended in the Five Islands-Economy Area, 1851-1893), Sackville, New Brunswick, Mount Allison University Archives. As noted below, oral histories have served to retrieve some information on community midwifery in more recent years. For a statement on the possibilities of incorporating oral history into general historical understanding see Paul Thompson, The Voice of the Past: Oral History, 1978, Oxford, Oxford University Press. 2 8 David Cayley, "Midwifery in Canada: Part IV," CBC Morningside, Canadian Broadcasting Corporation, 1981. 2 9 Anne Cameron, The Journey, 1982, New York, Avon Books, pp. 243-249. 78 British Columbia. 3 0 "In the earliest days there were no trained nurses such as we know in 1945, and there were no hospitals. It was not considered necessary for a mother to go to a hospital for the birth of a child, and, further, it was not considered a matter for hospital attention. Children, in those days, were born in their homes—not in hospitals....In Moodyville, a neighbour acted, assisted by an Indian woman, and at the Hastings Sawmill, and in Granville it was much the samc.Indian women never had mid-wives other than another Indian woman." A history of Pemberton, B.C. also indicates that native midwives assisted settlers. 3 1 At the turn of the 20th century, maternity cases in British Columbia were increasingly directed to two general hospitals, four or five maternity homes, and "dozens" of midwives attended women in labour at home. 3 2 There are oral histories on frontier midwives and nurses in Western Canada, including Icelandic midwives and other, ethnically-affiliated midwives. In some places women trained in nursing and midwifery worked with country doctors; sometimes neighbourhood women were the sole birth attendants. 3 3 Coburn concludes that community midwifery was essential since few doctors practiced in the colony. 3 0 J.S. Matthews, "Mid-wives", Typescript mimeo, file folder #175, Vancouver Public Archives, Vancouver, B.C. 3 1 "Babies were delivered by Indian mid-wives trained in their own traditional herb medicines, or by neighbours such as Mrs. Neill. The more prosperous or more nervous (women) preferred to travel to Vancouver several weeks ahead of time...." It was also noted that some settlers were anxious to have trained nurse-midwives in the Pemberton area. The arrival of Lorraine Carruthers, a nurse with the Squamish Public Health Service, had been long awaited according to this account See Francis Decker, Margaret Fougberg, and Mary Ronayne, Pemberton: The History of a Settlement, Pemberton, Pemberton Pioneer Women, 1978 (second edition, revised), pp. 241 and 258. 3 2 J.S. Matthews, "Letter re: Fred H. Goodrich's 'Victorian Order Born in Vancouver', The Daily Province, November 10, 1947," dated November 17, 1947, File Folder #17, "Victorian Order of Nurses," Vancouver City Archives. 3 3 Linda Rasmussen et al., A Harvest Yet To Reap, 1976, Toronto, The Women's Press. Others have noted the work of ethnic, lay midwives in the Red River Colony. See also Judi Coburn, "I See and am Silent: A Short History of Nursing in Ontario," in Linda Kealey (ed.), Women at Work: Ontario, 1850-1930, Toronto, Canadian Women's Educational Press, p. 132; and Alvine Cyr Gahagan, Yes, Father: Pioneer Nurisng in Alberta, 1979, Manchester, N.H., Hammer Publications, p. 1. 79 Benoit's oral histories of empirical midwives in 20th century outports in Newfoundland preserves a sense of the tradition of community self-help and folkways before the establishment of formal medicine and nursing in that province. 3 4 These midwives tended to be older than contemporary community midwives in Canada. The Newfoundland midwives were customarily 40 years of age, or older. Local midwives were generally well-respected. Their practice was diversified, ranging from midwifery to bone-setting and tending to animals. In contrast to the fee-for-service practice of the professions, payment to community midwives was often made through bartering. The world of the outport midwife in Newfoundland was not entirely self-contained. Threats to mothers and infants remained, and it was not uncommon for local midwives to accompany women to hospitals or nursing stations staffed by doctors or nurses. Some midwives also took formal training in Boston or other urban centres. Coburn explains the displacement of lay healers and midwives in early Canada by nurses as one instance in which patriarchial ideology aided the relegation of women to the domestic sphere, while professional ideology attracted trained nurses as allies with medical personnel against folk healing and birth attendants. 3 5 Historical accounts confirm the displacement and replacement of lay midwives by pioneer doctors and nurses. Increasingly, doctors were involved in home deliveries and practice in early hospitals, occasionally assisting by telephone when travel was impossible. 3 6 The exclusion of female birth attendants in the 18th and 19th centuries included bars to women applicants to medical schools in the United States and in Canada. 3 7 Likewise, a 3 4 Cecilia Benoit, "Midwives and Healers: the Newfoundland Experience," Healthsharing, 1983, pp. 22-26. 3 5 Coburn, op cit 3 6 See for example H.L. Burris, Medical Saga: The Burris Clinic and Early Pioneers, 1967, Kamloops, Mitchell, pp. 223-224. 3 7 See Donegan, op cit, Ch. 8, and Veronica Strong-Boag, "Canada's Women Doctors: Feminism Constrained", in Linda Kealey (ed.), A Not Unreasonable Claim: Women and Reform in Canada, 1880s-1920s, 1979, Toronto, The Women's Press, pp. 109-129. A woman who graduated from Queen's Medical School in Kingston, Ontario mentioned the hostility of 80 woman applying for admission to the Royal College of Surgeons in Edinburgh in 1869 was ridiculed by medical students. 3 8 The exclusion of women from medical education can be linked with broader restrictions on women in 19th century Canada. There was concern among some physicians that anatomy and physiology should not be taught to girls for fear of hypochondria. The belief that women were by their nature ill-suited for competition and higher education also reflected the patriarchial differentiation of women and men. 3 9 The professionalization of childbirth attendance in Canada has thus been placed in a critical framework of patriarchy and gender. Coburn maintains that the general ideology of women's inferiority promoted work structures in which women's labour was auxilliary (to men's work), either voluntary (charitable) or poorly-paid, and in which the material concerns of doctors and legislators were joined. The displacement of the lay midwife in Canada was not connected with the intrinsically superior power of medical and nursing attendants. Coburn adds that the intertwining of professionalism, sexism, and exclusion of women healers from lay practice and the barring of women from medical schools facilitated capital accumulation and industrialism, while the movement from the home to the hospital promoted structural, disciplinary environments more conducive to industrialism. 4 0 In her comprehensive essay, Buckley maintains that the liason between nurses and doctors in Canada, far from reflecting public opinion and preferences for professional "(cont'd) male classmates toward female medical students. See Elizabeth Smith, A Woman with a Purpose, 198(7), Toronto, University of Toronto Press. 3 8 Recent examples of dismissiveness and hostility directed toward female students in physics, psychology, and other disciplines are mentioned in Jo Ann Ashley, "Power in Structured Misogyny: Implications for the Politics of Care", Annals of Nursing Science, 1980, 2(3), pp. 16-17. 3 9 Wendy Mitchison, "Historical Attitudes Toward Women and Childbirth", Atlantis, 4 (2), Part II, pp. 19-20. 4 0 Coburn, op cit. Others have made the general point that the gradual achievement of improved medical and health conditions not only benefits the population at large, but also owners and managers of capital since the work-force is healthier and hence more productive. See for example, Ian Gough, The Political Economy of the Welfare State, London, MacMillan, 1979. 81 attendance, stemmed from professional interests in securing a monopoly over health-related services as well as middle-class preferences for higher-ranking attendants. The securing of childbirth attendance further served to establish family practices for general practitioners. 4 1 Cayley adds that doctors obstructed attempts to establish midwifery certification and practice in Canada, launching a "campaign of vilification" against lay midwives as ignorant, dirty, and dangerous. 4 2 Law and the Containment of Midwifery Legal prohibitions on midwifery practice also offered a deterrent to midwives practicing without the protection of law. As Ward indicates, the movement of the State in regulating birth has varied considerably. In New France, in the 1720s and 1730s, the Crown subsidized midwives trained in France. By 1788 the British required midwives practicing in the larger cities of Montreal and Quebec (and adjacent areas) to have a certificate. In 1879 the Quebec College of Physicians and Surgeons extended their control: in fact, about 95% of midwifery licenses were issued to male physicians and surgeons. In 1872, midwives in the City of Halifax were certified through a Medical Board, while country midwives remained unregulated. In 1881, licensed physicians were legally empowered to practice midwifery. 4 3 Biggs interprets the legislation governing midwives in Upper Canada and 18th century Ontario as a device enabling the exclusion of lay midwives: the 1795 Medical Act prohibited 4 1 Suzann Buckley, "Ladies or Midwives? Efforts to Reduce Infant and Maternal Mortality", in Linda Kealey (ed.), A Not Unreasonable Claim, 1979, Toronto, The Women's Press, pp. 131-149. 4 2 Cayley, op cit 4 3 W. Peter Ward (ed.), The Mysteries of Montreal: Memoirs of a Midwife, Vancouver, University of British Columbia Press, 1984, p. 7. He notes (p. 10) that: "Even educated, well-qualified licensed midwives found themselves largely superseded, while those without training were confined to the countryside". 82 the practice of physic and surgery. This prohibition was reversed, however, through new legislation in 1806. This legislation expressly protected midwifery practice: 4 4 "...nothing in this Act contained shall extend or be construed to extend to prevent any female from practising midwifery in any part of the Province, or to require such female to take out such license as aforesaid." Three bills to regulate or exclude domestic midwifery practice were defeated between 1845 and 1851. Nevertheless, medical influence was extended through establishment of licensing powers, a system of registration, and medical education. With the increasing objections to midwifery - for undercutting doctors' fees, and for allegedly dangerous practices - midwifery attendance declined as doctors established practices in urban areas and as new legislation removed the protective status of female birth attendants set out in the 1806 legislation. 4 5 There was thus substantial opposition to suggestions that lay midwives could be trained and used in (remote) district nursing in 19th century Canada. Attempts to import trained midwives were also resisted by some 19th and 20th century Canadian physicians: in 1917 the chief superintendant of the Victorian Order of Nurses in Canada, a foreign midwife, was criticized for her foreign status. 4 6 These initiatives followed much earlier attempts to restrict the practice of medicine in Upper Canada in 1795 to graduates from universities in the British Empire 4 7 Opposition to lay midwives was generally tempered by the geographical distribution of the population in Canada. Until the early part of this century the population was primarily rural. The substantial distances that often separated inhabitants, compounded by inclement weather and rudimentary transportation, meant that birth attendance was often left to 4 4 C. Lesley Biggs, "The Case of the Missing Midwives: A History of Midwifery in Ontario from 1795 to 1900", Ontario History, 75(1), p. 22. 4 5 Biggs, passim. 4 6 See Buckley, op ciL, p.143. 4 7 See Coburn, op ciL, pp. 133-134). 83 neighbouring women. Even where a clear preference for physican-attended births was stated, such limitations were recognized: One Commissioner reporting to the Saskatchewan Health Services Survey Commission allowed that: 4 8 "While it is desirable to have women delivered by physicans, if possible in a maternity home, there are still numerous sections of the province that have no physician at all, and that, during the winter, are completely cut off from hospitals. In such regions, a nurse-midwife, that is a nurse trained in midwifery, could render invaluable services, without encroaching upon the field of the physician. A course would have to be devised for which the system practiced in Alberta, England and other countries, would have to be consulted." It is also clear that opposition to midwives was not characteristic of all doctors in pioneer Canada. There is evidence that relations between some doctors and midwives were amicable. 49 A controversial point, developed in the next section, is whether the monopoly status of Canadian doctors and nurses contributed to direct improvements in maternal and infant well-being. 5 0 It is farfetched to attribute declines in the rates of infant and maternal mortality to medicine per se when larger factors influence these rates. Besides improvements in sanitation, diet, and so forth, childrearing customs affected the neonatal mortality rate. In 18th century France, the custom of child care by "wet" and "dry" nurses not uncommonly resulted in infant deaths through neglect. 5 1 The transition from home births to hospital births involved an interstitial period in which domiciliary midwifery was practiced extensively by public health nurses. Coburn notes 4 8 See Henry Sigerist, Saskatchewan Health Services Survey Commission: Report of the Commissioner, 1944, Regina, King's Printer [emphasis added]. 4 9 See Ward, op cit, p. 13. 5 0 Buckley, op cit,, p. 132, notes that maternal and infant mortality increased during this period of urbanization and replacement of the midwife in late 19th century Canada. Shortt, op cit, also mentions that early hospitals of the day were not uncommonly regarded as "gateways to death" (although he believes this allegation is exaggerated) and avoided by wealthier inhabitants who could afford home attendance and general practice of physicians. 5 1 Elisabeth Badinter, The Myth of the Maternal Instinct. See also Colette, "The Patriarch", in The Rainy Moon and Other Stories, 1979, Harmondsworth, Penguin, p. 128. 84 that in 1925, 38,634 births occurred in V.O.N, hospitals or Red Cross Outpost Hospitals, whereas the V.O.N, attended 14,700 obstetrical cases at home. 5 2 Thus, approximately 27 percent of births managed by the the Victoria Order of Nurses at this time were home births. Domiciliary midwifery in Vancouver was praised for its safety. Nationwide, approximately 24,000 maternity cases were assisted by members of the V.O.N., of which 5,000 were home births. Apparently, however, only a small minority at this time were managed by the nurse without the doctor present 5 3 Notwithstanding the work of public health nurses in attending home deliveries, the shift to hospital delivery was quite dramatic. It has been estimated that only 40 percent of Canadian mothers delivered in hospital in 1939, but 93 percent delivered in hospital by 1959. 5 4 The reasons underlying this shift from home to hospital deliveries include greater accessibility to hospitals and professional attendance, provision of services through provincial and federal funding of hospital construction, the development of Medicare plans, and a cultural shift which promoted the superior skills of physicians and surgeons over the midwives' skills. Midwifery in the United States The hegemonic status of doctors in the management of childbirth also characterized developments in the United Status. 5 5 The shift from lay practitioners -many of whom were women - in colonial America was gradual. Midwifery in 18th century America was not 5 2 Coburn, op cit, p. 150. 5 3 . Charlotte Whitton, "V.O.N. Stands for Victorious Over Need", Saturday Night, June 2, 1945, pp. 5 and 27. 5 4 W.G. Cosbie, The History of the Society of Obstetricians and Gynaecologists of Canada, 1944-1966, 1969(?) 5 5 Paul Starr, The Social Transformation of American Medicine, 1982, New York, Basic Books. 85 subject to substantial formal regulation. Midwives were not regulated until the middle of the sixteenth century when episcopal licensure ensured, among other things, that babies were baptized. 5 6 After Independence in 1776, many legislatures extended licensing powers to medical societies. These licensing powers usually exempted apothecaries, botanists, and midwives. In the Jacksonian period, however, women were no longer so dominant in healing. Doctors mobilized against lay midwives, an ideology of protection of women from "unfeminine" work gained currency, and urban, middle-class women in the United States began to gravitate to physician attendance in childbirth between the mid-1700s and the Civil War. 5 7 Later in the century the campaign against granny midwives continued in the Southern U.S.A. In W. Eugene Smith's photographs of the work of a black nurse-midwife, the accompanying essay clearly favours nurse-midwives over traditional birth attendants. The former maintains aseptic conditions and has proper supplies: a blood pressure gauge, cord ties, a stethoscope, and sterilized gloves. 5 8 In the early 19th century, accounts of fatalities attributed to unlicensed midwives enjoyed newspaper coverage, for example. Concerns over high rates of childbirth-related deaths culminated in 1933 in a major report on maternal mortality in New York City. The recommendation that proper training of midwives should be encouraged was largely disregarded. " Stan states that the lay midwife was seen as a competitor for physicians, while nurse-midwives were valued by obstetricians for their assistance in childbirth. 6 0 Even if 5 6 Jane Donegan, Women and Men Midwives: Medicine, Morality, and Misogyny in Early America, 1978, Westport, Greenwood Press. 5 7 Starr, op cit., p. 49; Donegan, op cit., pp. 4-5. 5 8 See W. Eugene Smith, "Maude Callen Eases Pain of Birth, Life and Death," Life, December 3, 1951, 31(23), pp. 134-145. On page 135 the distrust of lay midwives is clearly set out: "The new midwife had succeeded where the fast-disappearing 'granny' midwife of the South, armed with superstition and a pair of rusty scissors, might have killed both mother and child." 5 9 See New York Academy of Medicine, Maternal Mortality in New York City: A Study of All Puerperal Deaths in 1930-1932, 1933, New York, Commonwealth Fund. 6 0 Starr, op cit, p. 223. 86 midwives could circumvent licensing restrictions, they discovered that they could not collect from Blue Shield plans, and their patients could not collect under indemnity insurance plans. 6 1 As with their European counterparts, American physicians were successful in establishing clinical instruction in which medical students viewed the birth of babies. This innovation of "demonstrative midwifery" by Dr. James White in Buffalo in 1850 was widely debated but eventually became established. 6 2 CROSS-CULTURAL PERSPECTIVES ON MIDWIFERY Cross-cultural variation in midwifery practice and birth practices generally have long been recorded. Midwives are variously called sage- femme in France, dukun bagi in Java, nana in Jamaica, and partera in Spanish-speaking countries. Other names include comadrona, bidan, and dai. 6 3 Traditional midwives are almost always women, although there are cultures in which male midwives have practiced. 6 4 Several themes become evident in examining historical and cross-cultural materials on midwifery and childbirth. First, anthropological studies have captured the diversity of childbirth practices in various cultures. In many non-industrialized cultures a variety of beliefs and 6 1 Ibid., p. 333. 6 2 Judy Barrett Litoff, American Midwives: 1860 to the Present, 1978, Westport, Greenwood Press, p. 20. For a more detailed review of the incident see Virginia Drachman, "The Loomis Trial: Social Mores and Obstetrics in the mid-Nineteenth Century", in Susan Reverby and David Rosner (eds.), Health Care in America: Essays in Social History, 1979, Philadelphia, Temple University Press, pp. 67-83. Manual examinations of women by male physicians were permitted in mid-19th century but visual examination of a woman's genitals was forbidden. See Ward, op ciL, p. 14. ' 6 3 See S. Cosminsky, "Cross-cultural Perspectives in Midwifery", World Anthropology, 1976, pp. 229-248. 6 4 Laderman, op ciL, describes a male bidan in a Malaysian hamlet as "a great rarity". His practice ceased when a female village midwive relocated in his hamleL Another writer notes that males began practicing midwifery in the rural Philippines after 1963. Male midwives were referred to as sibulan. See Donn Hart, "From Pregnancy Through Birth in a Bisayan Filipino Village", in Donn Hart et al., (eds.) Southeast Asian Birth Customs: Three Studies in Human Reproduction, New Haven, Human Relations Area Files Press, 1965, pp. 22-23. 87 practices have been recorded. These include dietary restrictions and proscriptions on who may attend births. In some cultures, husbands are expected to be absent during the birth; in others the absence of the father is seen as a portent of misfortune for the newborn child. Birthing positions likewise vary from the standard lithotomy position (on one's back) in Western medical practice to a variety of birthing positions, including squatting, delivery on all fours, use of birthing stools, ropes or poles for support, and so forth. The complexity of this subject is not only evident between cultures but also within some cultures. Research on the Rogai in South Vietnam, for instance, suggested that women deliver their babies using a variety of gravitational aids: birthing stools, ropes, vines, and a pole for support 6 5 One issue in the modern debate over obstetrics and midwifery is the use of technology for control purposes. Critics of the unnecessary use of obstetrical technology claim that a variety of surgical measures such as episiotomy and Caesarean section serve more than medical purposes; they also help to consolidate medical power during childbirth. There have been shifts in this debate, however. Women's associations lobbied for scopolamine (a narcotic and analgesic, also known as "twilight sleep") in 1914 and 1915, whereas some modern feminists lobby for the right to unmedicated births. 6 6 "The twilight sleep movement helped change the definition of birthing from a natural home event, as it was in the nineteenth century, to an illness requiring hospitalization and physician attendance. Parturient feminists today, seeking fully to experience childbirth, paradoxically must fight a tradition of drugged, hospital-controlled births, itself the partial result of a struggle to increase women's control over their bodies." A number of writers have thus linked the growth of technological approaches to childbearing with alienation of mothers. Recourse to routine induction (without a clear demonstration of 6 5 See Lois Lee, "Pregnancy and Childbirth Practices of the Northern Roglai", Southeast Asia, 2(1), p. 40. 6 6 Judith Walzer Leavitt, "Birthing and Anesthesia: The Debate over Twilight Sleep", Signs: Journal of Women in Culture and Society, 1980, 6(1), p. 164. 88 the benefits of induction) has been associated with professional convenience, to some extent67 For some, the act of accepting pain relief in labour alters the essential quality of birth, reducing the women receiving medication to "a passive thing". 6 8 Variations in Infant Mortality Rates High life expectancy in many countries is a dramatic change from earlier periods: 6 5 "...'It is not uncommon, I have frequently been told,' Adam Smith soberly noted, 'in the Highlands of Scotland for a mother who has borne twenty children not to have two alive'. The poor died freely, in unrecorded numbers, but even men of means thought long life a stroke of unexpected luck." "Some progress has already been made in reducing infant mortality, but the differential in maternal mortality between rich and poor countries is among the highest observed in public health, reports WHO (World Health Organization). Eighty-five per cent of the world's births take place in developing countries but these same countries suffer 95% of the world's infant deaths, and a terrible 99% of all maternal deaths. WHO figures also show that more women die in India in 1 month than die in all of North America, Europe and Australia in 1 year." 70 There is substantial disagreement over the part played by medical science in reducing infant and maternal mortality, and the influence of improved hygiene, sanitation, and diet 7 1 Regardless, in Europe and other industrialized countries there has been a great reduction since 6 7 Ann Qutwright, The Dignity of Labour? A Study of Childbearing and Induction, London, Tavistock, 1979. Between 1965 and 1974 the percentage of births using induction rose from 15% to 41% in England and Wales. 6 8 Carol McMillan, Women, Reason and Nature, Princeton, Princeton University Press* 1982, p. 133. Setting aside this sweeping point, McMillan does establish the importance of reconsidering how women's consciousness is shaped and ordered in the course of pregnancy and childbirth. 6 9 See Peter Gay, The Enlightenment: An Interpretation (Volume II: The Science of Freedom), London, Weidenfeld and Nicholson, 1970, p. 21. 7 0 "International News", Midwifery, 1986, 2(1), p. 53. 