Editor’s note: This article was originally written for the book Paths to Becoming a Midwife: Getting an Education, 2nd ed. Edited by Jan Tritten and Joel Southern. Eugene, OR: Midwifery Today, 1998. It also appeared in Midwifery Today Issue 49, Spring 1999.
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Direct entry to what? A path to where? What is it that we are entering, and where is it we are going? Much as I would like it to be, “midwife” is not a self-evident, all-inclusive term. A midwife is, like everything else in this world, very much in the eye of the beholder.
Having studied midwifery issues for nearly 25 years now, I have quite the collection of midwifery T-shirts, including one from the first Midwives Association of North America (MANA) meeting, T-shirts from organizations long defunct, shirts with women and babies and moons and stars. But my favorite is the first one I ever got. Between the words “The Midwives” on top and “Daughters of Time” on the bottom is a drawing of two women, clearly intended to be midwives, striding forth. One is from the 1800s, wearing a shawl, long skirt and high-button shoes, hair knotted in back. The other, younger and taller, has long, loose hair, an open-necked shirt with rolled-up sleeves, a wristwatch, sandals and bell-bottoms. Midwives of the 1970s are now as much a part of our history as are midwives of the 1870s.
What is the continuity between these two midwives and the midwife just starting to stride forth on her path today? All are daughters of time, speaking to the continuity of midwifery across time, just as each is also a daughter of her own time, speaking to the different kinds of midwifery that different moments of time call forth.
The midwife of the 1970s was aspiring toward her midwifery: It was a goal, an ideal. She could not, as her sister/foremother of the 1800s could, take midwifery for granted. For an earlier midwife, the practice of midwifery was important, valued and respected, but also a part of ordinary life. Of course there were midwives, and of course what midwives did was practice midwifery. The work needed to be done, and someone would have to do it, such as, for instance, cobblers, the people who made shoes. That is not to say the work wasn’t much appreciated, and not to say better cobblers weren’t much in demand, but one wouldn’t think to venerate grand cobblers or hold up the ideals of cobbling.
Because midwifery was so deeply damaged, so all but completely destroyed in the years that separate the two midwives on my T-shirt, it can no longer be taken for granted. Midwifery came to be something more than the people who practice it—it came to be something of an ideal, a goal, a model to which one could aspire. The distinction arose between midwifery as an occupation or a practice, as something one does, and midwifery as a model. I am the person who first wrote about the distinction between a “medical model” and a “midwifery model” of pregnancy and childbirth. When Marsden Wagner pointed out to me that I was the first person who made this distinction, I was surprised—hadn’t we always known this?
I had a homebirth in 1974 with the assistance of a feminist obstetrician, someone who understood and agreed in principle with my right to birth as I saw fit, in the location of my choosing. In fact, she was clueless. When the baby was born and I was reaching up to take him, the doctor passed the child back over her shoulder to where she presumably expected a nurse to materialize. My mother—standing in the right place—was the first to hold my newly born son.
Homebirth, I saw, was very different from hospital birth, not only for the birthing woman but also for the women attending. I chose this topic to research for my dissertation as a graduate student in sociology. Living in New York City, I tracked down and interviewed all the people I could find who were attending homebirths. All were nurse-midwives. Some had gone through regular nurse’s training and then moved on to hospital-based midwifery before doing homebirths; some had been trained and worked as midwives before becoming nurse-midwives.
I observed a few births, but it was less what the midwives were doing that interested me and more how they were thinking about what they were doing. Their knowledge, their understanding, their way of thinking about birth intrigued me. How do people know what they know? That’s a basic question in sociology, and it was the one that captured my attention.
My key insight was seeing that there are different models underlying practice, different ways of thinking about birth that resulted in different ways of practicing. Ways of thinking, ideology and concepts underlie ways of practicing, of behaving and doing. I read the obstetrics literature, and I read the literature of the developing homebirth movement—newsletters, conference reports, Ina May Gaskin’s Spiritual Midwifery—what little there was out there on homebirth. I started comparing the way people think about birth at home and the way they think about it in the hospital. It was the difference between the two places that first caught my attention.
