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


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 It is argued that many of the reservations about community (lay) midwives are no longer applicable, and that the containment of nurse-midwives reflects an historical accommodation between the nursing and medical professions in Canada.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 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.

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