7 1 See J. McKinlay and S. McKinlay, "The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century", Millbank Memorial Fund Quarterly, 55(3), 405-428. 89 the 18th century in the proportion of children who die in childbirth or in the first few years of childhood. Historical research on parishes in Finland, for example, indicated that the infant mortality rate was 970 per 1,000 births (during a typhoid epidemic) and subsequently in 1881, the rate remained at 375 per 1,000 births. Many infants who died between one and six months of age suffered from gastric illnesses or contagious diseases, and breast-feeding provided greater protection against these illnesses. 7 2 Higher rates of infant mortality within Western societies have been noted for black infants in the United States 7 3 and for Native infants in Canada. 7 4 And even while it appears that the decline in the birth rate in some Western countries has halted, 7 5 there is a substantial difference in birth rates in comparison with Third World countries. Studies early in this century recorded what are today regarded as high rates of infant mortality. Two studies noted by Kitzinger address miscarriages in a South African tribe between 1929 and 1935, while the second study found that one-eighth of pregnancies in another African village resulted in miscarriage, while 28% of newborns did not survive to maturity. 7 6 Even in modern times comparatively high rates of infant mortality have been documented in non-industrialized areas. The authors of a UNICEF report in 1973 estimated that 17.6% of babies born in an Arabian community died in their first year. By 7 2 See Ulla-Britt Lithell, "Breast-Feeding Habits and their Relation to Infant Mortality and Marital Fertility", Journal of Family History, 1981, 6(2), 182-194. A comprehensive review of the politics of breastfeeding is provided by Maureen Minchin, Breastfeeding Matters: What we need to know about infant feeding, 1985, Alfredton, Alma Publications and George Allen & Unwin. 7 3 Alfred Yankauer, "Infant Mortality and Morbidity in the International Year of the Child", American Journal of Public Health, 1979, 69(9), p: 852. 7 4 A greater incidence of low birth weight (LBW) and of infant mortality in the Northwest Territories in 1972 was noted by Marcia C. Smith, "Changing Health Hazards in Infancy and Childhood in northern Canada" in Roy J. Shepard and S. Itoh (eds.), Circumpolar Health, Toronto, University of Toronto Press, 1976, pp. 448-449. Mortality rates among reserve Indians in Ontario in 1898 were three times higher than the provincial rate. See Sally M. Weaver, Medicine and Politics among the Grand River Iroquois: A Study of Neo- Conservatives, Ottawa, National Museums of Man, p. 43. 7 5 John Archer and Barbara Lloyd, Sex and Gender, 1985, New York, Cambridge University Press, p. 296. 7 6 Sheila Kitzinger, Women as Mothers, Glasgow, Fontana, 1978, pp. 75 and 107. 90 age two, this statistic exceeded 23 percent 7 7 Dangers to the mother during labour, delivery, and postpartum were also evident In the Yucatan, birth attendants are vigilant in watching for placental retention which can cause maternal deaths. 7 8 Again, in many cultures maternal deaths are attributed to supernatural powers, including witchcraft Smith-Bowen wrote a poignant account of the death of her friend Amara, a woman in a bush tribe in Africa. The exchange between Smith and Yabo reflects the contest between reliance on Western medicine as a lifesaving measure and the tribe's cultural belief in the powers of magic that are beyond the powers of doctors. 7 9 Others have noted the belief in spirits as causes of death in childbirth. In Malaysia, the badi mayat - an evil spirit or principle believed to exist in a human corpse - was associated with the wasting away of an infant Interestingly, the author also attributes the infant death to a misdiagnosis at a medical clinic. 8 0 One respondent in this study had assisted Bedoin women in Saudi Arabia in the late 1950s and early 1960s. She recounted one incident in which Western medicine was well-received by the Tribe. "I suppose it was about eight o'clock in the morning and I went out to this infant that had been born between four and five a.m. The doctor had delivered it It was a Friday, a religious holiday, and since it was a day of rest he had gone off to Kwaittown; as far as he was concerned it was a fairly standard delivery. It was the first time I've taken a pulse that I couldn't count quickly enough: the pulse rate was so high. The infant's temperature went off the thermometer, over 108 degrees.. I had never seen anything like this,' and what I did in panic (not through skill), was to move the mother and the family into the jeep and we drove across the desert to a medical clinic which happened to be air-conditioned. I sponged the infant down and his temperature came down nicely. I was scared to take him out again...I waited until 7 7 Women in Hamra (an oasis in Oman) attribute the death of a child to Allah; it is God's will. See Christine Eickelman, Women and Community in Oman, 1984, New York, New York University Press, pp. 126 and 181. 7 8 Brigitte Jordan, "Studying Childbirth: The Experience and Methods of a Woman Anthropologist" in Shelly Romalis (ed.), Childbirth: Alternatives to Medical Control, 1981, Austin, University of Texas Press, pp. 7 9 Elenore Smith Bowen, Return to Laughter: An Anthropological Novel, 1964, New York, Doubleday, Chapter 14. 8 0 Carol Laderman, op cit, pp. 95-102. 91 the sun went down to take him to a doctor at a neighbouring oil company. (What we found was that) this was the seventh baby this women had birthed, and every one had died on the first day of birth. Their metabolic rate followed the sun's temperature... and of course they would die once the sun was out...We kept this seventh child in the air-conditioned room and gradually exposed it to the outside. Eventually this infant's system just corrected itself and it grew, it coped. This made an incredible impact on the local people....(Former nurse, A3, January 1985). A common theme in reconstructing childbirth ritual in Third World countries is the control women usually exerted in birth attendance. This control extended to reproduction generally, including contraception and abortion. Some conclude that men were excluded from these matters or involved only marginally. 8 1 In some Phillipine villages fathers were expected to be present, while in other locales in Northern India fathers were excluded from childbirth. 8 2 This theme has also been qualified by other accounts pointing to the mythology of women as dangerous in a number of folk cultures. 8 3 Childbirth ritual has been specifically interpreted as reinforcing such devaluation of women. Traditional Practices and Medicalization of Birth The medicalization of childbirth is evident in Third World countries and elsewhere. Increasingly, traditional midwives, many of whom had apprenticed with other lay midwives and have practiced in their villages for decades, are being displaced in favour of nurses trained in obstetrical nursing or midwifery, or by physicians. The traditional reliance on touch, 8 1 For a detailed discussion of the takeover of reproductive care see Ann Oakley, "Wisewoman and Medicine Man: Changes in the Management of Childbirth", in Juliet Mitchell and Ann Oakley (eds.), The Rights and Wrongs of Women, 1976, London, Penguin, pp. 19-23 et seq. 8 2 See Beatrice Whiting and John Whiting, Children of Six Cultures: A Psycho-Cultural Analysis, Cambridge, Harvard University Press, 1979 (4th printing), p. 112 (??). Indian fathers in Guatemala were expected to assist their wives in childbirth, holding them from behind in a supported squat delivery position. See Eileen Maynard, "Guatemalan Women: Life Under Two Types of Patriarchy" in Carolyn Matthiasson (ed.), Many Sisters: Women in Cross-Cultural Perspective, New York, The Free Press, p. 90. 8 3 Nancy Chodorow, "Being and Doing: A Cross-Cultural Examination of the Socialization of Males and Females" in Vivian Gornick and Barbara K. Goran (eds.), Women in Sexist Society: Studies in Power and Powerlessness, New York, Mentor, p. 274. 92 on amulets, and so forth has likewise been overshadowed by technological machinery and the role of technicians in medicalized antenatal, postnatal, and labour and delivery stages. Record-keeping is emphasized, registration of births and deaths is required by law, and control over licensure and training is formally vested in such government bodies as Departments of Health. Traditional midwives in Malaysia - bidan kampung - have been trained in principles of hygiene, sterile techniques, and family planning. Home deliveries have however tended to shift to formally trained nurse-midwives. There has been some adaptation of government-trained midwives to local customs; nevertheless, the legislation requiring midwives to be registered (and the lack of registration procedures for new village midwives) means that the tradition of village midwifery is likely to disappear as the current bidans age. 8 4 The bidan kampung thus are responsible for instruction in breast-feeding ( or proper preparation of formula ) and family planning, but not for assistance in labour and delivery. 8 5 Western influences on traditional birth practices are not entirely irresistible. Opposition to Western medical practices has been noted of rural women in Guatemala, Malaysia, Papua New Guinea, and the Yucatan. 8 6 Despite such resistance, there has been a clear movement away from home delivery and toward hospital or clinic deliveries in many Third World countries. As set out below, this shift toward medical management of births has benefits for infants and mothers in terms of life-saving interventions through modern equipment and improved 8 4 Laderman, op ciL, Ch. 5. 8 5 See P.C.Y. Chen, "Incorporating the Traditional Birth Attendant into the Health Team: The Malaysian Example", Tropical and Geographical Medicine, 1977, 29(2), 192-196. Laderman op ciL, p. 91 indicates that village midwives may be trained in recognizing symptoms of hypertension, placental retention, and postpartum haemorrhage. 8 6 See respectively Cosminsky, op ciL; P.C. Chen, "Reasons Underlying the Maternal Choice of Midwives in Rural Malaysia", Medical Journal of Malaysia, 1978, 32(3), pp. 200-205; Naomi Scaletta, "Not Just Something Females Do: The Birthing Process in West New Britain, Papua New Guinea", Paper presented at the Annual Meeting of the Canadian Sociology and Anthropology Association, University of Guelph, Ontario, June 1984; Brigitte Jordan, Birth in Four Cultures: A Crosscultural Investigation of Childbirth in Yucatan, Holland, Sweden and the United States, 1980, Montreal, Eden Press. 93 training of birth attendants regarding nutrition, sepsis, and careful management of labour, delivery, and post-partum complications. A detailed account of this shift was provided by McClain. Her fieldwork in Ajijic - 40 kilometers from Guadalajara, Mexico - revealed a variegated system of maternity care: women delivered at home with traditional birth attendants or with an attending physician, although increasingly women in Ajijic were being delivered in hospitals. Accompanying this trend away from home deliveries was a decline in the number of practicing parteras coupled with the aging of two of the three practicing midwives (who were over 65 at the time of McClain's more recent fieldwork). There are numerous instances of resistance to the Western model or incorporation of valuable aspects of Western medicine (asepsis, more nourishing diets, encouragement of earlier breastfeeding to provide colostrum to newborns) with traditional rituals. 8 7 A detailed biography of Jesuita Aragon, a senior midwife in Los Vegas, a small community in northern New Mexico, captures the incorporation of traditional healing practices with modern principles of hygiene and professional attendance. At the time of writing, folk beliefs in supernatural elements coexisted to some degree with sterilized equipment, procedures for emergency transfers to hospital, instruction by nurses, and so forth. 8 8 Traditional Hispanic midwives have nevertheless fallen in numbers and it seems more appropriate to speak of the replacement or displacement of folk healers and midwives by professional healers. 8 9 One point of commonality between latter-day and modern lay midwifery is a spritual dimension in maternity care. 9 0 Source materials on the retention of African practices by Southern black 8 7 McClain (1975), cited in Cosminsky, op cit 8 8 See Fran Leeper Buss, La Partera: Story of a Midwife, Ann Arbor, University of Michigan Press, 1980. 8 9 Datha Brack, "Displaced: The Midwife by the Male Physician", Women and Health, 1976, 1(6), 18-24. 9 0 Black, granny midwives in the southern United States sang spirituals during meetings with nurses. Campbell adds that the advent of formal midwifery instruction was not always 94 midwives include documentation of practices in folk midwifery. The authors add (without elaboration) that many of these folk practices have been adopted by modern obstetricians to improve birth outcomes for mothers and infants. 9 1 Hull found that midwives in rural Java believed that colostrum was contaminated, used septic bamboo blades to sever the umbilical cord, and used manual removal of the placenta, sometimes causing serious infections. 9 2 Observations by a Western-trained midwife of four village midwives in India included harmful practices such as vaginal examinations after touching cow dung (thus producing tetanus and other infections), rupture of women's membranes with fingernails, manual pressure on the fundus, 9 3 and a cultural prohibition on "cold" foods and substances that led to labouring women becoming dehydrated and to ketosis poisoning. 9 4 Some researchers have disagreed with favourable assessments of the work of traditional midwives in Third World countries. Traditional midwives in rural Vietnam were described as lacking precise knowledge of management of complicated deliveries. Their ineptitude could lead to "disaster" for mothers or their infants. 9 5 Traditional midwives in Mexico, for instance, were perceived as not being knowledgeable about diagnosis of pregnancy, midwifery techniques in uncomplicated deliveries, and appropriate responses for complicated deliveries when a doctor '"(cont'd) opposed by the granny midwives, and in some instances it was welcomed. Op cit,m pp. 23-24. 9 1 Nancy Faires Conklin, Brenda McCallum, and Marcia Wade, The Culture of Southern Black Women: Approaches and Materials, University of Alabama, Archive of American Minority Cultures and Women Studies Program, 1983, p. 79. 9 2 V.J. Hull, "Women, Doctors and Family Health Care: Some Lessons from Rural Java", Studies in Family Planning, 10(11/12), p. 316. 9 3 Peruvian midwives were also observed applying pressure to women's abdomens to assist in delivery. See Gertrude E. Dole, "The Marriages of Pacho: A Woman's Life Among the Amahuaca" in Carolyn J. Mattiasson (ed.), Many Sisters: Women in Cross-Cultural Perspective, New York, The Free Press, 1974, p. 24. 9 4 Holiday Tyson, "Village Midwifery in Northern India: The Role of the Dai", Issue, #5(5), 5-6. 9 5 Richard J. Coughlin, "Pregnancy and Birth in Vietnam" in Donn Hart et al. (eds.), Southeast Asian Birth Customs: Three Studies in Human Reproduction, New Haven, Human Relations Area Files Press,1965, p. 213. 95 was unavailable to them. Moreover, criticisms of indigenous midwives have emerged from their home countries, for example, in the Philippines. 9 6 Other beliefs in traditional cultures clash with medical science. McClain's study of birth in a small Mexican community touched on the folk belief that a father's blood-drop created female embryos, while a mother's created male embryos. Congenital deformities, spontaneous abortions, and stillbirths were attributed to factors external to the mother, not to genetically-determined abnormalities. 9 7 It has been generally reported that septic procedures by traditional midwives in Tropical countries contributed to serious infections. 9 8 One programme in rural Bangladesh was designed to incorporate some traditional practices with principles of hygiene and adequate diet The attendance of the traditional midwife, the dai, was supervised by paramedical staff and complemented by a local clinic consisting of a physician and other paramedics. The custom of withholding breastfeeding for three to five days after birth did not allow the newborn to receive colostrum (which aids the developing immune response system). Education regarding appropriate supplementary feeding when breastfeeding continues into the sixth month was also carried out, as was instruction in sanitation and hygiene to reduce the substantial numbers of children dying of postpartum tetanus and sepsis during infancy. 9 9 High rates of infant mortality have thus been linked with inferior skills of traditional birth attendants. It has not however been established that decreases in infant and maternal mortality are attributable primarily to advances in the medical and nursing sciences. As one 9 6 See Helga Velimirovic and Boris Velimirovic, "The Role of Traditional Birth Attendants in Health Services," Medical Anthropology, 1981 (Winter), pp. 91-92. 9 7 McClain, 1975, op cit, pp. 40-41. 9 8 V. da Cruz, Bailliere's Midwives' Dictionary, London, Bailliere Tindall and Cassell, 1969 (fifth edition), p. 354. 9 9 Shushum Bhatia, "Traditional Childbirth Practices: Implications for a Rural MCH (Maternal and Child Health) Program", Studies in Family Planning, 1981, 12(2), pp. 70-71. 96 researcher concluded regarding birthing practices and infant mortality on a Guatemalan finca (plantation): 1 0 0 "...the main causes of this problem (high death rates) do not lie in the birth practices themselves, but in the poor nutritional and health state of the mothers, the poverty and the larger socioeconomic problems of the finca population". Research in American cities has likewise documented a positive correlation between poverty (and race) and infant mortality. It is generally accepted that many deaths of neonates (babies under 28 days old) are caused by congenital factors whereas postneonatal mortality is more likely associated with low income of mothers. 1 0 1 Birth Practices in Western Countries The diversity of birth ritual and belief systems in the countries mentioned above is not absent in wealthier countries. While there is no question that there has been an entrenchment of obstetrics and technological monitoring and management of childbirth, 1 0 2 there are variations within cultures that are predominantly, but not wholly dependent on professional maternity care. Hazell found that many of the women giving birth at home in California used a variety of birthing positions including supported squatting and delivery on all fours. She noted that in many non-European countries the upright birthing position and the side-lying position was commonly used, while the lithotomy position remains standard practice in Western obstetrics. 1 0 3 1 0 0 Sheila Cosminsky, "Childbirth and Midwifery on a Guatemalan Finca", Medical Anthropology, 3(1), p. 101. 1 0 1 For a detailed discussion see Charles Brooks, "Social, Economic, and Biologic Correlates of Infant Mortality in City Neighbourhoods", Journal of Health and Social Behaviour, 21(1), pp. 2-11. 1 0 2 For a discussion of the extension of "obstetrical space" see the structuralist analysis by William Ray Arney, Power and the Profession of Obstetrics, 1983, Chicago, University of Chicago Press, p. 9 1 0 3 Lester Dessez Hazell, Birth Comes Home, 1978 (2nd edition), Marble Arch, NAPSAC, pp. 97 Jordan's study of childbirth practices in four countries pointed to significant differences in childbirth management between Western nations: specifically, the Dutch approach retained domiciliary deliveries and discouraged routine medication, whereas Swedish practitioners relied on painkillers and hospital-based obstetrics. 1 0 4 Home birth is not only a feature of contemporary Third World countries. In Holland, for example, approximately one-third of births occur at home. 1 0 5 Nevertheless, the list of contraindications to home birth in Holland has increased over time while the percentage of births at home has slowly, but steadily decreased in recent years 1 0 6 A hallmark of Dutch birthing policy is the reliance on midwifery assistance in birth, whether at home or in hospitals or clinics. Midwifery in Japan and China The majority of published works on cross-cultural midwifery practices pertain to Europe, North America, and Third World Countries. A sense of midwifery practice and of kinship practices surrounding birth in the Orient is provided by some recent studies. For example, Kitahara reported that midwives in contemporary Japan must be licensed and, as in Denmark, must practice in hospital settings. 1 0 7 A contemporary observer depicted birth in Japan as hospital-oriented, technological, and medically-dominated, with some counter-trends in terms of 103(cont'd) 40-42. Nevertheless, there have been alternative approaches to childbirth in European and North American settings, including the LeBoyer method and more recently Michael Odent's reliance on supported squat techniques in France. Of 898 births there in 1980, the episiotomy rate was only 8% and the rate of Caesarean section was five percent See Michael Odent "The Evolution of Obstetrics at Pithiviers", Birth and the Family Journal, 1981, 8(1), 7-15. 1 0 4 Jordan, op cit. 1 0 5 Paula Brook, . "Midwives and Medicine", The Magazine (The Vancouver Province), May 18, 1980, p. 7. 1 0 6 See Gerald Kloosterman, "Organization of Obstetric Care in the Netherlands", Midwifery is a Labour of Love, 1981, pp. 9-24. 1 0 7 Ryuju Kitahara, "Health Care and Medicine in Japan", Presentation, Department of Anthropology and Sociology, University of British Columbia, March 11, 1982. 98 domiciliary and clinic midwifery practice. 1 0 8 In her detailed observations of health care customs in Japan, another writer drew attention to the incorporation of scientific medicine with established kinship relations. Specifically, the practice of satogaeri - returning to the natal home for delivery of a woman's first child - is fairly common and stands in some contrast to the usual practice in Canada of women delivering in their locality. 1 0 9 The blend of modernity and tradition is also evident in the frequent use of the pregnancy sash (iwata-obi) which is thought to promote easier delivery by restricting the size of the fetus, and in the reliance on obstetricians, hospitals, and clinics. 1 1 0 The global movement toward professionalized attendance in childbirth is apparent in China and Japan. This movement appears most pronounced in urban centres. In the early 1970s, it was reported that Chinese babies born in cities were usually delivered in hospitals, with doctors supervising these births. On the other hand, babies born in the countryside were delivered at home with the assistance of midwives. Anaesthesia was not used routinely for uncomplicated deliveries. 1 1 1 Conclusion Cross-cultural birthing practices reflect considerable variation in birthing customs and the role of the midwife. Crucial to an evaluation of midwifery development in Canada, however, is the finding that only nine of 210 nations studied by the World Health Organization made 1 0 8 Anna Jean Bradley-Low, "Observations on Midwifery and Maternity Care in Japan, Issue, #5, pp. 13-14. 1 0 9 The custom in some other cultures is for the child to be born in the father's house. Misfortune was believed to befall children born elsewhere. See Doranne Jacobson, "The Women of North and Central India: Goddesses and Wives" in Carolyn Mathiasson, op ciL, p. 108. 1 1 0 See Emiko Ohnuki-Tierney, Illness and Culture in Contemporary Japan, 1984, Cambridge, Cambridge University Press, pp. 181-188. 1 1 1 Ruth Sidel, Women and Child Care in China, 1973, Baltimore, Penguin, pp. 59-61. 99 no provision for midwifery service. Canada was one of these nine nations, and the only major industrialized nation without established midwifery services in the infrastructure of national birth attendance. The history of midwives in Europe reveals important variations: the promotion of scientific midwifery in France and Germany, for instance, contrasts with the general lack of publicly-sponsored midwifery instruction and government regulation in England. The conflict over midwifery in British North America reflected many of these European concerns. Much of the literature on midwifery in Canada is critical of the takeover of birth by physicians and the displacement of midwifery. Nevertheless, serious consideration must be given to benefits that have accrued from medical research, nursing and medical training. These benefits include a stronger knowledge base on pregnancy, birth, and child development, and the translation of this knowledge into improved clinical care. The point remains, however, that these benefits are not clearly predicated on medical dominance in childbirth. Substantial research and clinical programmes have been established in many countries worldwide in conjunction with developed midwifery programmes. Further work in understanding Canada's anomalous policy on midwifery could be connected with Upset's interpretation of greater deference to elites in Canada and the identification of deference as a trait in Canadian political culture. 1 1 2 Despite the renaissance of community midwifery and demands for direct entry midwifery training (autonomous midwifery), less than one percent of deliveries are planned, home births in North America. The midwifery conflict remains complex, however. Not all jurisdictions in Canada or the United States expressly prohibit the practice of community midwifery (or nurse-midwifery). 