Most of the midwives I was interviewing were in a way just like the feminist obstetrician who delivered my baby. They had the best of intentions, but they were really out of their element in the home. They didn’t know what to think much of the time. They were confused about what they were doing and seeing. I worked with a study group at the time in which we read each other’s dissertation work. Continually talking about these different midwifery paths, I had a hard time articulating the differences between home and hospital birth.
One day my friend and colleague Eileen Moran came back to my house the day after a study group meeting. She sat down with me in my office and drew two circles on a piece of paper. The one on the left, she said, is the way doctors think about birth—the way midwives are taught about birth in their hospital training. The circle on the other side of the paper, the homebirth approach, represents the lay midwives in California and what spiritual midwifery is about. And here in the middle, trying to find their way, are these midwives you’re interviewing.
That was exactly right. Those were the midwives, as I quickly came to call them, “in transition,” that most painful, intense, hard part of labor right before you make clear and obvious progress. Those midwives were right there, that part where you don’t know if you’ll ever pull through, that part where you are vulnerable and scared and working very, very hard.
It wasn’t really about “home” or “hospital.” A midwife could bring the hospital way of thinking into the home with her. And a midwife could bring the home way of thinking into the hospital. Many of those midwives would tell me stories of doing homebirths one day and then doing hospital births the next, trying to take what they had learned at home and apply it in the hospital. “Midwifery” was a way of thinking to which most of these nurse-midwives were aspiring. I started to call these different approaches “medical” and “midwifery,” rather than hospital and home.
Like many graduate students of the time, I was heavily influenced by the work Thomas Kuhn had done in his book The Structure of Scientific Revolutions, in which he introduced the idea of a paradigm shift. Science, Kuhn pointed out, doesn’t proceed at an even pace. Data is collected and analyzed and collected and analyzed. And then there comes a moment when the data no longer seems to fit the old analysis, and a “scientific revolution,” a “paradigm shift,” lurches the science ahead to a new place.
Kuhn gave a simple example from a psychology experiment. Subjects were asked to identify playing cards flashed on a screen. Most were from a standard deck, but some were made anomalous—a red six of spades or a black four of hearts. Something interesting happens when you show people these cards. At first, they “normalize them.” They identify a black heart as a regular red heart or see it as a spade. After a while, though, subjects begin to hesitate. More and more hesitation is shown, until they switch over and come to see a black heart as a black heart, and a red spade as a red spade. Kuhn said science works like that too. “Novelty emerges only with difficulty, manifested by resistance against a background provided by expectation.”
But medicine and midwifery aren’t sciences. They are clinical practices. Science has as its goal the production of knowledge. Medicine and midwifery are geared to the provision of services, to the improvement of outcome. It is the nature of scientific work to expose inconsistencies, to show the flaws in the old paradigm. Clinical practice, on the other hand, is not about generating data; it’s about treating people. There are no control groups in clinical practice; once something is accepted as a treatment, it is offered. It works or it doesn’t work, but the situations in which treatments are offered—the real world—are far too complex for us to consistently learn anything about the treatment. Maybe the condition would have cleared up without the treatment, maybe it only cleared up in spite of the treatment, maybe it wasn’t the condition diagnosed anyway. Maybe the patient never really followed the treatment. Who knows?
Not only is clinical work not organized to produce new knowledge, but one could argue that it is really designed to avoid the production of knowledge. If the data you see—what is actually happening in the patient before your eyes—does not conform to the model of the illness, the practitioner is expected to reconsider the patient. For example, medical texts offer both the theoretical effectiveness of a contraceptive, how it is supposed to work, and also its “use-effectiveness”—how well it actually works in practice. If a contraceptive doesn’t work the way it is supposed to, the problem lies with the user.
While I found the story Kuhn was telling extraordinarily useful, I didn’t want to adopt his vocabulary. If science works with paradigms, what could I say clinical practice works with? “Models” are what I came up with. Models serve much the same purpose for the clinical practitioner as paradigms serve for the scientist: They attract groups of adherents, they become focal points for social organization as well as the organization of knowledge. And while paradigms are open-ended enough to leave all sorts of problems for the scientist to solve, models are useful to provide guidelines for practice. Both make work possible. Kuhn looked at paradigm shifts and scientific revolutions; I saw shifts in models and clinical revolutions.
What makes a clinical revolution? If, unlike science, clinical practice is not designed to produce new knowledge, where does new knowledge come from?
Where does knowledge come from in the first place? We learn from each other. We are taught by one another to think. Models or paradigms or whatever you want to call them give us the picture we have in our heads, against which we look at the world. We hold up what we know to be true and judge what is before us according to that. If the model tells me what a normal labor is like, then what is this labor I am seeing when compared with that? Longer? Shorter? Stronger? Weaker? Or take something very simple: We have learned what a newborn baby should look like. There is a model, an ideal type—not ideal in the sense of being the “Gerber baby,” but ideal as in paradigmatic, the essence of new babyhood—having the necessary and essential characteristics that mark it as a new baby. Given that model, we can look at any new baby and ask if it varies, and how. In the direction of pathology? Is the head too big? Too small? Are the limbs proportional? How is the muscle tone? Compared with what? Compared with what you know is “normal,” compared with the model you have in your head of what a baby’s muscle tone should be at birth.
So where do models come from and how are they developed? We are accustomed to thinking that we know what we know from what we have observed, but it is just as true that how we practice sets up what we can observe—what is observable in the first place. If every new baby you ever saw was born from a deeply anesthetized mother, what would you know about normal muscle tone in a newborn?
That was the type of problem, if less dramatic, that was confronting the midwives in transition—these hospital-trained nurse-midwives doing homebirths for the first time. Their models did not apply. So how could they know what was normal? Clinical practice in hospitals was structured to avoid the production of just the knowledge they now needed. Want to know how long a placenta can take to separate from the uterine wall and still be healthy? You will never find out if all placentas are removed within 15 minutes of the birth, as is done in hospital delivery rooms. Want to know if you are looking at a “second stage arrest,” a pathological condition, or a normal “rest period” for a woman who has had a difficult labor, before she begins the work of pushing forth the baby? If you always and immediately treat any cessation of contractions after full dilation as second stage arrest and rush to pull the baby out, as they do in hospitals, you will never observe the rest period or its resolution.
Examples such as these flowed forth in those early years as midwives confronted the limits of hospital-based knowledge for home-based practice.
Setting—place, location—counts. The differences between medical and midwifery models of birth are not just about attitudes, not even just a set of guidelines for practice. Different bodies of knowledge are produced in different settings.
Education is about the passing on of knowledge. It would be very difficult to teach obstetrics at homebirths. It is no less difficult to teach the midwifery model of birth in the hospital. Because nurse-midwifery has come through the hospital, it has been very hard to become a midwife, to develop a midwife’s body of knowledge, in that medically dominated setting. I have brought midwives I respect and admire to tears by saying this. Get angry, hate me if you will, but a midwifery model does not develop under medical domination. And hospitals are places where medicine sets the rules.
On the other hand, it is hard to reach women who most need midwifery care without going through medically based certification. It is hard enough then. Nurse-midwifery—medically based midwifery—needs home-based midwifery to produce and maintain the midwifery base of knowledge, which some midwives bring into hospital settings. That is the problem confronting the midwife just starting to stride forth on her path today. Unlike the midwife of the 1800s for whom midwifery was a self-evident destination, today’s midwife-to-be faces different paths leading to different places.
It is tempting to talk only about how we all share a concern for birthing women, how all kinds of midwives and mothers need each other, and how women need all kinds of midwives in all kinds of circumstances. But this focus alone does a disservice to the serious attempt to achieve an alternative body of knowledge, a disservice to midwifery not just as a practice but as a goal, as a model, to minimalize the differences between midwifery as it is developed and practiced in different places.
We’re used to thinking about how home-based and apprenticeship midwives need hospital-based midwives—to accept the transfers, to work with the women who “risk out” of homebirth, to work with the women who have learned to fear birth. But hospital-based, medically entrenched midwives need the outsider’s view of the other midwives just as much or even more if they are to retain sight of midwifery as a goal.
If I were to design a new T-shirt now, I’d show the Daughters of the Millennium, striding forth, seeking their own paths, recreating midwifery for their own time.
- Kuhn, Thomas. (1970). The Structure of Scientific Revolutions. University of Chicago Press.
- Katz Rothman, Barbara. (1979). Two Models of Maternity Care: Defining and Negotiating Reality. New York University. Also published in In Labor: Women and Power in the Birthplace. W. W. Norton (1993).