1 1 3 1 1 2 Seymour Martin Lipset, "Historical Traditions and National Characteristics: A Comparative Analysis of Canada and the United States", Canadian Journal of Sociology, 1986, 11(2), p. 138. According to Lipset, this diffuse respect for elitism is interpreted as greater encouragement of State powers in economic and social affairs. Edgar Z. Friedenberg, Deference to Authority: The Case of Canada, 1980, New York, Sharpe. 1 1 3 See Eleanor Barrington, Midwifery is Catching, 1985, Toronto, NC Press, pp. 140-141. State legislation of midwives is reviewed by Pacia Sallomi, Angie Pallow, and Peggy O'Mara McMahon, "Midwifery and the Law", Healthsharing, 1981, #21, pp. 63-83. 100 The regulation of midwives in British North America also varied from province to province. The variations in provincial statutes lend support to the historically specific nature of States as opposed to a monolithic view of State regulation of midwives. Federal, provincial, and state levels are not uniform in their statutes and may vary in their enforcement of these statutes. Historical accounts of midwifery in Canada have generally highlighted the struggle between men and women: the exclusion of women from the universities, and the ideology of a "proper sphere" of reproduction and domesticity. 1 1 4 The fault-finding remarks by some physicians toward midwifery practice are misplaced, especially concerning the competency of trained midwives practicing as an autonomous or semi-autonomous profession. As this Chapter has indicated, the general rejection of independent midwifery practice in North America stands in contrast to its acceptance in many other countries. The review of midwifery practice in Canada in the next Chapter provides additional support for the viability of regulated midwifery practice in home and hospital settings. 1 1 4 Ramsay Cook and Wendy Mitchinson (eds.), The Proper Sphere: Women's Place in Canadian Society, 1976, Toronto, Oxford University Press. 101 CHAPTER IV RESEARCH METHODS Introduction: Studying Childbirth This study attempts to overcome several methodological difficulties with previous research on midwifery in Canada. The first difficulty is that women's voices are often absent in accounts of childbirth and in other forms of research. 1 Notwithstanding the proliferation of specialized journals and organizations devoted to midwifery, it is still unusual to find detailed studies of midwifery, especially community midwifery, from the viewpoint of midwives. There are of course exceptions. The articulation of spiritual midwifery in the United States is one case-in-point. 2 Recent interviews with community midwives in Canada also reflect the consolidation of knowledge about modern practicing midwives. 3 The second difficulty is that the study of birth is dominated by medical and scientific evaluations of childbirth. Birth outcome data, socio-demographic or medical descriptions of clients or patients, and continuing debates over the appropriateness of maternity care provisions in the health sector tend to be appraised within a paradigm of scientific measures. The study of childbirth has been predominantly associated with medical research. Childbirth has been transformed into a medical phenomenon, flanked by legislation prohibiting non-medical attendance, and accompanied by a cultural expectation of medically-attended, hospital-situated births. 4 The obstetrical literature includes the central concern with reducing 1 See for example Margrit Eichler and Jeanne LaPointe, On the Treatment of the Sexes in Research, 1985, Ottawa, Social Sciences and Humanities Research Council of Canada; Helga E. Jacobson, "Women's Perspectives in Research", Atlantis, (1979), 4(2), 98-107. 2 Ina May Gaskin, Spiritual Midwifery, 1978 [revised edition], Summertown, The Book Publishing Company. 3 Eleanor Barrington, Midwifery is Catching, 1984, Toronto, NC Press. 4 Ann Oakley, "Wisewoman and Medicine Man: Changes in the Management of Childbirth" 102 rates of maternal and infant mortality and morbidity, the appropriateness of caesarean section operations, and other interventions alongside vaginal deliveries, the influence of diet and lifestyle on birth outcomes, and so forth. The corresponding model of pregnancy thus retains the traditional medical concern with disease and pathology. While childbirth is not identified as a disease akin to cancer, polio, or other diseases, it is seen as a process that can produce morbid conditions for mothers or fetuses. Some medical advances have in fact made major contributions in the management of pregnancies. Amniocentesis (analysis of amniotic fluid to check for congenital abnormalities of the fetus), ultrasound, and fetal heart monitoring are but a few of the technological approaches that can be utilized in the management of pregnancy and childbirth. The midwifery debate is thus not usually pitched as midwifery versus technology. Instead, serious concerns have been voiced about routine and unnecessary medical interventions in childbirth and how the excessive use of valuable interventions has dramatically altered women's experience of birth. The medical paradigm emphasizes the specific etiology of disease, the treatment of diseases and illnesses by a professional health care team, and the development of health care policy by professional consultants, researchers, and administrators. An overarching theme in health care is the rationalization of resources, including the centralization of health care resources. This paradigm of health care now represents the dominant way of perceiving health and illness and of organizing material and human resources. The upper level of the health care research hierarchy, as in scientific research generally, is predominantly male. 5 "(cont'd) in Juliet Mitchell and Ann Oakley (eds.), The Rights and Wrongs of Women, 1976, Harmondsworth, Penguin, 17-58. See also Diana Scully, Men Who Control Women's Bodies. 5 Specifically, research on reproductive technology tends to be carried out by male researchers. See the discussion by Angus McLaren and Arlene McLaren, The Bedroom and the State: The Changing Practices and Politics of Contraception and Abortion in Canada, 1880-1980, Toronto, McClelland and Stewart, 1986, pp. 144-145. 103 The hegemony of the medical paradigm has however been challenged by a folk model of health care. This model has roots in the Popular Health Movement and in a centuries-old tradition of community healing. 6 This folk paradigm is opposed to several tenets of the medical paradigm. Specifically, prevention of illnesses and disease is often sought through diet, stress reduction, visualization, and spiritual healing. Non-medical practitioners such as massage therapists, chiropractors, acupuncturists, herbalists, and naturopaths may also be involved in health care. Many forms of illness are seen as treatable by nonprofessionals or by self-help. Certainly the organization of health care administration and research and development has been criticized for the overrepresentation of men at the apex and for the dehumanizing treatment of women as patients and health care workers. 7 Finally, attempts to further centralize health care delivery are countered by local health care services, including maternity care centres and health collectives. 8 Alternatives to the medical perspective on birth have also been broadened through social research, including participant-observation studies. 9 These interpretive studies provide a greater appreciation of mothers' subjective experiences of birth. This complements the more tangible, "hard" measures of such variables as length of labour, parity (number of live births), and rates of infant or maternal mortality. There has also been a renewed interest in controlled studies of birth outcomes that compare midwife-attended home, births (and transfers) 6 Barbara Ehrenreich and Deirdre English, Witches, Midwives and Nurses, 1977(7), Old Westbury, New York, The Feminist Press. 7 Lesley Doyal with Imogen Pennel, The Political Economy of Health Care, 1980, Boston, Beacon Press. 8 For a discussion of feminism and collectivity in health care see Linda Light, Feminism and Collectivity: The Integrative Function, September 1981, M.A. Thesis, Unpublished, Department of Anthropology and Sociology, University of British Columbia. 9 For critical accounts of childbirth management in hospitals see: Sandra Danzinger, "Treatment of Women in Childbirth: Implications for Family Beginnings", American Journal of Public Health, 69(9), 895-902; and Michelle Harrison, A Woman in Residence, 1983, Harmondsworth, Penguin. A comparative view of birth in various settings is developed by Brigitte Jordan, Birth in Four Cultures: A Crosscultural Investigation of Childbirth in Yucatan, Holland, Sweden, and the United States, 1980, Montreal, Eden Press. 104 with physician and nurse-managed births in hospitals. 1 0 These studies are frequently used to bolster the claim that midwife assisted deliveries at home - with proper screening of mothers and fetuses and with skilled attendants present - do not pose a greater risk of maternal or infant mortality or morbidity. There are however opposing studies and viewpoints on the desirability of out-of-hospital births. This research project on Canadian midwifery was therefore designed to explore the safety of midwifery practices in Canada, and to link the findings with international studies of midwifery practice and development Research Design The medical and folk approaches to childbirth have influenced the design of my study. The medical-scientific influence on community midwives is reflected in improving documentation of their practices, more sophisticated equipment in their kits, examinations in clinical practice and theory, and the important liason with medical practitioners (e.g., screening out high-risk patients, and transfers to hospital during labour or post-partum). The influence of the folk model on hospital births is perhaps less dramatic: interventions in childbirth continue to be the norm, although there has been greater awareness of humanism and the role of family members in the management of childbirth. My study design began with standard medical variables, including obstetrical and gynecological histories of patients, kinds of medications and monitoring devices during labour, and Apgar scores (a composite score of the newborn's heart rate, respiratory effort, muscle tone, reflex irritability, and colouration). While it was possible to document many of these variables, limits of time and human resources required a selective approach. I broadened the study methods to suit the practices of midwives operating outside of hospital settings. These included a description of the number of births attended by nurse-midwives and community 1 0 Two widely cited American studies are: Lester Hazell, Birth Goes Home, 1978, Marble Arch, NAPSAC and Lewis Mehl, "Outcomes of elective home births: a series of 1,146 cases", Journal of Reproductive Medicine, 19(5), 281-290. 105 midwives, the location of these births, the kinds of management and interventions utilized, along with standard birth outcome data. This descriptive approach was supplemented by interviews of practicing midwives and by my examination of memoranda pertinent to midwifery in British Columbia. Another difficulty I faced was the time required to collect and analyze birth data gathered by community midwives. Midwives are notoriously busy with their practices, with a great deal of time devoted to prenatal care, consulations, postpartum checks, and attendance during labour and delivery. In addition, I was not personally acquainted with many practicing midwives, especially those who lived outside the lower Mainland region. Over a year was spent contacting these midwives by letter, using follow-up telephone calls or letters, and arranging meetings to discuss my study. There was an understandable reluctance to part with their documents, especially since very personal matters such as gynecological histories and marital relationships were often noted in prenatal visits. Some midwives were able to arrange drop-off of records personally or via friends, and out-of-province midwives usually enriched Courier services with their packaged birth records. From the initial 19 records handed to me by a B.C. midwife, the number of home birth records was gradually increased to over 1,000 cases of attempted home births. There were some irresolvable differences. Some midwives did not have copies of their records and were only willing to have me code the records in their homes. Since some B.C. midwives lived a day's travel from my residence, and since the coding could require four or five days' work, this arrangement was untenable and their records are not included in my analysis. Other midwives had records stolen from their vehicles and in at least one instance records were destroyed out of fear that they could be used as evidence in a court prosecution. The study methods are especially appropriate for the central problem of the research. The current status of midwifery in the context of State control becomes understandable 106 through a close examination of birthing practices, of the system of maternity care and its financial considerations, and through recent examples of prosecution of midwives through criminal law or quasi-criminal proceedings. The combination of documentary analysis, reference to case law and to the recommendations of Coroner's juries in Ontario and British Columbia, semi-structured interviews, and the available literature thus provides a backdrop against which the complex, containing function of the State is intelligible. The following sections elaborate on methodological procedures for the literature review, in-depth interviews, and my statistical analysis of midwifery practice in British Columbia. Literature Review The primary data gathered in interviews and through documentary analyses were set in context through a literature review. The review was initially used to determine issues surrounding midwifery practice. These included the controversy surrounding alternative (out of hospital) birthing centres, the viability of domiciliary midwifery, professional regulation and the organization of midwifery practice, and details of State regulation in various jurisdictions. The literature review began with a search of social science citations on midwifery between 1975 and 1984, using the Social Science Citation Index. The available literature on nurse-midwifery was traced through a "Medline" computer search of references in Index Medicus between 1977 and 1984. A supplementary Medline search was completed on references to birth outcomes between 1977 and 1984. These references centred on current issues in obstetrics: rates of episiotomy, forceps extraction, and Caesarean section; reduction of maternal and infant mortality; induction and augmentation of labour, among others. In addition, a search of legal periodical literature was undertaken to identify case law and legal commentaries pertinent to childbirth-related law. 107 These core searches were followed by reference to Current Contents, specialized journals such as The Practicing Midwife, The Journal of Nurse- Midwifery, and Mothering. Two Canadian-based periodicals - The Maternal Health News and Healthsharing were also consulted. Various newsletters from midwifery and consumer associations added to these sources of information. Articles from larger-circulation magazines served to round out the available literature on contemporary midwifery; and reference was made to historical accounts of midwifery in England, France, the United States, and Canada. Materials from the Public Archives of Canada and the Vancouver Public Archives were also used in the literature search. The theoretical dimension of the thesis was developed with reference to the growing literature on State theories and social control. The hegemonic status of liberal-democratic pluralism required attention to its precepts, particularly the notion that groups compete for political recognition within a general social consensus. Critical readings on the State have been integrated with the primary data and the available literature. Thus, the methodology has been to employ the primary data as a means of testing several assumptions about the manner of State intervention into health services, the interests served by this intervention, and the nature of resistance to State-defined social relations. The specific apparatus of legal authority is considered with respect to the special (monopolistic) status of the health professions. 1 1 This focus is then linked with the intricate connections between legal enactments, legal enforcement, and midwifery practice. 1 2 These considerations are inseparable from the cultural critique of contemporary medicine as profit-oriented, male-dominated, and undercutting the public interest in favour of professional self-protection 1 1 Eliot Freidson, Profession of Medicine, 1970, New York, Dodd, Mead and Company; Pierre Issalys, "The Professions Tribunal and the Control of Ethical Conduct among Professionals", McGill Law Journal, 1978, 24, 588-626. 1 2 Much of this material arises from litigation in the United States. See Mary Forrest, "Natural Childbirth: Rights and Liabilities of the Parties", Journal of Family Law, 1978/79, 17, 309-322; and Raymond DeVries, Regulating Birth, Philadelphia, Temple University Press, 1985. 108 and remuneration. 1 3 These considerations are also connected with sexual stratification in the health care sector. Women workers tend to be lower paid than males, and this appears true for midwives when compared with other obstetrical personnel. 1 4 This research project thus required the integration of two often disparate research traditions - state theory and professional influence - with feminist work on gender, health, and law. Sampling Procedures As the researcher became more familiar with a number of midwifery projects that had been attempted or were ongoing, it became clear that a fairly complete sample of practicing community midwives could be obtained. Since nurse-midwives tend to be employed as obstetrical nurses, there was a fairly small number of nurse-midwives who had contributed to the birthing clinic proposal for Vancouver in 1980, to the Low-Risk Clinic Project between 1981 to 1984, or to the recent Midwives' Programme at the new Grace Hospital. Some midwifery initiatives required an overlap of community midwife and nurse-midwife involvement These included media presentations (radio, television), lobbying government officials to establish Midwifery legislation outside of the British Columbia Medical Practitioners Act, plus the inauguration of a sub rosa Midwifery School in 1985 in Vancouver. The identification of these initiatives and the creation of a roster of people involved in them were facilitated through "snowball" - or chain referral sampling. A chain referral sample involves a number of referrals established through a network of people who know 1 3 The major work from a cultural viewpoint is Ivan Illich, Limits to Medicine, 1977, Harmondsworth, Penguin. 1 4 One writer mentions that the low salaries of nurse-midwives in Britain have contributed to a shortage of trained midwives. See Robert MacDonald, "Midwives in Britain handle 76% of the births", The Toronto Star, July 18, p. A16. Commumty midwives in British Columbia currently require between $600 and $700 for prenatal, postnatal, and labour and delivery services. As will be demonstrated, this does not provide a high standard of living, especially if travel costs, equipment, time, and risk of legal prosecution are considered. 109 each other. 1 5 It differs from random, representative sampling techniques in that the researcher does not have access to a standard information source such as a mailing list or a telephone directory; rather, direct references to other people is the central method for proceeding. The snowball approach has been widely used in sociological research, especially with populations who are difficult to contact through more conventional means such as telephone directories. It is an appropriate method for contacting individuals engaging in activities that are illegal. 1 6 Snowball sampling has been employed in earlier studies of midwifery and obstetrics. An anthropological study of the West African Bariba used the chain referral method to correct deficiencies in lists of officially-known indigenous midwives. 1 7 Snowball sampling was crucial in contacting community midwives in British Columbia and other provinces. Some community midwives had appeared on televison and radio programmes addressing midwifery, others had advertised their practices, and some had published monographs or made other contributions in print But only a small number of community midwives were this visible, so six community midwives known to the researcher were interviewed as a point of departure. These midwives had practiced in various regions of British Columbia - in Vancouver, in the Fraser Valley, on the Gulf Islands, and in the Kootenays - and had diverse bacgrounds. Some had completed nursing training; others had apprenticed as community midwives. They also differed in their affiliations: some were active in a Midwives' Collective, others were members of the Midwifery Task Force or the Midwives' Association of B.C., and some had contacts with other Associations in North America and Europe. These midwives knew one another personally but did not socialize together on a weekly basis. These midwives provided names of other midwives known to 1 5 Biernacki and Waldorf, "Snowball Sampling: Problems and Techniques of Chain Referral Sampling", Sociological Methods and Research, 10(2), 151. See also Nan Lin, Foundations of Social Research, 1976, New York, McGraw-Hill, pp. 162-163. 1 6 For example, see John L McMullan, " 'Maudits voleurs': Racketeering and Debt Collection in Montreal", Canadian Journal of Sociology, 1980, 5(2), 121-143. 1 7 Carolyn Sargent, The Cultural Context of Therapeutic Care: Obstetrical Care Among the Bariba of Bebin, 1982, Dordrecht (Holland), D. Reidel. 110 them in order that they might be contacted by the researcher, and the growing list of active midwives was increased further by contacts with people active in the Midwives' Association of British Columbia. The 1986 Conference - Midwifery in the Americas: Woman to Woman -attracted many other midwives to Vancouver. The author met several midwives from B.C., Saskatchewan, Manitoba, and Saskatchewan. After considerable discussion of my study and the problems of sending documents to me, all agreed to send material or to discuss this research project with other practicing midwives known to them. In some cases several weeks elapsed between this meeting and receipt of records. Approximately five community midwives from British Columbia and Manitoba did not provide records. Most of these midwives offered no explanation for their decision. One midwife was reluctant to release her records but expressed support for the study. Her suggestion that I travel to her home to examine the records was not feasible due to the distance and time required. Table Two outlines the representation of birth records by province. Table 2: Home Birth Records by Province n % British Columbia 613 61.9 Ontario 346 35.0 Saskatchewan 20 2.0 Other 11 1.1 Total 990 100.0 Source: B.C. Home Birth Records Community midwives are unregistered practitioners under current provincial legislation. In light of their outlaw status, few community midwives openly advertise their services. Most prefer to act less publicly, finding clients through word of mouth, self-referral, or through referrals from other midwives or organizations sympathetic to community midwifery. For sampling purposes, then, the most appropriate method of interviewing community midwives was 111 through the chain referral method. The pre-test interviews with midwifery lobbyists, lawyers, community midwives, and nurse-midwives provided a roster of currently practicing community midwives. This roster was then checked against the membership list of the Midwives' Association of British Columbia. The sample of nurse-midwives was also drawn through a chain referral method. Unlike the community midwife sample, this was not necessary for legal reasons. Nurse-midwives are able to practice obstetrical nursing under the provincial Nurses Act and they are not on the same precarious legal footing as community midwives. Rather, the difficulty is that the majority of certified nurse-midwives and obstetrical nurses in Canada are restricted in using their skills. In theory, if not always in practice, doctors are primarily responsible for the management of childbirth, including "catching" the baby. Since the focus of the research was on more autonomous midwifery practices it was not helpful to draw a random, representative sample of nurse-midwives currently registered in British Columbia. Instead, interviews were conducted with midwives who had contributed to the Low-Risk Clinic, to the new Grace Midwives' Project, to the grant proposal for an out-of-hospital Birthing Clinic, and to other attempts at innovative midwifery practices. For this sample and the community midwife sample, an attempt was made to interview each midwife to address the problem of skewed samples sometimes associated with the snowball sampling technique. 1 8 The scope of interviews and birth record data followed the contours of midwifery practice. For community midwives, most respondents were active in the lower mainland of British Columbia, the Kootenays, and to a lesser extent, on Vancouver Island and in the Okanagan Valley. Nurse-midwife initiatives tended to emerge from the more urbanized regions, especially Greater Vancouver. For the community midwives and the nurse-midwives, the researcher sought to gain as complete a sample as possible. Since the number of eligible respondents was fairly small this strategy was feasible; in a larger pool of eligible 1 8 David Downes and Paul Rock, Understanding Deviance, 1982, London, Martin Robertson. 112 respondents a randomized sampling approach might have been necessary. There were few refusals. Most midwives were quite agreeable to the interview, supplying their birth records and other documentation upon request, and all respondents were generous with their time. The face-to-face contact likely resulted in fewer non-responses than might have been expected with mailed questionnaires, particularly those requiring detailed responses. 1 9 Interview Frame The core interview frame for the study (see Appendix D) was adapted to the midwife respondents. Since training for nurse-midwives and community midwives was rarely identical -all nurse-midwives were trained in formal nursing or midwifery programmes while most community midwives had not completed these programmes but had learned through apprenticeship and their own empiric - the basic interview frame was designed to record such dissimilarities and also points of commonality, including opinions on specific issues in maternity and infant care. Semi-structured interviews with community midwives and nurse-midwives were used to complement the other sources of evidence. The interviews enabled the researcher to probe behaviours that were not usually available from the other sources: involvement with other health care professionals; contact with legal authorities and threatened legal action against midwives; training in midwifery and experience in maternity and infant care. The initial interview frame was developed from current literature on midwifery. The researcher provided the Consent Form (see Appendix C) to the respondent prior to the interview. Once the Consent Form had been signed by the respondent and the researcher, and dated, several general topics were covered in the interview. The initial questions were 1 9 Daniel Koenig, Gary Martin, and Lauren Seiler, "Response Rates and Quality of Data: A Re-Examination of the Mail Questionnaire", Canadian Review of Sociology and Anthropology, 1977, 14(4), 432-438. 113 very open-ended, dealing with why the respondent became a midwife, and how she justified midwifery. This open question occasionally had a chilling effect, but most midwives articulated their attachment to midwifery at some length. This enabled the respondents to sketch the elements of midwifery they perceive as most important in their decision to enter midwifery. Specific data on training - e.g., state-certified midwifery [Britain], certified nurse-midwifery [United States], empirical training, and so forth - were often elicited; when they were not, the researcher probed for details of training. Subsequent questions dealt with the capacity in which the respondent attended births. Most began as apprentice midwives, later moving into primary caregiving and, in many cases, into partnerships with another midwife. The years in which births were attended, the number of births for each year, and reasons why the respondent might have undertaken fewer births in a given period were also determined. Additional information on the number of prenatal visits, timing of visits, and philosophy concerting prenatal care were noted. The management of labour, delivery, and the postpartum period is central to the work of midwifery. Questions about screening of clients were asked in a structured fashion to begin with. This included asking the respondents if they would screen out (i.e., refer them elsewhere or simply decline to see the client in future) clients for such reasons as breech presentation at term, previous caesarean section, epilepsy, gestational diabetes, smoking during pregnancy, home birth. Respondents were then asked if they referred to a written set of guidelines or standards regarding contraindications to attendance. Additional information included their "transfer rate" to other settings. For community midwives, this involved transfer of women in labour or after delivery to hospital; for nurse-midwives, transfer usually involved the movement of women to another setting within the hospital or the involvement of other specialists when complications arose. These verbal reports were combined, where possible, with documentation of birth attendance. These documents dealt explicitly with birth outcomes, including rates of forceps delivery, caesarean section, induction, episiotomy, and the like. This 114 information was crucial with respect to the continuing debate over unnecessary interventions and the contention that midwives can lower intervention rates without jeopardizing the safety of mothers or infants. The section on optimal structures for birthing in British Columbia augmented the above information. This allowed the respondents to reflect on what could be (or what ought to be) in place. This was a useful point of departure for the companion questions on the role of the State in encouraging or impeding optimal maternity and infant care. The specific role of the legal sector in regulating birthing - through the monopoly status of doctors and nurses, and through criminal sanctions that can be brought against birth attendants - helped to illuminate the relationship of State intervention to occupational practices. This was especially useful in probing the controversial issue of whether the State should be involved in establishing standards of care, and if so, what considerations should be foremost The final part of the Interview Frame consisted of specific social and demographic information on each respondent Marital status, age, educational level completed, personal income and family income (where appropriate), religious or spiritual affiliation, associations and memberships, nationality, and the like were queried. This helped to round out the profile of respondents and to provide valuable detail on how midwives are able to practice (what resources are available to them), and the general nature of contemporary midwifery. The interview frame developed through the pre-test and subsequent interviews thus allowed a good deal of construct validity. Since, as a researcher, I was not involved as a practitioner, the midwives were able to reflect on the questions set out and to suggest other significant aspects for midwifery practice in particular regions of British Columbia. The interview frame was used, where applicable, in the four interviews with non-midwives. Two lawyers, a nursing educator, and a lobbyist for midwives were interviewed to determine their views on the midwifery debate in British Columbia. 115 The researcher decided against interviewing physicians during the course of data collection. In part, this reflected the illegal status of community midwives. Since the researcher could not be guaranteed that the documents in his possession or his knowledge of particular midwives' practices would not be used in a police investigation or trial, it was best to restrict interviews to the midwifery community at this point. Moreover, given the effort required to gather and code the midwives' documents, there was little time during the study when the author could have scheduled several interviews with non-midwives. Reference is made in Chapter Six to some critical reflections by physicians on unregulated midwifery practice. Physicians' and nurses' views on optimal maternity and infant care are needed to complement the materials gathered in this project Interviewing Techniques Interviews were designed to allow the researcher and the respondent to cover a variety of issues in a relaxed manner. Two to three hours were allotted for the interview: In some cases this allotment was exceeded; in others the interview took place in two or three installments if the respondent was unable to meet for a lengthy time-bloc. The pre-test interviews confirmed that the complexities of midwifery practice and of the political context in which it occurs could not be covered in depth in less than the three hours. A few midwives, who had practiced for several years and attended a few hundred births as a primary caregiver, were interviewed for several hours. The interviewing strategy required a sensitivity to possible sources of distortion in respondents' accounts. Probes were used to clarify what the respondent mentioned. 2 0 "Triangulation" techniques - reference to other sources of information - was employed to supplement or cross-check the interview data. Birth records were one source of verification; records and recollections of other midwives involved with the particular respondent were other 2 0 Seymour Sudman and Norman Bradburn, Asking Questions: A Practical Guide to Questionnaire Design, 1983, San Francisco, Jossey-Bass. 116 sources. 2 1 The semi-structured format also avoided some of the difficulties associated with pre-figured, closed interview formats. 2 2 At the same time, the interview strategy and frame allowed for comparability of data. This offset the possibility that a completely open format might result in fairly idiosyncratic material that could not be comparatively assessed. Documentary Evidence Birth records are a valuable source of descriptive information about the management of birth, the number of prenatal and postnatal visits recorded by the midwives, birth outcome, and aspects of the woman giving birth. In this study, the documentary analysis began with records of attempted home deliveries with midwife assistance. This sample of records includes planned attempts to deliver at home, whether the delivery was completed there or not, regardless of the birth outcome. A preliminary sample of 440 home birth records was gathered from midwives primarily active in Vancouver, the Fraser Valley, and the Kootenays. These records were examined and numerous variables were coded on Fortran sheets using a preliminary codebook. 2 3 The codebook served to quantify numerous variables associated with the management of labour and delivery. For example, the three stages of labour indicated on the home birth records were noted. The first stage is conventionally recorded from the onset of regular contractions to full dilation (10 centimetres) of the cervix. This stage is usually far longer than the other two stages, averaging 12 hours for primagravidas and about six hours for multigravidas. 2 1 Biernacki and Waldorf, op ciL, p. 150. 2 2 For a demonstration of the differences in responses associated with different formats see Howard Schuman and Stanley Presser, "The Open and Closed Question", American Sociological Review, 1979, 44, pp. 697-712. 2 3 Earl Babbie, The Practice of Social Research, 1979, [second edition], Belmont, Wadsworth, pp. 367-369. 117 The second stage of labour lasts from full dilation to delivery of the fetus. For primigravidas its duration is about one hour; for multigravidas this stage averages 20 minutes. The third stage begins from the time of delivery of the baby until the placenta is delivered. Usually the placenta is delivered spontaneously, although it may also require manual assistance or oxytocin for its expulsion. 2 4 Normally, labour is expected to be completed within 24 hours of onset of regular contractions. A fourth stage of labour may also be denoted. This stage lasts until about two hours after the placenta is delivered. Birth attendants are watchful of post partum complications, including haemorrhage or other kinds of excessive bleeding. Other variables recorded included the duration of active labour and specific information on the mother giving birth. Data on the woman (or couple) electing home deliveries were quite limited. Nevertheless, age of the mother, her parity (number of previous pregnancies), and gravida (number of live births), along with information on previous births where applicable were frequently indicated on the records. Reasons for electing a home delivery were quite instructive. In most cases this involved a feeling that hospital deliveries were inappropriate with respect to interventions during labour and delivery, separation of mothers from newborn babies, and a general sentiment that giving birth in the presence of people one knows well can foster a healthier birth for mothers and infants. A central issue in the midwifery debate is whether midwives can reduce such interventions as episiotomy, caesarean section, forceps delivery, induction and augmentation of labour while maintaining safety of the mother and child. These two dimensions were quantified for the home birth records and then compared with similar statistics from hospital-situated deliveries. The records also traced the rate of transfer from an attempted home delivery to hospital as well as calls to paramedics for resuscitation or transfer to hospital. 2 4 For a thorough coverage of the duration of these stages of labour see Margaret Jensen et al, Maternity Care: The Nurse and the Family, 1979, St Louis, C.V. Mosby, p. 423. 118 Once the preliminary coding of 206 births was completed by the researcher, the preliminary codebook was taken to two senior community midwives for their comments. A physician and a nurse-midwife were also consulted and suggested changes to the codebook. These suggestions included more precise notations of delivery positions, inclusion of diverse measures of perinatal and neonatal mortality, and recording the time elapsing between rupture of the membranes and birth (to establish if serious infections resulted from prolonged rupture of the membranes before birth). A nurse-midwife also made several suggestions for revising the codebook, especially with respect to possible statistical comparisons between births at home and births in hospital. With her suggestions in mind, the preliminary codebook was tentatively revised. The revised codebook (Appendix B) and the Fortran sheets on which the 206 births were coded were then taken to three practicing midwives who were involved in most of these births. Their reflections on the codebook and on the Fortran data were helpful in correcting mistakes, in filling in missing data, and in providing construct validity due to their familiarity with the situations documented in the birth records. At this point the remaining home birth cases were coded, either by the researcher or by research assistants under his supervision. A central guideline during the coding was that missing data would be inserted only if adequate documentation could be secured or if the primary care midwife was certain about missing data. Guesswork was strongly discouraged. The midwives were urged to not guess at information or speculate as to what might have happened. Missing data were thus left blank on the coding sheet Where they could be determined, they were entered subsequently into the data file; where they were not recoverable, they were coded as "not available" for data analysis purposes. All files were then checked by the researcher for accuracy, missing data, and possible recoding. The coding sheets were then submitted to the Data Entry Services department at the University of British Columbia Computing Centre. Each case was entered as machine-readable data, and analyzed using S.P.S.S. (Statistical Package for the Social Sciences). 119 Care was taken to insure that it would be impossible to identify any individuals through the use of the data. Documentary evidence from nurse-midwife assisted births was comparatively small. The birth records from the Low-Risk Clinic 2 5 and from the Grace Hospital Midwifery Programme were gathered to provide an initial point of comparison. Where possible, these statistics were compared against hospital-wide statistics within these hospitals, and with with province-wide intervention statistics and birth outcomes. 2 6 Each birth record in this study was treated as a single case. The statistical analysis began with the birth of each child, indicating how many birth attendants were involved, the date of delivery, and so forth. As set out in Appendix B (Codebook), other variables included the city or region in which the birth occurred, mother's age, gravida (number of pregnancies during the woman's lifetime), and parity of the mother, previous home births by the mother, diet, number of prenatal and postnatal visits by the midwives, time of each stage of labour, birth outcomes and interventions, transfers to hospital and calls for paramedics (where applicable), baby's weight and sex, information on the delivery of the placenta and suctioning or resuscitation procedures. Summary This study explores several dimensions of community and nurse-midwifery practice. Through interviews and documentary analysis a profile of midwifery as an occupation is developed and linked with the literature on medical dominance and occupational resistance to 2 5 The report of the Project Team included numerous measures of the clientele, surgical interventions, and birth outcomes. See Elaine Carty et al., The Low-Risk Clinic: Family Care Based on the Midwifery Model, 1981-1984, 1984, Vancouver, Shaughnessy Hospital and University of British Columbia, School of Nursing. 2 6 Roger Tonkin, Child Health Profile: Birth Events and Infant Outcomes, 1981, Vancouver, Hemlock Printers. Dr. Tonkin's study was largely concentrated on the period between 1971 and 1979. Additional data were obtained from Statistics Canada, Births and Deaths, and Surgical Interventions and Treatments. 120 monopolies such as the medical profession. A central dimension is the manner of State intervention in birthing. This is tapped through the available literature on the State (see Chapter Two), case law pertaining to criminal and quasi-criminal prosecution of birth attendants, instances in which B.C. midwives have been subject to legal threats or investigation, and the wider structuring of patterns of health care practice under the aegis of the State. The State is conceptualized within a structuralist framework for contemporary purposes. This reflects the limits of instrumentalist approaches to the State and the professions. Instrumentalism fails to consider the benefits offered through State intervention and professional service, does not account for fractions within the State and the professions, and fails to recognize that State officials can be held accountable for policy decisions and that affect the public interest Several methodological approaches are combined in this project The available literature was used to isolate significant issues in the midwifery debate and to complement the primary data analysis. The primary data were gathered through qualitative and quantitative sources. Quantitative data were obtained via semi-structured, in-depth interviews with practicing community midwives and practicing nurse-midwives and through interviews with other people who were active in obstetrics and gynecology, teaching, or lobbying for more autonomous midwifery training, licensure, and practice. The interviews were conducted with samples of midwives drawn through a chain referral technique, accompanied by a cross-check of membership lists where possible. This sampling technique was necessary since a roster of independently practicing midwives is not readily available for nurse-midwives or community midwives. The interview data were transcribed in point form, numerous details were coded and statistically analyzed, and selected passages pertinent to the study are reproduced verbatim throughout this report Quantitative data were secured through an examination of birth records. The final set of birth records involved over 1,000 cases of attempted home births in British Columbia, Ontario, and Saskatchewan between 1972 and 1986. Information on women seeking to birth at home, the nature of prenatal and postnatal care, and labour and delivery, 121 were coded and analyzed using S.P.S.S.. These records were then compared, where possible, with province-wide statistics on hospital-based births, complemented by statistics from particular hospitals and specific programmes, especially demonstration projects in which midwives were the designated primary caregivers. The home birth records were cross-checked through other sources to obtain missing information and to check the accuracy of data initially gathered. It was thus customary to probe respondents' answers during the in-depth interviews. Moreover, coding of birth records was cross-checked with the primary care midwives to identify discrepancies between reportage and recall, and also to obtain information that was not set out in the birth records. Validity checks were also made by comparing multiple records (of the same birth) provided by midwives. The pre-test phase of research involved interviews with five nurse-midwives, eight community midwives, and four persons who were either lobbyists for midwifery, nursing educators, or lawyers who had been involved either in midwifery litigation or in providing advice to midwives. Following the pre-test phase, the interview frame for practicing community midwives and nurse-midwives was refined. This involved the addition of more specific questions on their experiences with State regulation (actual or threatened prosecution, containment of their scope of practice). The interview frame was also altered in the interest of clarifying obstetrical procedures and terminology. The interview frame for the sample of non-midwives was semi-structured, including several standard questions about the viability of midwifery practice and the appropriate role of trained midwives. Some problems were not resolvable in the course of research. Some midwives indicated that they were too busy to participate in the augmentation of data phase, while others no longer had pre-natal records (the records had been passed on to the client, had been destroyed by the midwife, or had been stolen). Again, the face-to-face contact or being vouched for by a midwife known to prospective contributors seemed to be vital in securing 122 these documents. Extensive attempts have been made by the researcher and research assistants to record as much information as possible from the available records. Documents were examined carefully, and the augmentation phase of research provided either new information or correction of earlier codes. Nevertheless, where Apgar scores were not recorded, family income, and so forth, guesswork was not encouraged, and these blanks in the data set remain. This said, the data gathered here represent the largest number of attempted births managed by community midwives and they are interpreted in greater detail than in any previous accounts. 123 CHAPTER V COMMUNITY MIDWIFERY AND NURSE-MIDWIFERY "Pessimists may comment that one should not aspire to natural childbirth in case complications develop. This is like saying one shouldn't bond with the baby in case it dies, or one shouldn't fall in love in case one gets hurt. Such timidity and antilife sentiments lead to self-fulfilling prophecies and deny the human potential to respond to the unexpected." 1 "The autonomous midwife - frequently self-trained - is a major anomaly in Canadian health care...Over 200 midwives ...have provided care for thousands of women in their homes over the past 15 years in Canada. This is a situation that organized medicine, nursing and properly trained midwives should not contemplate with satisfaction." 2 Introduction The above excerpts illustrate the diversity of opinion surrounding the proper sphere of midwifery. The growth of the "New Midwifery", a form of community midwifery rooted in home birth and intensive prenatal and postnatal care, has attracted great controversy since its appearance in B.C. in the early 1970s. This chapter presents a detailed examination of midwifery practice and birth outcomes, primarily using B.C. data in combination with documentation from Ontario and Saskatchewan and, where possible, national statistics. This form of community midwifery has endured despite legal prohibition. Community midwives in Canada derive incomes from their practices, obtain necessary supplies and equipment, and are active in lobbying for recognition through the State. For example, the 1 Elizabeth Noble, Childbirth with Insight, 1983, Boston, Houghton Mifflin, p. 15. 2 Robert A.H. Kinch, "Midwifery and Home Births", Canadian Medical Association Journal, 1986, 135(4), p. 280. Dr. Kinch favours the accreditation of Canadian midwives and the elimination of the self-taught midwife. 124 Midwives' Association of B.C. (MA.B.C.) lobbies for legalized, autonomous midwifery and to develop guidelines for midwifery practice. They consult with sympathetic medical and nursing practitioners, and only a few births out of thousands assisted by community midwives in Canada have resulted in criminal prosecution or prosecutions for violation of the B.C. Medical Practitioners Act. However, community midwifery is marginalized and illegal. Out-of-hospital births comprise less than one percent of births in British Columbia (and nationwide). Community midwives are unable to bill for their services through the provincial Medical Services Plan and they do not have established hospital privileges. Community midwives are also more likely than medical personnel to be prosecuted for criminal negligence causing death. They are also subject to the quasi-criminal charge under the Medical Practitioners Act of practicing medicine without a license. Community midwifery in Canada illustrates the structural limits placed on female birth attendants working outside the norm of professionally accredited, hospital situated childbirth. In spite of these limitations, for the past 15 years a debate over childbirth attendance has been evident in Canada and other industrialized countries. This debate addresses several issues: maternal and infant wellbeing throughout pregnancy, delivery, and the postnatal stage; women's control over pregnancy and childbirth; personal liberty and the overreaching powers of the State (including the institution of the hospital and powers allotted to the professions). There is concern over the increased use of childbirth technology in labour and delivery, and what some regard as the alienation of health care practitioners from their direct work with women. 3 In recent years, several midwives attending home deliveries have abandoned the term "lay midwife". The connotation is one of the laity, of hierarchy, and has long been 3 William Ray Arney, Power and the Profession of Obstetrics, 1982, Chicago, University of Chicago Press, p. 9. See also Stewart Wolf and Beatrice Bishop, The Technological Imperative in Medicine, 1981, New York, Plenum Press. 125 connected with unprofessional standards. Community midwifery emphasizes the decentralized nature of childbirth attendance along with the more personal emphasis between the community midwife and her constituency. The sphere of practice is a continuing issue among midwives. The International Definition of the Midwife adopted by the International Confederation of Midwives clearly sets out a broad range of activities that can comprise midwifery. The midwife can be active during pregnancy, labour, delivery, and the postpartum period. She is also able to detect abnormal conditions (although a doctor should be summoned) and to work in domiciliary settings as well as hospitals, clinics, and the like. The sphere of practice also stipulates that midwives should be sensitive to the client's right to make decisions about the place of birth and general care. 4 COMMUNITY MIDWIFERY PRACTICE IN CANADA The community midwife network in British Columbia is complex. Most midwives have learned their skills through a mixture of apprenticeship with senior midwives, their own empiric, reading, and some have moved into community midwifery after completing formal nursing requirements. The dichotomy between the traditional midwife and the professional midwife seems more appropriate for non-Westernized societies in which there may be substantial gaps in literacy, formal education, knowledge of hygiene and birth management between the two groupings. 4 International Federation of Gynaecology and Obstetrics (F.I.G.O.) and the International Confederation of Midwives (I.C.M.), "International Definition of Midwifery", Maternity Care in the World, (second edition), 1976, pp. x-xi. 126 Empirical Training and the Midwifery School One development in the community midwifery movement has been the extension of formal instruction into the movement. A full year of academic training was recently completed sub rosa by 17 students through a Midwifery School established in Vancouver by local community midwives and some of their supporters. 5 The academic phase, paid for by the students, staffed by trained nurse-midwives, and examined by midwives with International training is followed by a clinical phase of perceptorship. While many of the new community midwives have not completed formal nursing requirements, a number of British Columbia midwives are either registered as (or are eligible to join) the Registered Nurses' Association of B.C. One practicing community midwife expressed her ambivalence toward formal nursing training in childbirth: "The nursing (training) was a mixed blessing. Nursing gave me a lot of the skills. I was comfortable giving injections, comfortable with catheterizations, with taking blood pressure and pulse, just those basic nursing skills that a midwife apprentice has to learn. And it can be difficult learning those skills. The thing that was really difficult for me was that even though I basically knew that women could birth babies, and birth them graciously and have them at home, it took me a long time to understand that on a gut level, and to really believe, yes, that women could give birth." (Community midwife #3, February 1985). Thus, the complex relationships between State and community initiatives are again evident. Against the norm of professionalized nursing — situated in the hospital and supervised by physicians — some nurses have opted for community midwifery practice. Others have contributed to an unlicensed, unrecognized Midwifery School. One irony here is that accreditation for this School is currently being sought through Washington State, even as efforts continue to lobby for legalized midwifery in British Columbia. Some out of province midwives report attending workshops as a form of instruction. A 5 See Cheryl Anderson, "Midwifery and the Family Physician", Canadian Family Physician, 1986, 32, p. 11. 127 Manitoba community midwife noted:6 "After those first four births I went and took a very good workshop in Vancouver. I invested money and bought books and equipment and felt a little more like I knew what I was doing...." Teamwork A general principle is that community midwives prefer to assist in labour, and delivery with at least one other midwife present It is rare for birth attendants to attend births by themselves, with the possible exception of emergency situations when another midwife or birth attendant cannot be present The philosophy of the Freemont Birth Collective is clear on this point: two midwives are ordinarily present for births, sometimes a third, but never one. 7 There are instances where a midwife may assist at a precipitous labour and delivery by herself but these are not planned. A senior midwife (CM #2) explained that of over 200 primary care births only one or two were conducted without another midwife present There is a commonsense basis to this. Midwives are likely to encounter situations which require the skills of two attendants. "Probably the highest stress of any year in my practice was handling all the responsibility at births for about a's a huge disadvantage, there is no advantage as far as I am concerned. It's really high stress. And it's really important to have a second opinion, especially if you are emotionally involved and often you have an attachment to the woman. It is helpful to have someone present who doesn't have that rapport and who can look at it more objectively. The turning point for me was when I did a birth alone (in an area where a hospital was not at hand). The woman had a precipitant labour, one hour start to finish for her first birth, which runs a lot of risk for the mother and the baby. The baby didn't breathe and the mother had a massive post-partum haemorrhage. There was a real sense of having only two hands...the father completely flipped out and left the room. It was managed by giving the mother an injection to stop the bleeding with one 6 See Ya'qub ibn Yusuf, "Learning from Birth - an interview with midwife Darlene Birch," Chautauqua Review, Summer 1984, #2, pp. 13-23. 7 Freemont Birth Collective, "Lay Midwifery - Still an 'Illegal' Profession", Women and Health, 1977, 2 (3), p. 20. 128 hand, and using the other hand to stimulate the baby... That was the last time I did a birth alone" (Community midwife #4, March 18, 1985) Community midwives also maintain contacts with general practitioners. This may involve referrals of the midwife's clients to a physician for a check-up; in other cases the contacts are more direct "The back-up physician for one birth had been at the home, as a friend only, and had been completely informed about the care of this client The physician knew an hour before we arrived that (this client) would be transferred from home to hospital. S/he called in a specialist that we knew would not be hostile: this specialist likes women and is cooperative with us...I knew there would be no repercussions against any of us because the whole team had been in on it" (Community midwife #4, March 18, 1985) Collaboration between general practitioners and obstetricians and the community midwives indicates that midwifery is not entirely an oppositional movement, and that there are some medical personnel are sympathetic to the midwives' efforts to reestablish more autonomous midwifery services. Caseload The available literature on lay midwives indicates that caseloads are not particulary high, perhaps because of the organization of lay midwifery practice relative to more formalized practices of obstetricians and general practitioners. A midwifery practice shared by two midwives in a rural area of Montana ranged between 20 to 30 women. 8 Community midwives in British Columbia generally report that they have more demand for their services than they can provide. It is now fairly common for a community midwife to attend between two to four births monthly. This caseload allows a sufficient monthly income for midwives. It also is a manageable number since the midwives' time must be allocated to prenatal visits, postnatal check-ups, time with the midwives' own family (most community midwives have 8 Joyce Sutley, "Montana Midwife", Mothering, 1982, #24, pp. 80-81. 129 children). This varies considerably but is usually constrained by the time midwives devote to prenatal and postnatal visits with clients, time with their own children, and meetings and formal instruction. Barrington found that contemporary community midwives in Canada play many roles: 9 "She is a domestic helper, a community worker, and a feminist health activist. Chances are, she is also someone's mother and someone's sweetheart A midwife doesn't get much sleep!" Community midwives interviewed by the author also reported that their work was very demanding. They were usually "on call" for their clients, care for their children was not always at hand if they were called to a birth, and financial pressures added to their stress. It is noteworthy, however, that a number of these midwives have since restricted their caseloads and made arrangements for childcare and some additional time for themselves. Fees and Payment: "Eggs for a Year" The term "fees" may be inappropriate since lay midwives have not always stipulated a fee, and there is evidence of lay midwives accepting payment "in kind" in lieu of cash payment 1 0 In a discussion with a senior community midwife in 1987 she mentioned that she had been given "eggs for a year" after attending a birth in the Kootenay region of B.C. An important change has been a clear trend toward more standardized cash payments. The early days of the New Midwifery, where spiritual inclination was emphasized, has shifted toward a more businesslike stance. The days when a midwife took the bus to a birth or hitch-hiked (because she could not afford a car) have passed. Fees also have a professional connotation, something that lay midwives may wish to avoid since hypothetically it could bolster allegations that they are practicing medicine without a license. One lay midwife in British Columbia charged $400 in 1983 for prenatal and postnatal care, labour, and delivery. 1 1 Currently, midwives interviewed by the author charge approximately $600 for this package. 9 Eleanor Barrington, Midwifery is Catching, 1985, Toronto, NC Press, p. 14. 1 0 Campbell, op cit, pp. 45-47. See also Sandra Klein, A Childbirth Manual, 1980 (revised) Victoria, B.C., Typescript Mimeo. 130 Community midwives enjoy tax advantages since they are self-employed. Supplies, transportation costs, costs of electricity, telephone, and office space can be calucalated and deducted as employment expenses when midwives report their self-employed income to tax authorities. Supplies Another difference between lay midwives historically and their contemporary, North American counterparts is the latter's access to medical supplies and equipment These could include oxygen, intravenous equipment, drugs, and so forth. The establishment of professional medical and nursing schools and practice has been accompanied by a degree of control over birthing supplies as well as technical knowledge and practice. Community midwives in B.C. have access to surgical gloves and scissors, oxygen, pitocin. It has been observed that practicing midwives in British Columbia have fewer difficulties obtaining such supplies than midwives in the United States, as a rule. 1 2 One lay midwife relied on oxygen supplies, a fetal monitor, and (unspecified) drugs in her practice. 1 3 A variety of technological aids including telephone answering machines, pagers, and answering services are also commonly used by community midwives. A number of community midwives have completed nursing training, while others have empirical training and the option of study within the Midwifery School. The question remains: to what extent is this control partial, how accessible are supplies to non-professional birth attendants in various locales? Home Births by Province and Year "(cont'd) 1 1 Tim Padmore, "Vancouver Hospital Tries Midwifery Program", The (Montreal) Gazette, February 21, 1983, p. A7. 1 2 Paula Brook, "Midwives and Medicine", The Magazine, May 18, 1980, p. 6. 1 3 Tim Padmore, op ciL 131 The records used for the documentary analysis were drawn primarily from community midwives who were active in British Columbia, Ontario, and Saskatchewan. 1 4 A few records from Manitoba, New Brunswick, California, and Washington State are also included. The entire sample of records spans the period between 1972 and 1986, with most records concentrated in the 1980s. The difficulty in obtaining records from 1972 to 1977 is apparent in this Table. A number of the midwives who were active with a Birthing Centre in Vancouver and in attending births have since moved out of province. Moreover, record-keeping for many midwife-assisted births in this period was not extensive. This stands in some contrast to the current emphasis on careful charting of prenatal and postnatal developments, as well as labour and delivery. Nevertheless, the bulk of births analyzed in this chapter occurred between 1978 and 1986, and primarily in British Columbia and Ontario. Clients The clients of community midwives vary considerably within British Columbia. There has certainly been a stronghold of New Age philosophy in the Kootenays, where alternative lifestyles have taken root including adaptation of Navajo rituals, traditional healing, and the like. " There is clearly an expectation by community midwives that their clients should take precautions against poor nutrition and other factors that might pose problems for the fetus or mother. The following outline of the "Parents' Role and Responsibility" is part of an Informed Choice Agreement prepared by two senior community midwives in B.C. 1 4 There appears to be a lower proportion of home births in Saskatchewan compared with British Columbia. One source indicated that there were approximately four births per month in Saskatoon. See Cindy Devine, "Childbirth Surrounded by Myths, lack of medical information", Network of Saskatchewan Women, 1981, 1(3), p. 6. 1 5 The most extensive work on community midwives in Canada, including the Kootenay midwives, is Eleanor Barrington's Midwifery is Catching, Toronto, NC Press, 1985. 132 Table 3: Home Births by Year and Province YEAR B.C. Oni Sask. Other Total 1972 1 0 0 1 2 1973 6 0 0 1 7 1974 1 0 0 0 1 1975 0 0 0 0 0 1976 2 0 0 0 2 1977 22 0 1 0 23 1978 51 1 0 2 54 1979 40 16 4 0 60 1980 32 10 2 0 44 1981 57 54 2 3 116 1982 57 74 4 1 136 1983 59 39 1 3 102 1984 63 58 2 3 125 1985 81 59 3 3 146 1986 23 33 1 0 57 Total 495 344 20 17 875 Source: Home Birth Records. "We request that the mothers we are involved with be responsible about the health of themselves and their babies, follow a balanced diet, receive good prenatal care and get adequate sleep and exercise. We also request that the couple acquire knowledge and skills necessary for labour and birth and relaxation, either through completion of prenatal classes, or a sufficient programme of self education. A midwife's care is individualized according to the clients she serves. It is important for you to make her aware of your expectations. In order for us to be effective as caregivers, we require that parents keep us well-informed as to problems or situations which may affect their care." 133 The natural childbirth style is often captured in the mother's intention to breastfeed. Of all the women attempting to deliver at home, 99.5% intended to initiate breastfeeding. This percentage even exceeds the 93% figure of breastfeeding among members of a Parents' Choice sample; i.e., women inclined to breastfeed their infants, on discharge from hospital. 1 6 The ages of women attempting home births ranges between 17 and 42 years. Two age-groupings that are at greater statistical risk of birth complications were underrepresented in this sample. Only a few teenagers attempted a home birth, and there were few women over 35 years of age in the home birth sample. 1 7 Other midwives practicing in Alberta report a similar profile of clients' ages. Their ages ranged from 20 to 42 years old, with an average age of 28.3 years. 1 8 Table 4: Ages of Home Birth Clients and Women Giving Birth in Canada Home Birth B.C. Canada Ages N % N % N % 15-19 9 1.1 2,348 5.4 22,090 6.0 20-24 154 18.4 11,212 26.0 98,272 26.8 25-29 317 37.9 16,349 37.9 143,386 39.1 30-34 268 31.9 9,990 23.2 79,121 21.5 35-39 84 10.0 2,914 6.8 21,048 5.7 40-44 6 0.7 287 0.7 2,400 0.6 Total 838 100.0 43,100 100.0 366,317 99.7 1 6 Other comparison groups in a Vancouver-based study did not rely so extensively on breastfeeding. Specifically, the percentage of women who initiated breastfeeding, by ethnicity, was as follows: English-Canadian (79%), East Indian (59%), Italian (50%), Greek (47%), and Chinese (31%). See C.F. Bradley et al., Perinatal Health for the City, Vancouver, Vancouver Perinatal Health Project, 1978, pp. 18-19. A study of 123 Malaysian women found that 75% breastfed their babies, 22% combined breastfeeding with bottlefeeding, and only three percent used formula milk exclusively. See Carol Laderman, Wives and Midwives: Childbirth and Nutrition in Rural Malaysia, 1983, Berkeley, University of California Press, p. 84. 1 7 The median age of 28 years is squarely in the middle of the childbearing years. The average age for women (having live births) in Canada in 1985 was 27.3 years, and the median age was 27.1 years. Statistics Canada, Births and Deaths: Vital Statistics 1985, November 1986, Ottawa, Supply and Services Canada, p. 17. 1 8 Noreen Walker, Sandy Pullen, and Marilyn, "Domiciliary Midwifery Report: 1980-1985", Safe Alternatives in Childbirth, Edmonton, 1986 (March/April), 3(2). 134 Sources: (1) Home Birth Records; and (2) Statistics Canada, Births and Deaths: Vital Statistics 1985, November 1986, Ottawa, Supply and Services Canada, pp. 6-7. Gravida and Parity (Pregnancies and Births) of Clients The number of pregnancies and previous births are two significant variables in establishing a client profile for community midwifery. Gravida refers to the number of times a woman has been pregnant, including her pregnancy at the time she is seen by the midwife. Parity indicates the number of times she has given birth. Table 5: Gravida and Parity of Home Birth Clients Gravida Parity N % . N % None N.A.* N.A.* 411 40.9 One 220 22.1 369 36.7 Two 318 31.9 162 16.1 Three 247 24.8 42 4.1 Four 123 12.4 16 1.6 Five 50 5.0 3 0.3 Six 25 2.5 2 0.2 Seven 7 0.7 0 0.0 Eight 1 0.1 0 0.0 Nine 2 0.2 0 0.0 10+ 3 0.3 1 0.1 Total 996 100.0 1,006 100.6 Source: Home Birth Records. * The minimum gravida is one. This measure includes the current pregnancy at the time of contact with the midwife. 135 A minority of the sample (22.2%) had previously given birth at home. Most of these women had just one previous home birth (n =156), twenty-one had two previous home births, and one Mennonite woman had seven previous home births. 1 9 Approximately one-third of these attempted home births were made by women who had not given birth previously, and about one-third of the sample had one previous birth. Income and Occupation of Clients The variables of income and occupation have been linked with birth outcomes in previous studies of health care. As noted in Chapter Three, there seems to be a positive correlation between greater income and higher status occupation, and lowered rates of infant mortality. Community midwives did not usually indicate income of their clients and spouses, although one Ontario midwife tended to record these incomes, along with occupation. What is presented below, then, is a partial profile of couples attempting home birth. It serves, however, as an indicator of the diversity of occupations held by these people. The author's impression is that fewer lower-income people are evident in the home birth sample in recent years. Community midwives did not usually indicate income of their clients and spouses, although one Ontario midwife tended to record these incomes, along with occupation. There is considerable variation in occupations of the home birth clients and their spouses. The entire range of occupations is reproduced in Appendix F. There were 54 homemakers listed among the women attempting home birth. Sixteen women were listed as "unemployed", and there were 10 nurses in the sample. The majority of women (29 of 182 listed) were working in clerical or secretarial positions. There was also a great range in occupations among the spouses of the women attempting home birth. Artists and salespersons were the 1 9 See Eleanor Barrington, Midwifery is Catching, 1985, Toronto, NC Press, pp. 93-100 for an account of midwifery practice in Mennonite communities. 136 Table 6: Family Income: Home Birth Clients Gross income N % $10,000-$14,999 4 8.7 $15,000-$19,999 5 10.8 $20,000-524,999 6 13.1 $25,00O-$29,999 9 19.5 $30,000-$34,999 9 19.5 $35,000-39,999 5 10.9 $40,000+ 8 17.5 Total 46 100.0 Source: Home Birth Records two most frequent categories for these spouses. A full profile of occupations is impossible since most midwives did not indicate clients' occupations on their records. It does however appear that the home birth alternative is attractive to a fairly broad cross-section of people, and certainly not to a small range of occupations or incomes. There is a considerable range in combined spousal (gross) incomes recorded on the birth records. While there are few people who were on social assistance in this sample, the combined family incomes appear to correspond to average family incomes. There are few couples whose income is far above the average family income. There is a continuing debate over the advisability of attempted home births for women attempting a vaginal birth after caesarean (VBAC). The dictum, "Once a caesarean, always a caesarean" has been challenged by research findings that rupture of the uterine scar occurs in a small minority (.005% to 1.0%) of attempted vaginal deliveries after a caesarean delivery. It is revealing that the Society of Gynecologists and Obstetricians of Canada recently supported 137 a motion favouring VBAC trials of labour. 2 0 While there is sympathy among many community midwives for women wishing to attempt a VBAC at home, only 3.7% of the birthing clients in this sample attempted a VBAC. lf the clients who had not given birth previously are excluded, about five percent of the remainder were attempting birth at home after a caesarean section. Table 7: Previous Caesarean Section N % No births* 252 32.9 No previous C-sect 496 64.8 Previous C-section 18 2.4 Total 766 100.0 Source: Home Birth Records. •This indicates the number of women who had not given birth previously and therefore could not have had a previous caesarean section. Diet and Alcohol Intake A stereotypic interpretation of midwives' clients is countercultural, including a vegetarian philosophy. The birth records suggested a more cosmopolitan orientation regarding diet In fact, the midwives' documents indicated that while a substantial minority of home birth clients were vegetarian (21.6%), over two-thirds included meat in their regular diet Contemporary concerns over alcohol intake during pregnancy include harm to unborn children if alcohol intake is heavy. Fetal Alcohol Syndrome (FAS) refers to fetal 2 0 Editorial, "Health Views", Today's Health, 1987 (March), pp. 62-63. 138 Table 8: Home Birth Mothers' Diet DIET N % Meat 465 70.6 Vegetarian 156 23.7 Seafood 38 5.8 Total 659 100.1 Source: Home Birth Records malformations such as dysfunctions of fine motor functions, slower rates of weight gain, linear growth, and head circumference, and mental retardation. The effects of FAS tend to persist after birth as well. 2 1 Table 9: Alcohol Use During Pregnancy: Home Birth Clients N % None 355 60.9 Occasional 220 37.7 Daily 8 1.4 Total 583 100.0 Source: Home Birth Records Home Birth clients, while not wholly abstemious as a group, are clearly moderate in their alcohol intake during pregnancy / / they consume alcohol at all. This measure, combined with the very high percentage of mothers intending to breastfeed, and the relatively low percentage of daily smokers (see below), supports the notion that these women tend to follow some standard advice directed toward pregnant mothers and to be responsible in preparing for 2 1 See Jensen et al., Maternity Care: The Nurse and the Family, St. Louis, C.V. Mosby, 1981, pp. 809-812; Ruth E. Little and Ann Pytkowics, "Drinking During Pregnancy in Alcoholic Women", Alcoholism, 2(2), 179-183. 139 birth. Table 10: Smoking among Home Birth Mothers N % No smoking 560 86.6 Occasional 16 2.5 Daily 71 10.9 Total 647 100.0 Source: Home Birth Records Approximately 80% of the clients reported not using drugs other than alcohol or cigarettes. The most commonly used of these other drugs was marihuana (13.9%), followed by painkillers (3.2%), and insulin for diabetes (0.3%). Prenatal Visits Community midwives generally place great emphasis on continuity of care throughout pregnancy. This is also true of nurse-midwives concerned with the problem of anonymity that often occurs when women deliver in hospital. 2 2 Of 466 birth records in which prenatal visits by the midwife were recorded, only a few cases with no visits or three or less visits by the midwife were found. The median number of visits was five, with over a quarter of the women being seen on seven or more occasions. It should be kept in mind that most women also had visits with general practitioners or obstetricians in addition to visits from their midwife (or midwives). Therefore, the statistics presented above do not represent all prenatal visits or consultations for the home birth clients. 2 2 For a detailed review of a midwifery demonstration project that emphasized the importance of prenatal care, see Elaine Carty et al., The Low- Risk Clinic: Family Care Based on the Midwifery Model, 1981-1984, Shaugnessy Hospital Education Services & University of British Columbia School of Nursing, 1984, 67 pp. (typescript mimeo). 140 Table 11: Prenatal Visits by Community Midwives N % No visits One to Five Six to Ten Eleven or more 7 301 460 94 0.8 34.9 53.3 10.9 Total 862 99.9 Source: Home Birth Records Midwifery Practice and the Course of Labour Midwives usually claim that their training allows them to minimize interventions during labour and delivery. Specifically, midwives contend that they do not regularly artificially rupture their clients' membranes, are sparing in the use of oxytocin to induce or augment labour (or expedite delivery of the placenta after birth), and in relying on anaesthesia during childbirth. Immobilization of women in labour is also discouraged. Midwives encourage women to move about and to bathe during labour. Furthermore, in keeping with the premise that birth is a personal process, women are encouraged to use delivery positions other than the lithotomy position if they wish. Rupture of Membranes A key premise of the community midwives is that by respecting the normal course of labour they provide a service to their clients and this protects the unborn child. One measure of their practices is the rupture of the woman's membranes, releasing the amniotic fluid. The great majority of women attempting home birth experienced spontaneous rupture of membranes. Artificial rupture of membranes (A.R.M.) may be employed to induce labour, or more commonly as a procedure when the amniotic sac is bulging, and ready to burst According to 1980-1981 data, artificial rupture of membranes occurred in 8.6% of all hospital 141 births in Canada. 2 3 In discussing the increased incidence of artificial rupture (in the attempted home birth sample) with several community midwives, they expressed surprise that A.R.M. occurred in about 15% of the sample. Other community midwives have reported A.R.M. in 15.6% of the births they attended between 1980 and 1985. 2 4 It may be that A.R.M. is used to induce labour, or because a number of women about to give birth at home had intact amniotic sacs just prior to delivery and the sac had to be ruptured to permit delivery of the baby. The national rate of A.R.M. may be lower since all women giving birth are included Table 12: Rupture of Membranes: Attempted Home Births N % Spontaneous Rupture 659 80.4 Artificial (Home) 124 15.1 Artificial (Hosp.) 21 2.6 Born in caul 9 1.1 Trailing membranes 7 0.8 Total 820 100.0 Source: Home Birth Records •Born "in the caul" refers to babies who are delivered within the amniotic sac. In most cases the membranes will either rupture spontaneously or be ruptured by the birth attendant Meconium Staining The presence of meconium (feces expelled by the infant) in amniotic fluid may indicate fetal distress. All sourcebooks recommend careful monitoring of the infant's heartbeat during labour if meconium is observed, with special attention to abnormal heartbeats (decelerations or accelerations). Meconium is not however an automatic indication of fetal distress. It is 2 3 Statistics Canada, Surgical Procedures and Treatments, 1979-1981, November 1984, Ottawa, Supply and Services Canada, p. 34. 2 4 See Noreen Walker et al., op cit, 1986. The 15.6% A.R.M. statistic applies for women who had reached six centimetres dilation. 142 customary for the newborn infant to be suctioned with a DeLee catheter to remove meconium or mucous that may endanger the infant's respiratory system. 2 5 It is significant that over a tenth of these attempted home births involved some meconium. It is not always clear from the home birth records what procedures were taken to protect against fetal distress (which may be manifested in passage of meconium). Table 13: Meconium in Waters: Attempted Home Births N % Clear waters 610 83.7 Old meconium 13 1.8 Fresh meconium 30 4.1 Unspecified 76 10.4 meconium Total 729 100.0 Source: Home Birth Records Oxytocin and Anaesthesia The critique of obstetrical management of childbirth also rests on what is seen as the unwarranted, routine use of drugs to influence the natural course of labour. The use of oxytocin to induce labour, augment contractions, or as a routine procedure to assist delivery of the placenta is one case-in-point The norm in attempted home deliveries was to avoid the use of oxytocins, although it is more prominent in the third stage of labour (between the birth of the child and expulsion of the placenta). 2 5 See Elizabeth Davis, A Guide to Midwifery: Heart and Hands, 1981, Santa Fe, John Muir Publications, p. 104. 143 Table 14: Use of Oxytocin in Attempted Home Births N % No oxytocin given 606 81.8 To induce labour 7 0.9 To augment labour 12 1.6 Post-partum (bleed) 109 14.7 Delivery of placenta 7 0.9 Total 741 99.9 Source: Home Birth Records Anaesthesia was used very sparingly in the home births. Epidurals and general anaesthetics can only be given in hospitals, so all births completed at home did not have any anaesthesia. Emotional support was often provided by the midwives and spouses during painful contractions. Again, this raises the issue of the community of women and how this level of support may reduce the conventional use of anaesthesia. Certainly there have been statements concerning the reliance on technological solutions to birth events, particularly how a technological approach to birthing may increase women's fear of labour and promote more instrumental deliveries, use of pain relief, among other things. 2 6 While administration of analgesics (for pain relief) was not recorded in the study, it was used very sparingly, according to the home birth records. Table 15: Anaesthesia in Attempted Home Births N % No anaesthesia 767 95.6 Epidural only 31 3.9 General anaest 3 0.4 Epidural & General 1 0.1 Total 802 100.0 Source: Home Birth Records 2 6 Grantly Dick-Read, Childbirth Without Fear, 144 Immobilization of women during labour and delivery has been challenged by some birth attendants and researchers. Walking during labour is thought to be beneficial for the mother and the fetus. The duration of labour may be shortened, and blood supply to the fetus may be increased if the mother is not restricted to the lithotomy position and is active during the labour. A majority of women in the home birth sample walked at some point in their labours. Some women who did not walk during labour were experiencing rapid, strong contractions. Others may simply have been more comfortable in a prone position. Table 16: Walking During Labour : Home Birth Clients N % Walking 365 56.6 Not walking 280 43.4 Total 645 100.0 Source: B.C. Home Birth Records Source: Home Birth Records Delivery of die Infant Place of Delivery Studies of home birth attempts demonstrate that most births can be completed successfully at home. A report by midwives practicing in Alberta indicated that 7.3% (n = 34) of women seeking a home birth were transferred to hospital and 1.7% of babies were 145 transferred to hospital.27 Table 17 indicates that 86.3% of mothers in the attempted home birth sample delivered at home. It appears that only eight of these 885 women gave birth at the midwives' home or the home of a friend or relative. There was one case of a mother giving birth in a vehicle during a transfer to hospital, and just over 13% of mothers gave birth in hospital after an attempted home birth. Table 17: Place of Delivery N % Home* 852 86.3 In transit 2 0.2 Hospital 133 13.5 Total 987 100.0 Source: Home Birth Records •Includes birth at a birthing centre, midwife's home, or relative's home. The commonplace emphasis on complications requiring transfer of home birth clients might be turned on its head. There is very little media attention to stillbirths in hospital. Of 43,911 live births in B.C. in 1985, there were 193 stillbirths (of infants over 28 weeks gestation). This converts to a rate of 4.4 stillbirths per 1,000 live births and specified fetal deaths. 2 8 In contrast stillbirth at home garners considerable media attention and is more likely to be followed by criminal charges against the birth attendants. It is clear, however, that congenital problems that cause the death of an infant are unlikely to result in criminal 2 7 See Noreen Walker, Sandy Pullen, and Marilyn, "Birth Stats: Domiciliary Midwifery Report 1980-1985", Birth Issues: Safe Alternatives in Childbirth, 1986 (March/April), 3(2), p. 6. The babies were admitted for various problems: meconium aspiration, congenital heart abnormality, fever, spinal abnormalities, respiratory difficulties, and aspiration pneumonia. 2 8 See Statistics Canada, Births and Deaths: Volume One, 1986 (November), Ottawa, Supply and Services Canada, pp. 4-5. 146 prosecution of birth attendants whether they are physicians or midwives, in hospital or at home. Delivery positions The importance of matching birth management with the needs of the mother is clearly reflected in the variety of birthing positions adopted by women giving birth in this study. In contrast, the conventional position for spontaneous vaginal delivery and forceps delivery is the lithotomy position. The lithotomy position for delivery occurs when the woman lies on her back, with flexed knees, and her abducted (drawn away from the mid-body) thighs drawn toward her chesL 2 9 The conventional use of the lithotomy position in hospital deliveries has been criticized for prolonging labour since it does not utilize gravitational force, among other things. Attempts by physicians to control delivery positions have prompted consumer demonstrations, most notably at the Royal Free Hospital in Hampstead, England. The introduction of active delivery positions, such as delivering in an upright position, had been followed by measures to discourage any position other than on one's back. A protest rally was organized by the National Childbirth Trust 3 0 Results of a recent survey commissioned by the Canadian Medical Association indicate that only 26 percent of women surveyed had their choices of delivery positions respected by the attending staff. 3 1 Community midwives believe that birthing is very personal, that a woman in labour may choose from a variety of positions to find one that is most comfortable for her. Just over two-thirds of the birth records (for which delivery position was indicated) mentioned non-lithotomy positions. Table 2 9 See Margaret Jensen et al., Maternity Care: The Nurse and the Family, St Louis, CV. Mosby and Company, 1981 (second edition), p. 952. 3 0 For an account of this, see CSP editors, "Birth Rights: Radical Consumerism in Health Care", Critical Social Policy, 1982, 2(2), p. 64. Another instance of lobbying for improved maternity and infant services is reported in The Spastics Society, "A Charter for the Eighties", Joint Statement on Maternity and neonatal services supported by 14 voluntary and professional groups, May 1981. 3 1 The survey of 2,013 women who had babies within the previous two years was completed in the summer of 1986. Canadian Press, "Birthing care gets a 'satisfactory' rating", The Vancouver Sun, April 3, 1987. 147 17 provides a general outline of delivery positions taken by women attempting a home birth. Precise information on these positions is provided in Appendix F. Women who were transferred to hospital likely delivered in the lithotomy position or a supine position. It is difficult to establish the exact kinds of position in hospital because midwives' records tended to be weakest if the woman was transferred out of their supervision. Table 18: Delivery Positions: Attempted Home Births N % Lithotomy 31 3.6 Supine 131 15.4 Other 689 81.0 Total 851 100.0 Source: Home Birth Records A variety of birthing positions were used by women in the home birth sample. The most frequently used position was on hands and knees and squatting was frequently used. A key point here is that midwives believe that there is no one superior delivery position that is suitable for all women. Most records indicated that women used a single delivery position to deliver their children. In about 10% of the births, however, women used two, positions - for example, squatting and then side lying, - in order to deliver their babies. 148 Type of Delivery Community midwives, as well as nurse-midwives, have indicated that through skill and emotional support for birthing women, rates of instrumental deliveries such as Caesarean sections and forceps deliveries can be reduced. Indeed, community midwife attendance is accompanied by a dramatic reduction in the rates of instrumental deliveries. The national rate for Caesarean section was 15.9% in 1980-1981, compared with a rate of under five percent for the attempted home births. Likewise, the percentage of forceps deliveries among the attempted home birth sample (2.9%) is substantially lower than the nationwide rate of approximately 20 percent 3 2 Table 19: Type of Delivery: Attempted Home Births N % Spontaneous vaginal Primary c-section Repeat c-section Forceps 784 33 1 21 93.4 3.9 0.1 2.5 Total —Source: Home Birth 839 Records 99.9 3 2 Statistics Canada, Surgical Procedures and Treatments, 1979-1981, November 1984, Ottawa, Supply and Services Canada, p. 34. 149 Episiotomies Community midwives contend that with perineal massage and support and skillful management of birth, most women can deliver babies without resort to episiotomies (surgical enlargement of the vaginal opening). The episiotomy rate in Canada has been estimated at approximately 80% of all births in Canada and about 70% of births nationwide in the United States. 3 3 Nationwide figures indicate that 26.4% of births in 1980-1981 involved episiotomies. 3 4 These figures may reflect the higher rate of Caesarean section nationwide, for these births do not require episiotomies. The following table depicts the dramatic decrease in episiotomies among attempted home births relative to hospital statistics. Table 20: Episiotomies: Home Births and the Low-Risk Clinic Home Births Low-Risk Clinic Grace Hospital N % N % N % No 846 94.0 37 78.0 356 53.6 Yes 54 6.0 11 22.0 308 46.4 Total 900 100.0 48 100.0 664 100.0 Source: Home Birth Records; Elaine Carty et al, The Low-Risk Clinic, 1984, pp. 20-21. In their review of the available literature on episiotomies, Thacker and • Banta concluded that there is no clear evidence of the benefits of routine use of episiotomies. They added that episiotomies are associated with discomfort and pain for women during the postpartum period, and some maternal deaths have been attributed to infections following episiotomy. 3 5 3 3 See respectively Candy Kerman, "Birth in a Small Town," Kinesis, 1982-83 (December/ January), p. 13; Student Nurses Association of Illinois, "Episiotomy as an American Phenomenon," Journal of Nurse-Midwifery, 1979, 24(1), p. 31. 3 4 Statistics Canada, Surgical Procedures and Treatments, 1979-1981, November 1984, Ottawa, Supply and Services, p. 34. 3 5 Stephen B. Thacker and H. David Banta, "Benefits and Risks of Episiotomy: An Interpretative Review of the English Language Literature, 1860-1980", Obstetrical and Gynecological Survey, 1983, 38(6), 322-338. 150 Midwives argue that the interventionist training of many physicians promotes the routine use of episiotomies. Moreover, perineal tears can often be avoided through perineal massage and support of the perineal area during crowning of the infant's head. The following table presents a comparison of perineal tear rates at Grace Hospital, at the Low-Risk Clinic, and among the Community midwives. It should be noted that 20 unspecified tears were documented in the home birth records. Since the degree of the tear could not be assessed, they have been included as a separate row in the table. Deliveries over an intact perineum are most common in the home birth sample. As noted in the previous table, the Low-Risk Clinic clients had a relatively low rate of episiotomy (22%) compared with hospital-wide statistics collected at the Grace Hospital in March 1983. Table 21: Perineal Tears Home Births Low-Risk Clinic N % N % Intact 362 41.8 7 14.3 1st d* 308 35.6 20 40.8 2nd d. 121 13.9 11 22.4 3rd d. 13 1.5 0 0.0 4th d. 1 0.1 0 2.0 Unsp. 20 2.3 N.A. N.A Epis. 40 4.7 11 22.5 Total 865 99.9 49 100.0 Source: Home Birth Records; Elaine Carty et al, The Low-Risk Clinic, 1984, pp. 20-21. •denotes degree of the tear: e.g., 1st d indicates a first degree perineal tear. 151 Post-Partum Measures Suctioning of the newborn baby is undertaken in a considerable number of home births in the study. In some cases this is a precautionary measure; in others where the infant is in respiratory distress it may be a life-saving measure. Suctioning is not routinely undertaken by the community midwives as a grouping. It can however be used as part of the midwives' repertoire, especially if the infant appears to have inhaled meconium or mucous during labour or delivery. Table 22: Suctioning Techniques: Attempted Home Births N % No suctioning 405 53.9 Bulb syringe 103 13.7 De Lee 117 15.6 Unspecified suet 126 16.8 Total 751 100.0 Source: Home Birth Records Apgar Scores The Apgar scoring method was developed in the 1950s by • Dr. Virginia Apgar, an American anesthesiologist The infant's health after delivery is conventionally assessed on five measures - heart rate, respiration, muscle tone, colour, and reflexes - at one minute after birth and five minutes after birth. 3 6 Thus, a child who is given a maximum rating of two points on each of these five measures would have an Apgar score of ten. A score of zero indicates that the child is stillborn. Intermediate scores indicate some deficits in the child's health at the time the measure is taken. Scores in the lower range can indicate serious 3 6 See Suzanne Arms, Immaculate Deception, New York, Bantam, 1977, p. 84. 152 difficulties in the newborn's health. This composite measure of newborn health is usually recorded by community midwives. The following Table sets out the distribution of Apgar scores for infants delivered at home. Apgar scores are generally within the normal range for newborn infants. As the table indicates, there is a predictable increase in the Apgar scores over time for most infants. The small number of cases coded for 10 minutes after birth (n = 215) occurs because midwives tended to not record Apgar scores at 10 minutes unless there was infant distress. Table 23 : Apgar Scores: Infants Delivered at Home One minute Five minutes Ten minutes N % % N % Zero 5 0.6 5 0.6 5 2.3 One 3 0.4 0 0.0 0 0.0 Two 3 0.4 1 0.1 0 0.0 Three 8 0.9 2 0.2 1 0.5 Four 21 2.4 0 0.0 1 0.5 Five 22 2.5 12 1.4 0 0.0 Six 49 5.7 6 0.7 0 0.0 Seven 86 9.9 13 1.5 1 0.5 Eight 207 23.8 40 4.6 3 1.5 Nine 331 38.1 230 26.5 13 6.0 Ten 133 15.3 558 64.4 191 89.0 Total 868 100.0 867 100.0 215 100.0 Source: Home Birth Records. The third stage of labour comprises the time lapsing between delivery of the baby's body and delivery of the placenta. Spontaneous delivery of the placenta occurs when it is expelled without partial (or complete) manual removal, and when oxytoxics are not used to hasten delivery. Birth records often indicated "controlled cord traction" by the midwife; however, this procedure is classified as a spontaneous delivery provided that oxytocin or manual removal were not used. 153 Table 24: Delivery of Placenta N % Spontaneous Assisted 762 62 92.5 7.5 Total 824 100.0 Source: Home Birth Records Delivery of the placenta was assisted in hospital for 31 cases (3.8% of all cases). Manual removal of the placenta was undertaken in four cases (0.5% of all cases). The Alberta midwives reported that only a small minority of labours required manual removal of the placenta (0.7%) 3 7 Neonatal, Perinatal, and Infant Mortality: A Review The debate over whether community midwifery is dangerous or desirable is not simply ideological. There have been a number of research studies addressing the issue of safety in planned home deliveries compared with planned hospital deliveries and the nature of the attendants as correlated with birth outcome. Standard measures include: perinatal mortality (deaths between 20 weeks' gestation and of neonates between birth and the following six days), neonatal mortality (deaths during the first 28 days after birth), and infant mortality which refers to deaths between birth and the first year of life. In the discussion of the Canadian home birth study which follows, only the first two measures (perinatal and neonatal mortality) are used. The postnatal period recorded by the community midwives does not usually follow up through the first year of life. Some exponents of midwifery argue that trained midwifery attendance has always produced results - infant and maternal morbidity and mortality - that are superior to physician-attended births in a wide variety of countries. 3 8 3 7 Noreen, Sandy Pullen, and Marilyn, "Birth Stats: Domiciliary Midwifery Report," Safe Alternatives in Childbirth, Edmonton, 1986 (March/April), 3(2), p. 5. 3 8 David Stewart, The Five Standards for Safe Childbearing, Marble Hill, NAPSAC, pp. 111-154. 154 An Illinois physician also concluded that home deliveries, if properly managed, could be safer than hospital deliveries. He believed that the home was generally bacteriologically safer, and that physicians assisting at home were more cautious. 3 9 Others have produced mixed findings regarding the home birth issue and the question of qualified attendants. A research team studying neonatal deaths in North Carolina reported that the neonatal mortality rate among the 242,245 babies delivered in hospital was 12 per 1,000 live births. For physicians attending a planned home delivery, there were no infant deaths among the 55 cases recorded. For trained lay midwives attending home deliveries the neontal mortality rate was 4 per 1,000 live births; moreover, the three deaths among the 768 babies delivered were related to congenital abnormalities. In one study of home births in North Carolina between 1974 and 1976, Burnett and his associates found that the rate of infant mortality varied as a function of planning for such births and midwifery attendance. Specifically, planned home deliveries with lay midwives in attendance has a rate of three neonatal deaths per 1,000 live births. The corresponding rate for planned home deliveries without lay midwives was 30 per 1,000; for unplanned home deliveries the neonatal death rate increased dramatically to 120 deaths per 1,000 live births. 4 0 One study of Hutterite midwives used physicians' records and birth certificates for Hutterite children born in Montana between 1961 and 1970. 4 1 The authors found that 63% of deliveries of Hutterite children in their sample were attended by indigenous midwives -without training in nursing or obstetrics - and that the infant mortality rate for these children was not significantly different than that for Hutterite children delivered by physicians or non-Hutterite, Caucasian children delivered by physicians. Nevertheless, the neonatal 3 9 See Gregory White, "A Comparison of Home and Hospital Delivery Based on 25 Years' Experience with Both", Journal of Reproductive Medicine, 1977, 19(5), 291-292. 4 0 Claude A. Burnett III et al., "Home Delivery and Neonatal Mortality in North Carolina", Journal of the American Medical Association, 1980, 244(24), pp. 2741-2745. 4 1 Thomas Converse, Richard Buker, and Richard Lee, "Hutterite Midwifery", American Journal of Obstetrics and Gynecology, 1973, 234 (5), pp. 719-725. 155 mortality rate for Hutterite births managed by indigenous midwives was higher than Hutterite births attended by physicians; specifically, 16.4 versus 8.1 deaths per 1,000 live births. Additional problems included the midwives' lack of instruments to monitor fetal and maternal vital signs, infrequent and inadequate prenatal visits, reliance on the lithotomy position, and difficulties associated with managing uterine dystocia, cephalopelvic disproportion, and abnormal presentation of the fetus. The best evidence, however, is that with proper screening procedures, transfer of mothers experiencing complications, and trained attendants, home birth does not result in higher rates of infant or maternal mortality. A large-scale study conducted by Mehl and his associates in northern California studied 1,146 home births attended by midwives, physicians, or both. They found that birth outcomes and rates of complications compared favourably with average rates in California. 4 2 A variety of studies of home birth outcomes in Britain and Holland have been published. All confirm that home birth compares favourably with hospital deliveries in terms of neonatal and perinatal mortality, and with lower rates of medical intervention in the birthing process. 4 3 While the issue remains whether women electing home birth are a healthier population in general than women delivering in hospital, there is clear support for the safety of home birth under some circumstances. It is important that women are screened for complications, that there is adequate prenatal care, that birth attendants are skilled in 4 2 Lewis Mehl et al., "Outcomes of Elective Home Births: A Series of 1,146 Cases", Journal of Reproductive Medicine, 1977, 19(5), pp. 281-290. 4 3 See the following: (1) R. Campbell et al, "Home Births in England and Wales, 1979: Perinatal mortality according to intended place of delivery", British Medical Journal, 1984, 289, pp. 721-724; (2) M. Klein et al., "A comparison of low-risk Women booked for delivery in two systems of care: shared-care (consultant) and integrated general practice unit I. Obstetrical procedures and neonatal outcome. II. Labour and delivery management and neonatal outcome", British Journal of Obstetrics and Gynaecology, 1983, 90, pp. 118-122 and 123-128; (3) S.M.I. Damstra-Wijmenga, "Home confinement: the positive results in Holland", Journal of the Royal College of General Practitioners, 1984, 34 (265), pp. 425-431. These studies have been reviewed by M. Tew, "Place of birth and perinatal mortality", Journal of the Royal College of General Practitioners, 1985, 35 (277), pp. 390-394; and by Caroline Flint, Sensitive Midwifery, 1986, London, Heinemann, pp. 29-30. 156 domiciliary mangement, and that back-up (emergency) services are in place. With respect to this study of Canadian births, three essential dimensions in infant deaths are employed. First, the accurate measurement of such deaths; second, careful comparisons of time-frames; and finally, attribution of responsibility for these deaths. Since reports of infant deaths must be made under the Vital Statistics Act in Canada, difficulty does not usually arise with respect to infants at or near term. There are however various forms of fetal loss at earlier stages of pregnancy including planned abortions (therapeutic abortions) and spontaneous abortions (miscarriages) As noted earlier in this section, two standard measures of fetal and infant death were used. Perinatal mortality measures death of a fetus of 20 or more weeks' gestation or of a neonate between birth and the following six days. Neonatal mortality is a more specific measure, addressing neonatal deaths during the first 28 days after birth. Both measures are expressed as the number of deaths per 1,000 live births. The last dimension will be discussed at greater length after the following measures of mortality. It is important, however, to distinguish between unavoidable infant deaths that may be due to congenital malformations and those that may be attributable to caregivers' negligence. 4 4 Perinatal mortality rates are arrived at by dividing the number of stillbirths plus the number of early neonatal deaths (during the first week after birth) by the number of live births and the number of stillbirths, then multiplying the result by 1,000. 4 4 This is conventionally referred to as iatrogenic (physician-caused) death. I am speaking here of negligence generally associated with caregivers, be they physicians, nurses, or midwives. 157 Table 25: Perinatal Mortality: Home Births, B.C., and Canada (per 1,000 births) B.C.(Home) B.C.(Prov.) Canada N R N R N R Perin. death 3 12.34 NA 10.9 NA 13.0 Source: Home Birth Records. The B.C. perinatal mortality rate is assessed from 1979 data; the Canada-wide rate from 1978 statistics. See Roger Tonkin, 1981 (below). The perinatal mortality rate calculated above should be interpreted with caution. It is possible that the rate may have increased if all attempted home births in British Columbia and the other provinces had been analyzed. One reason is that the author has not sought access to birthing records of community midwives who were involved in criminal prosecution, nor is reference made to another community midwife who left British Columbia after an infant death following an attempted home birth. It is arguable that exclusion of these records may deflate the actual mortality rates of midwife-attended, attempted home births. There are other possibilities, however. One community midwife who attended hundreds of births in B.C. provided a small sampling of records which included a few perinatal deaths, including a stillborn twin. She had not been the primary care midwife for the woman, and was reluctant to deliver twins out of hospital. Nevertheless, she agreed to assist the woman who was about to deliver the babies. The point here is that the sample of attempted home births is missing thousands of these births between 1972 and 1986, and it is not possible to measure precisely the safety of hospital birthing alongside home births. A second point is that community midwives did not always select the most healthy clients. There are cases of women who might be screened out of home birth guidelines who delivered at home, for example, and it should be kept in mind that many women delivering in hospital are healthy and many have received good prenatal care. 158 Reports from other community midwives in Canada indicate that perinatal mortality rates are not above those for populations intending to deliver in hospital. 4 5 In his study of birth statistics in British Columbia, Tonkin concluded that: "The mortality rate for infants born at home is not markedly different from that of hospital born infants". 4 6 A report on 465 home births in Alberta between 1980 and 1985 indicated that there were only three infant deaths and one stillbirth. This converts to a perinatal mortality rate of 8.68 per 1,000 live births. 4 7 The measure of neonatal deaths also shows a similarity between domiciliary midwifery outcomes and province-wide and Canada-wide comparisons. Table 26: Neonatal Mortality: Home Births, B.C., and Canada (per 1,000 births) B.C.(Home) B.C.(Prov.) Canada N R N R N R Perin. 4 4.97 NA 6.7 NA 8.1 death Sources: Home Birth Records; Statistics Canada, Births and Deaths: Volume I (1984). These comparisons appear to support the community midwives' claims that planned home births are not necessarily more dangerous than hospital-based births. These findings are consistent with earlier, published reports of low rates of perinatal and neonatal mortality among women seeking home births supervised by trained midwives. The corresponding figures 4 5 This issue does not necessarily revolve around community midwifery versus hospital births. For example, Penny Armstrong, an Ontario midwife who has practiced midwifery with Amish women, provides a contemporary account of midwifery practice at home and in hospital. See Penny Armstrong and Sheryl Feldman, A Midwife's Story, 1986, Toronto, Fitzhenry and Whiteside. 4 6 Roger Tonkin, Child Health Profile: Birth Events and Infant Outcome, 1981, Vancouver, Hemlock Printers, p. 18. 4 7 Noreen Walker, Sandy Pullin, and Marilyn, "Birth Stats: (Domiciliary Midwifery Report, 1980-1985)", Safe Alternatives in Childbirth, Edmonton, 1986 (March/April), 3(2), p. 1. 159 for births managed by midwives on The Farm in Tennessee was 11.1 neonatal deaths per 1,000 live births. 4 8 Post-Partum Visits There was considerable variation in the number of postnatal visits. The convention is for the midwife to make at least three post-partum visits to assess the mother and the newborn. There were exceptions. One midwife reported that a client disappeared from the area shortly after the birth (and without paying the midwife for her services). In other cases where the birth took place some distance from the midwife's home, the midwife might stay for a few days or several days after birth. It may be that midwives did not document all home visits. If this is the case it underscores the need for improved documentation of practice, including post-partum activities of community midwives. The author's impression is that charting of births and midwifery practice has become more thorough since the early to mid 1970s. Table 27: Post-Partum Visits: Home Birth Clients N % No visits 15 3.2 1-5 visits 394 82.9 6-10 visits 59 12.8 11 or more 7 1.5 Total 475 100.0 Source: Home Birth Records 4 8 Ina May Gaskin, "Spiritual Midwifery on the Farm in Summertown, Tennessee", Birth and the Family Journal, 1978, 5(2), p. 104. 160 Safe Practice: Guidelines and Peer Review The issue of infant and maternal safety is central to discussions of childbirth. Along with the feminist critique 4 9 of conventional obstetrics - the reduced freedom of parturient women and the substantial power vested in the (predominantly male) medical profession - it is also asserted that midwife attendance (at home, or in hospital) can be as safe or safer than physician-managed, hospital deliveries. In British Columbia, many community midwives have devised collective standards and peer review procedures to assess what constitutes safe practice. Most practicing community midwives are members of the M.A.B.C., with several members founding a separate Midwives' Collective. At this point the debate over guidelines for practice is discussed with respect to self-regulation. The "Guidelines to Midwifery Practice" are taken from the experience of community midwives, the Board of Directors of the M.A.B.C., and general lists of contraindications to home birth. 5 0 The M.A.B.C. Guidelines provide a comprehensive list of procedures for the community midwives. These procedures include initial and. ongoing assessments of the client's social and family history, obstetrical and gynecological history, physical examination, and testing for urinalysis, blood pressure, pulse, and the like. The midwife may also refer the client to laboratory specialists for such work as RH antibodies, haemoglobin, and rubella titre. The schedule for pre-natal care is set out as follows: a monthly visit up to the 28th week of pregnancy; a bi-weekly visit thereafter until the 36th week; and weekly visits from that point until the birth. Measures of blood pressure, weight gain, fetal heart tones, fundal height and so on should be made by the midwife. The midwife is expected to maintain accurate records of these visits and to monitor whether these measures are "within normal limits". 4 9 This critique also highlights the erosion of community control as childbirth becomes more centralized via the professions. See Gene Corea, The Mother Machine: Reproductive Technologies from Artificial Insemination to Artificial Wombs, New York, Harper and Row, 1985. 5 0 M.A.B.C., "Guidelines to Midwifery Practice", 1984 (sixth draft), typescript mimeo. 161 There is an accompanying list of guidelines that are presented as "definite" indications for a hospital birth. 5 1 Midwives disregarding these contraindications may be brought forward for peer review. This is not however a formal disciplinary hearing. Other contraindications to home birth are grouped under two headings. The first heading - Obstetrical history - includes women who have had three or more successive spontaneous abortions, a previous unexplained stillbirth, previous uterine surgery (which includes a previous Caesarean section), and others. The second heading - Obstetrical Factors in the Current Pregnancy - comprises intrauterine growth retardation, multiple pregnancy (e.g., twins), confirmed fetal heart abnormalities, and inter alia, premature rupture of membranes (before 37 weeks). There is also an extensive list of possible indications for a hospital birth. The midwife is expected to consult with a Physician when such situations occur as smoking during pregnancy, being more than 30 minutes away from the nearest hospital, maternal age less than 17 years old or over 40 years, and abnormal weight gain. These guidelines, taken with subsequent guidelines for intrapartum care and post-natal care, appear to be a synthesis of international guidelines for midwifery and local debates over responsible midwifery practice. The key point here is whether midwives can be held accountable for practicing out of guidelines, especially when some of them are not very specific. What constitutes "drug addiction or abuse"? Should the woman be automatically screened out for home delivery if her membranes rupture at just over 36 weeks and other factors are well within guidelines? The interpretation of the rules to this point in time appears less formal, allowing for the midwives to have some discretion in their work. What appears to be forged, then, is a 5 1 Definite contraindications to a home birth, as set out in the M.A.B.C. guidelines, include the following maternal Factors: cardiovascular disease, congenital heart disease, Essential hypertension, vascular disease, achondroplasia, drug addiction or abuse, acute psychiatric problems, renal disease, endocrine disorders, thrombosis, emboli, Addison's disease, hyp/hyper thyroid, diabete(s) mellitus, neoplastic disease, immunocomplex disease, history of subarchnoid haemorrhage, TORCH infections, uterine infection, active tuberculosis, and asthma. 162 middle-ground between mandatory hospitalization for birth and utter subjectivity on the part of community midwives. In the Western world there has been a clear shift to almost complete hospitalization of birth. Once established as a viable alternative to hospital-based obstetrics, the practice of domiciliary obstetrics in Britain including the "flying squads" staffed by an anaesthetist, obstetrician, and a midwife in the event of birth complications 5 2 - has given way to almost universal recourse to hospital obstetrics. It has been reported that approximately 97% of births in Britain take place in hospitals. " In Britain, the delivery of Prince Charles at home, by Sir John Peel has been followed by the general recommendation by a Commission headed by Dr. Peel that all deliveries in Britain occur in hospital. 5 4 The official policy in Britain has thus discouraged domiciliary midwifery. " "...despite the lip-service paid by successive Health Ministers to patient choice in the matter of home or hospital delivery under the Health Service (which, incidentally, means at no charge), any woman wanting a home birth on the National Health Service must possess the political skill of a Metternich, the patience of a Griselda and the persistence of a PankhursL If she is to succeed, she must begin to fight the Health Service bureaucracy as soon as possible in her pregnancy and be prepared to continue, perhaps for months, in order to overcome the almost insurmountable obstacles put in her way...." It is important to note that the research underlying this policy against domiciliary births has been criticized in medical journals and other venues, and that there may be a more favourable outlook on domiciliary midwifery by government in Britain. Setting aside official policy, there have been a number of initiatives to estabish a more pluralistic maternity and infant care system. It is not at all difficult to establish the borders 5 2 V. da Cruz, Bailliere's Midwifes' Dictionary, London, Balliere Tindall and Cassell (fifth edition), 1969. 5 3 Sheila Kitzinger, The Experience of Childbirth, Harmondsworth, Penguin, 1978, p. 51. 5 4 Sheila Kitzinger, Women as Mothers, Glasgow, Fontana, 1978a, p. vii. 5 5 Jean Donnison, "The Development of the Occupation of Midwife: A Comparative View", in Midwifery is a Labour of Love, Vancouver, Maternal Health Society, 1981, p. 9. 163 of debate over the appropriateness of home birth. Some support out-of-hospital birthing clinics and home birth while others have held categorically that homebirths are "...the earliest form of child abuse...." 5 6 and ought to be outlawed. Others encourage pregnant women to deliver at home and to lobby for the legal right for childbirth attendants to practice domiciliary obstetrics and midwifery. 5 7 Clearly, then, the struggle over birth attendance is in large measure a political and ideological debate over power and women's freedom over reproduction. The political and ideological dimensions of this debate are brought forward in the next section, with specific reference to the role of the State in regulating birth practice. State Control and Resistance An understanding of the community midwife movement in British Columbia is best located within the broad paradigm of conflict theory within sociology. Childbirth became a battleground between lay midwives, doctors, nurses, and scientists. Writing of the struggle over childbirth attendance in England, Jean Donnison described it as "inter-professional rivalry". 5 8 The nature of the conflict is complex, involving not only the economic interests of the established professions and the alternative practitioners, but conflicts with various groupings in the public over safety and standards, and the gatekeeping functions of State officials. The conflict approach as applied in the case of midwifery invariably addresses the self-interest of the medical profession in presiding over childbirth and the premise that medical attendance is 5 6 Warren H. Pearse, "Home Birth Crisis", A.C.O.G. Newsletter, 1977; W. Pearse, "Home Birth: Editorial", Journal of the American Medical Association, 1979, 241, pp. 1039-1041. 5 7 Sam Bittman and Sue Rosenberg Zalk, Expectant Fathers, New York, Hawthorn, 1978. For a statement from representatives of the Association for Childbirth at Home International (A.C.H.I.) see Tanya Brooks and Linda Bennett, Giving Birth at Home, Curritos, California, A.C.H.I., 1976. 5 8 Jean Donnison, Midwives and Medical Men: A History of Inter-Professional Rivalries and Women's Rights, 1977, New York, Schocken. 164 demonstrably superior to midwifery attendance.59 One point worth emphasizing is that the nature of the conflict is not static. As Thompson noted in his critique of structural Marxism, even fairly powerless people can struggle against oppression, occasionally relying on the rule of law to secure their rights. 6 0 This is also true of community midwives since they reject unfavourable interpretations of their work, continue to practice midwifery, and lobby for legalization of midwifery. Public education campaigns and media submissions - most notably letters to newspapers editors - illustrate this action of a quite visible nature; workshops and educational initiatives reflect less visible, collective initiatives to improve community midwifery services. 6 1 Other activities within the community midwifery movement include fundraising via benefit dances, gambling casinos, and mail solicitation. These fundraising activities are usually designed to benefit a group, such as the Midwifery School, or to defray legal costs associated with coroners' inquests or criminal prosecution following an infant death. A key point is that the resources of community midwives are indeed slight in comparison with the financial resources available in the State and through provincial and national Medical Associations. Midwives can innovate, however. Nine community midwives were also developing a collective in which education is ongoing and in which each of the members has pledged to contribute up to a thousand dollars in the event that any one of the collective faces legal costs. 6 2 5 9 See Ronald Hamowy, Canadian Medicine: A Study in Restricted Entry, Vancouver, The Fraser Institute, 1984. 4 0 E.P. Thompson, Whigs and Hunters: The Origin of the Black Act, Harmondsworth, Penguin, 1975. 6 1 On this point see Rose Weitz and Deborah Sullivan, "Virtuous Deviance and Identity Maintenance Among Midwives", Unpublished paper. 6 2 Information provided informally by one of the members of the Pacific Midwives' Group, 1986. 165 The New Midwifery is a hybrid form of midwifery in British Columbia. With ties to a tradition of local self-help and some linkages with modern New Age spiritual philosophy, a number of practitioners have formal instruction in nursing and a formal school curriculum has been designed and implemented. Guidelines for midwifery practice have been drafted (and redrafted) and peer review is one mechanism that mirrors a more professional approach to birth attendance by community midwives. The community midwives are not wholly united, however. Some midwives practice autonomously on the M.A.B.C. and there is disagreement over the appropriateness of attempting home birth without sufficient medical back-up, emergency services (ambulatory care), whether women who have been delivered via Caesarean section should attempt a vaginal birth at home, and so forth. Community Midwifery has also been troubled from without State measures are taken against community midwives. Criminal prosecution of midwives and other birth attendants has been implemented in B.C. (and elsewhere), as has prosecution under the provincial Medical Practitioners Act for practicing medicine without a license. The financial losses incurred for retention of a defence lawyer, loss of income (if the midwife is forbidden to practice midwifery, pending the outcome of a court case), along with the uncertainty of the eventual verdict reflect some influences of the State on these midwives. Other State measures bear on our theoretical understanding of the State, the professions, and community initiatives. Despite years of lobbying for legal status for midwives and notwithstanding a substantial evaluation literature documenting the benefits of skilled midwifery practice, community midwives remain illegal practitioners under this provincial legislation. They are also excluded from the provincial Medical Insurance Plan and lack a substantial defence fund in the event that they are charged with criminal or quasi-criminal offences or if a private writ is served against them. Currently, then, community midwives are relatively free to practice and even to declare themselves, to advertise their home birth practices, to develop an academic curriculum and 166 practical training, and to transfer women to hospital if a home birth is not successful. This freedom is circumscribed, however, by their complete exclusion from provincial health insurance plans. It is further constrained by the general powers of the Medical Associations through the State and the reluctance of State officials to further expand medical coverage. The preliminary evidence on the midwifery movement seems best suited to a "relative autonomy" perspective on the State. Liberal democratic States will vary in terms of the degree of their autonomy from Civil Society. The point remains that the State is not acting simply as an instrument of powerful interests, nor is it promoting the pluralistic principles often linked with liberalism. In the wake of three Coroners' Inquests into baby deaths in Ontario, and following years of pressure by the Ontario Midwives' Association (composed of midwives and consumer advocates, among others) and other pro-midwife organizations, midwifery is on the verge of legal recognition in Ontario. The Ontario Minister of Health has proposed direct entry into midwifery (rather than mandatory- nursing training aside from midwifery training). The arguments for legalized midwifery - on the safety of home births attended by trained midwives, the so-called "soft" measures of client satisfaction, and the fundamental democratic principle that the State should not interfere with private decisions of citizens - are quite strong as are the measures taken to stifle autonomous midwifery practice. The current inertia with respect to legalizing midwifery seems to reflect professional resistance to autonomous midwifery practice and the reluctance of the State to permit community-based, decentralized initiatives at a time when State trajectories are toward greater control. 6 3 Nevertheless, it must be emphasized that the State in Canada is relatively autonomous, and the degree of autonomy is neither a static nor a permanent feature of the capitalist State. The administration of health is a provincial responsibility, and there have been varying 6 3 This is variously known as the "cunning" or "exceptional" State. See Stanley Cohen, Visions of Social Control, 1985, London, Polity Press, pp. 107-109. The use of "moral panics" as a strategy for consolidating State powers is set out in Stuart Hall et al., Policing the Crisis, London, MacMillan, 1978, pp. 219-222. 167 degrees of response among the provinces toward recognizing midwifery in law and public policy. Ontario and Quebec are in the forefront of legalizing midwifery, and B.C. has reviewed a number of submissions proposing direct entry midwifery training and a separate legal status from the nursing and medical professions. The dominant status of the medical and nursing professions will likely not be set aside in maternity and infant care. Virtually all nation states actively promote medical and nursing education and practice, and there is a strong case for further developing the knowledge base and clinical practices associated with the medical and nursing professions. A related point concerns the artificiality of some constraints on birth attendants. As was set out in Chapter Three, the monopoly powers of the various Provincial Medical Associations and their Colleges have been achieved, in part, through the denunication and prosection of the ancestors of the New Midwives. The issues ahead will revolve around whether current midwifery initiatives are coopted by the established health professions in Canada and who controls licensure, training, and peer review. 168 NURSE-MIDWIFERY PRACTICE Introduction The first chapter established several differences between accredited nurse-midwives and community midwives As a rule, nurse-midwives in Canada work as salaried employees in hospital settings. They belong to professional nursing associations, (e.g., the Registered Nurses' Association of British Columbia), and are usually not responsible for prenatal care of clients nor do they usually assume responsibility for the delivery stage of childbirth. Physicians tend to be responsible for prenatal visits and delivery in many settings. Stereotyping nurse-midwives as a grouping is of course hazardous: there is great variation in the sphere of practice, especially in northern regions where midwives may be responsible for many decisions ordinarily assumed by medical personnel. In this chapter, the role of nurse-midwives is evaluated, with special attention to community midwifery practice. Significant initiatives are discussed: the attempt to establish an out-of-hospital birthing clinic in Vancouver, the Low-Risk Clinic which allowed more independent practice and continuity of care by nurse-midwives, and the succeeding Midwives' Project at the Grace Hospital in Vancouver. These initiatives illustrate central problems in nurse-midwifery as outlined below. Central Problems in Nurse-Midwifery Whatever the attempts to promote midwifery services, it is not uncommon for nurse-midwives to express resentment at the containment of their skills in attending women in childbirth. For some, the opportunity to apply these skills is truncated when they arrive in urban settings where physicians are dominant within the occupational hierarchy of hospitals. 169 "I worked on the obstetrical unit (of a 55-bed hospital in the North). That was really interesting I did quite a few deliveries because the medical coverage wasn't always that great And basically I worked autonomously, with some limitations...I was allowed a lot of freedom to practice in my own way. I think if I had not had that I would have found it very limiting. The physicians who were there were very inexperienced in obstetrics...! realized why I was necessary, why they made a prerequisite of midwifery training for anyone who worked on the obstetrical uniL..they really needed my skills. The most shocking experience I ever had in Canada was when I moved to (a large city in Alberta) to work in a University Hospital. Every woman had an obstetrician. It was a high-risk unit, but many of these women were not high risk. There were 18 obstetricians on staff. Women literally came in and had birth done to them. It was incredibly shocking...." (Nurse-midwife #4, 1985) The leitmotif of professionalism that appears throughout the definitions of nurse-midwifery has been criticized by some. A few community midwives have expressed their misgivings about what they see as the proprietary nature of obstetrical nurses, taking the baby as their property while disciplining errant parents and community midwives. The converse may be found as well; that is, people who praise nurse-midwives for taking time with patients, for combining this rapport with clinical skills that are at least on a par with medical staff. 6 4 The movement for greater recognition of nurse-midwives as birth attendants has contributed to an expanded role in conventional obstetrical settings. The recent proliferation of . Nurse-midwifery programmes in the United States. 6 5 has often been interpreted in terms of consumer demand for alternatives to standard obstetrical attendance at birth. Midwives are active in tertiary care, and can collaborate with obstetricans and anaestheologists over decisions about pain relief in obstetrical care. 6 6 A survey of practicing 6 4 See Diana Scully, Men Who Control Women's Health: The Miseducation of Obstetrician- Gynecologists, 1980, Boston, Houghton Mifflin, pp. 125-126. Of course, this clinical style can be denigrated as unexciting "handholding" within the clinical hierarchy. 6 5 Anne Scupholme, "Nurse-Midwives and Physicians: A Team Approach to Obstetrical Care in a Perinatal Center", Journal of Nurse- Midwifery, 1982, 27(1), p. 21. " G.C. Ghosh-Ray et al., "An Integrated Pain Relief Service for Labour: Co-operation between obstetricians, anesthetists, and midwives", Anaesthesia, 1980, 35(5), pp. 510-513. The order of the professions in the title - obstetricians first, midwives last - gives some 170 midwives in the United States in 1976, which gathered data on 1,213 nurse-midwives, confirmed that the collaboration between physicians and nurse-midwives permitted a degree of treatment of birth complications by nurse-midwives. 6 7 "In general, the more invasive N and risky the procedure, the less likely nurse-midwives are to perform it However, nearly as many (89 per cent) reported they managed the care of prenatal patients with some complications. A number of minor complications occur quite commonly in otherwise normal pregnancies, creating a gray area between 'normal, well, uncomplicated patients' and 'high-risk' or 'complicated' patients. Most nurse-midwives providing prenatal care have developed collaborative relationships with physicians in which they can continue to care for patients who experience certain kinds of prenatal complications" One difference frequently suggested in the literature is that contemporary lay midwives are more politicized than nurse-midwives. There appears to be a sub-cultural approach by some community midwives, including a resolve to respect the woman's wishes during labour and delivery, and throughout the pregnancy and post-partum period. The lay midwife, according to this portrait is more inclined to respect the wishes of women (or couples) during labour and delivery, and more likely to regard organized medicine as profit-oriented and male-dominated. In her practice she may contravene guidelines for practice (local or international guidelines) on the basis of her judgement of the situation and out of respect for the women. This apppears to be linked with two major themes: the historical takeover of birth by physicians from community midwives, and the perception that nurse-midwives are greatly constrained within the hospital hierarchy and unable to apply their skills fully to the women they serve. Certainly, Cobb indicates that nurse-midwives have been coopted by the dominant medical profession. 6 8 "(cont'd) indication of the ranking that may affect patterns of decision-making within the team. 6 7 This survey found that only 15% of nurse-midwives working in the general area of deliveries managed multiple births, and only 12% were responsible for breech deliveries. Nevertheless, 99% of C.N.M.S performed and repaired episiotomies. See Rooks and Fischman, op cit, 1980, 992-993. 6 8 Cobb, op cit, p. 75. 171 The sub-cultural motif may be overdrawn with respect to many community midwives. The author's impression is that midwives tend to be oriented toward a community of clients and not toward a particular community or locality. In fact, the great majority of home births analyzed in this study took place in over 200 localities throughout Ontario, B.C., and Saskatchewan. It is also unsupportable to juxtapose community midwives against nurse-midwives as if the latter were not also serving a community or constituency. This constituency would tend to be disinclined to home birth and to be fairly positive toward conventional management of childbirth by physicians and nurses. 6 9 Starr holds that even in the 17th and 18th centuries in the United States, the lay midwife was regarded as a competitor by many medical men while the nurse-midwife was not 7 0 Others are in agreement that nurse-midwifery in the United States is primarily a dependent occupation: 7 1 "It is perhaps a mistake to refer to midwifery in the United States as an emerging profession. Midwifery as it was known in Europe and England never really existed; decisions, political and economic, were made which led to the elimination of midwifery. What is slowly emerging is a health worker called a nurse-midwife - an asssistant to the obstetrician and not an independent practitioner. Only 10% of American nurse-midwives are presently employed in positions that offer • full use of their training..." Another difference between lay midwifery and nurse-midwifery involves the apprenticeship in birth attendance. Unlike the formal training in midwifery, usually in conjunction with completion of nursing training, lay midwives tend to learn by their "empiric"; that is, through attending births and reading birth manuals. This differentiation of midwives trained in nursing, and other midwives, can in turn be linked up with comments 6 9 There are of course instances of nurses taking action outside of the conventional hospital network. An Ontario nurse published a favourable account of her decision to give birth at home with medical attendance. Mavis Swedlo, "Childbirth at Home," Canadian Journal of Public Health, 1979, 70(5), pp. 307-353. 7 0 Paul Stan, The Social Transformation of American Medicine, 1983, New York, Basic Books, p. 223. 7 1 P. Anisef and P. Basson, "Institutionalization of a Profession - Comparison of British and American Midwifery", Sociology of Work and Occupations, 1979, 6(3), p. 368. 172 on the "proleterianization" of nursing and the deflection of efforts to achieve greater autonomy by nurses in the United States. 7 2 A related point is that solidarity among nurses in Canada is narrowly defined. 7 3 Deference to medical authority is pronounced, although the emergence of provincial and national organizations and of collective bargaining status has countered this historical situation. In Canada the direction of legal lobbying and professional recognition has been toward an expanded role of certified nurse-midwives. It is estimated that there are at least 100 certified nurse-midwives in British Columbia. 7 4 Independent midwifery practice has generally been restricted to nurses working in remote regions with limited or non-existent access to physicians. 7 5 The movement toward more independent practice of midwives in Canada was favoured by Louise Miner, past President of the Canadian Nurses' Association. She criticized general practitioners for simultaneously acknowledging their limitations while resisting midwifery practice; moreover, she felt that all normal pregnancies should be delivered by midwives and that they should practice independently. 7 6 In 1971 a survey of members of the Society of Obstetricians and Gynecologists of Canada found that the majority of members responding to the survey accepted the premise of trained midwives taking more responsibility in prenatal and antenatal care. Nevertheless, there was a general reluctance to endorse delivery of babies by midwives and concern expressed about possible lack of supervision by physicians of 7 2 David Wagner, "The Proleterianization of Nursing in the United States, 1932-1946," International Journal of Health Services, 1980. 10(2), pp. 271-290. 7 3 Suzann Buckley, "Ladies or Midwives: Efforts to Reduce Infant and Maternal Mortality," in Linda Kealey (ed.), A Not Unreasonable Claim: Women and Reform in Canada, 1880s- 1920s, 1979, Toronto, The Women's Press. 7 4 Paula Brook, "Midwives and Medicine," The Magazine, May 18, 1980, p. 6. 7 5 A midwifery programme at the Master's level has been offered at Memorial University, Newfoundland, an Advanced Obstetrical Nursing Course is continuing at the University of Alberta, and outpost nursing - with a midwifery component - is available at Dalhousie University in Nova Scotia. 7 6 Milan Korcok, "Health Planners Debate the Midwife's Role: Her Capabilities are Unquestioned, but Acceptance Hinges on Physician and Patient Reactions," The Medical Post, February 23, 1972, 8(4), p. 45. 173 midwives in maternity practice. 7 7 This reluctance to endorse nurse midwives as birth attendants is also evident in the drafting of a document over regionalization of maternity and newborn care in the United States. The American College of Nurse-Midwives (A.C.N.M.) was not invited to contribute to the drafting of this document 7 8 A statement in support of nurse-midwifery practice was adopted by the Registered Nurses Association of British Columbia in June, 1979, following a 10-month investigation by a three-member Committee. This statement included resolutions that: the role of the nurse-practitioner should be established in British Columbia; that the practice of nurse-midwifery should be legally defined as "Part of the ordinary calling of nursing", thereby meeting an exemption from prosecution under section 71 of the Medical Practitioners Act; that standards of nurse-midwifery practice should be met; that various types of practice could be subsumed, domiciliary (home) births and management of low-risk and high-risk births in hospitals or clinics; and that refresher courses be made available for nurse-midwives (R.N.A.B.C., 1979). 7 9 Home Birth and Midwifery Policy The issue of home birth has generated some consensus on the preferability of hospital settings for delivery. The Western Region Nurse-Midwives Association registered their preference for working with obstetricians in clinical settings. 8 0 More recently, a spokeswoman 7 7 Ibid., p. 7. 7 8 Muriel Sugarman, "Regionalization of Maternity and Newborn Care: Facts, Fantasies, Flaws, and Fallacies," in David Stewart and Lee Stewart (eds.), Compulsory Hospitalization or Freedom of Choice in Childbirth, 1979, Marble Arch, N.A.P.S.A.C., p. 69. 7 9 Registered Nurses' Association of British Columbia, "Policy Statement - Nurse Midwifery," 1979, Typescript mimeo, 2 pp. 8 0 Canadian Press, "Parents Must Decide on Home Childbirth," The Province, August 26, 1976 (no pages noted). 174 for the Registered Nurses' Association of British Columbia stated the Association's opposition to home deliveries as an alternative to hospital deliveries, adding that inadequate back-up services in British Columbia did not allow for safe home deliveries. 8 1 The spokeswoman added that this policy position does not discredit home birth per se but instead emphasizes the importance of not undertaking domiciliary obstetrics without established access to emergency back-up services. The concept of nurse-midwives working in hospital settings, supervised by physicians, was recently endorsed by a joint Committee including representatives from the Registered Nurses Association of British Columbia and from the College of Physicians and Surgeons. 8 2 Another potential area of conflict between midwives involves attempts to legitimize community midwife practice. The Midwives Alliance of North America (hereafter, M.A.N.A.) comprises nurse-midwives and lay midwives, and the Midwives'. Association of British Columbia encourages membership of nurse-midwives and community midwives. Nevertheless, some certified nurse-midwife members have opposed the lack of clear standards of education and practice for lay midwives. 8 3 M.A.N.A. representatives have sought to establish standards for "basic competency" for certified nurse-midwives and community midwives alike. 8 4 The tension between certified midwives and other midwives is linked with a general trend toward professionalized health care, including nursing. In organizational theory there is however a tendency for certain tasks to be delegated to subordinates as organizations become more complex: for example, record-keeping and scheduling, once deemed the bailiwick of doctors, 8 1 See Marilyn Carmack, "Birthplace pangs," MacLean's, 1980, 93(5), p. 13. 8 2 Tim Padmore, "Vancouver Hospital Tries Midwifery Program," The (Montreal) Gazette, February 21, 1983, p. A7. 8 3 Shelley Campbell, "Midwives United: The Midwives Alliance of North America," Mothering, 1872, #24, pp. 75-76. 8 4 Fran Ventre and Carol Leonard, "The Future of Midwifery - an Alliance," Journal of Nurse-Midwifery, 1982, 27(5), pp. 23-24. 175 have been delegated to nursing staff.85 Alternative Birth Centres The introduction of alternative birth centres (A.B.C.s) as a compromise between domiciliary birth settings and obstetrical wards is one example of innovation that rests, in part, on consumer demands for humanistic, flexible management of pregnancy and childbirth. For example, staff at a free-standing birth centre in Culver City, California encourage families to remain together throughout labour, and allow women to take a variety of delivery positions. Certified nurse-midwives are employed in the centre. 8 6 This apparently neat equation of birth innovations and public demands does not take into account the historically-rooted rivalry between various professional and non-professional associations. 8 7 It also must address suggestions that A.B.C.S do not in fact significantly alter the incidence of obstetrical interventions. With direct reference to alternative birth centres, DeVries contends that the apparent freedom accorded patients in A.B.C.S is in fact used ideologically to consolidate the power of birth centre staff. Notwithstanding the home-like decor and nods toward unmedicated births, where possible, A.B.C.S thus are characterized by unjustifiably high rates of invasive treatment, including analgesia, anaesthesia, episiotomy, and forceps delivery. 8 8 In a more recent article, 8 5 This is not a recent phenomenon. See Everett C. Hughes, Helen M. Hughes, and Irwin Deutscher, Twenty Thousand Nurses Tell Their Story: A Report on Nursing Functions Sponsored by the American Nurses' Association, 1958, Philadelphia, Lippincott, p. 7. 3 6 Margaret Mettelbach, "The Midwife Crisis", Los Angeles's Free Weekly: The Reader, December 12, 1986, 9(9), p. 10. 8 7 See for example Eliot Freidson, "The Organization of Medical Practice," in Howard E. Freeman, Sol Levine, and Leo G. Reader (eds.), Handbook of Medical Sociology, 1972 (second edition), Englewood Cliffs, N.J., Prentice-Hall, pp. 343-358. 8 8 Raymond G. DeVries, "The Altenative Birth Centre: Option or Cooptation?" Women and Health, 1980, 5(3), pp. 47-60. 176 DeVries cites one study which documented a transfer rate of 46% of patients from an alternative birth centre to a conventional labour and delivery suite. 8 9 A recent documentary on home birth in the United States indicated that between 20 and 50 percent of women entering an A.B.C. will be transferred to operating rooms; (e.g., for a forceps delivery, Caesarean section, electronic fetal monitoring, and so forth). 9 0 Establishment of birthing rooms within hospitals is another method of adapting settings to consumer demands, although it has been reported that in some hospitals the birthing rooms account for only a small proportion - in some cases as low as three percent - of all births in hospital. Some disagree that A.B.C.S are in the best interest of pregnant women and infants. The growth of birth centres is tied to the professional interest of nurse-midwives, long subordinated to doctors' control through denial of hospital privileges and inadequate back-up services. 9 1 Another point of concern arises from the failure to establish out-of-hospital birthing centres. The recent denial of government funding to a Toronto-based group was attributed to the lack of physician support for such a Centre. An earlier proposal to develop an out-of-hospital clinic in Vancouver was not accepted by a federal funding agency. It was suggested that the lack of support for the clinic among physicians was a factor in rejecting the proposal. The resistance to such centres thus involves a measure of self-interest among more established institutional staff and professsions. 9 2 8 9 R.G. DeVries, "'Humanizing' Childbirth: The Discovery and Implementation of Bonding Theory," International Journal of Health Services, 1984, 14(1), p. 98. 9 0 C.B.S. News, Programme Featured on Sixty Minutes, March 21, 1982. 9 1 The critique of A.B.C.S is far from absolute. One author acknowledges that women giving birth in A.B.C.S tend to be satisfied with their experience, and she appears to have a "blind spot" with respect to the limitations of home birth arrangements. See Barbara Katz Rothman, "Anatomy of a Compromise: Nurse-midwifery and the Rise of the Birth Center," Journal of Nurse-Midwifery, 1983, 28(4), pp. 3-7. 9 2 Ruth Watson Lubic, "Alternative Maternity Care: Resistance and Change," in Shelly Romalis (ed.), Childbirth: Alternatives to Medical Control, 1981, Austin, University of Texas Press. 177 Demonstration Projects: Canada and the U.S. The Low-Risk Clinic (Vancouver, British Columbia) There have been few studies of midwifery practice by nurse-midwives in Canadian hospitals. The Low-Risk Clinic was a pilot project that operated at the Grace Hospital in Vancouver from September 1981 until May 1984. Four nurse-midwives and four obstetricians worked together in caring for 61 women. This pilot project in a major hospital in Canada's third largest city was designed to provide safe deliveries of babies, to demonstrate the competency of trained nurse-midwives in managing births with less interventions than conventional birth attendance. Continuity of care was sought with the women who were to give birth. Extensive prenatal care was provided by the midwives, along with consultation with the physicians and nursing staff. The report on this project generally confirms the viability of more independent midwifery practice within a major hospital. A follow-up survey also indicated that the clients were generally pleased with the project. One measure of the success of the project was the increased rate of spontaneous vaginal deliveries among the Low-Risk Clinic patients in comparison with hospital-wide statistics at the Grace Hospital. As noted earlier, approximately 92% of the attempted home births with the community midwives resulted in spontaneous vaginal deliveries. The report of the Low-Risk Clinic provides a useful portrait of specific policies and procedures for assessing the health of the woman and fetus throughout the pregnancy, as well as procedures for consultation with pediatricians, general practititoners, obstretricians, and nursing staff. An integral part of the Clinic was to accomodate the wishes of the couple where possible, and to ensure safe deliveries. The satisfactory results of the Low-Risk Clinic led to the development of a subsequent Midwives' Project in the Grace Hospital. This 178 Table 28: Mode of Delivery Low-Risk Clinic Grace Hospital N % N % SVD 40 73.0 N.A. 58.7 Forceps 9 16.0 N.A. 19.8 Caesarean 6 11.0 N.A. 21.5 T o t a l 55 100.0 N.A. 100.0 Source: Elaine Carty et al., The Low-Risk Clinic, 1984. p. 25. ongoing project is an established part of the Labour and Delivery budget at the hospital. A continuing difficulty in assessing the nature of contemporary birth attendance, including attendance in alternative birth centres, is the lack of information on particular centres. To some extent this lack has been overcome by recently published accounts of birth centres and nurse-midwifery practice in hospital settings in the United States. Several of these published accounts will be outlined to indicate general themes and to underscore difficulties associated with evaluation studies from California, Arizona, Georgia, and Florida. These selected studies provide additional evidence in support of the safety of nurse-midwifery practice. Perinatal mortality rates are lower than the average rate in the respective states and well within expected rates of perinatal mortality generally. There also tends to be a reduction in caesarean section rates, forceps delivery, and the use of analgesia. 179 Table 29: Demonstration Projects in the United States S. Francisco New Mexico Georgia Flor 1975-79 NA 1976-?? 1977-81 No. of births 1,005 838 2,050 6,313 Analg. 29.1% NA 8.0% 51.3% C-section 9.0%* 5.0 9.4% 2.1% Forceps 7.5% NA 5.0% 2.0% Spont vag. 80.3% NA 85.6% 96.0% Episiotomy** NA 31.0% 27.0% 58.2% Intact perin. 39.9% 37.0% 37.0% 22.7% Lacerations+ NA. 32.0% 36.0% 19.1% Per. Mor.++ 9.0 NA 9.3 NA •In this study, 0.9% of births occurred with vacuum extraction and 2.3% of cases had no indication of the method of delivery. ••Episiotomy rates reported here exclude people delivered by Caesarean section. +Indicates lacerations requiring repairs (suturing). ++Perinatal mortality rate per 1,000 live births. The incommensurability of these reports highlights a general difficulty of reportage. Although reportage usually centres on conventional variables such as birth outcome, obstetrical interventions, and infant mortality and morbidity, there is nevertheless a tendency toward unstandardized reportage, with certain variables presented and others not, without a clear statement of why some are deemed salient to the evaluation of nurse-midwifery practice vis-a-vis other kinds of birth attendance. This unstandardized method of reportage, along with missing data, impede comparisons of findings pertaining to nurse-midwifery services. These demonstration projects address a central tenet in the continuing debate over midwifery attendance: that midwifery attendance is uniquely suited to uncomplicated births. In 180 a recent editorial 9 3 it was asserted that: "Nurse-midwives are cost-effective because we can show improved neonatal and maternal outcomes with fewer medical interventions, because we provide safe births in less expensive out-of-hospital settings or for fewer hospital days, and because we can show that emotional support and education about nutrition, exercise, breastfeeding, and self-care are worthwhile". Haire 9 4 also contends that nurse-midwifery practice is superior to conventional medical attendance in many respects, particularly in promoting unmedicated births, reducing the incidence of episiotomies, instrumental deliveries, and so forth. Haire combines her observations of maternity hospitals in Great Britain, Russia, Western Europe, and other countries with more detailed observations of nurse-midwifery practice in the North Central Bronx Hospital, the Frontier Nursing Service in Kentucky, and the Su Clinica Familia in Texas. With specific reference to the North Central Bronx Hospital, of 2608 midwife-assisted births in 1979, a relatively high percentage (88%) delivered vaginally and spontaneously. Analgesia or anesthesia was resorted to in less than 30% of all labours, while force