In 2010, the European Court of Human Rights affirmed that the human right to private life includes the right to choose the circumstances of giving birth. In Ternovszky v. Hungary (2010), the human rights tribunal made clear that this right includes the choice between giving birth with a midwife or with a doctor, at home or in the hospital. The Court held that governments violate this human right if they fail to regulate out-of-hospital birth in a way that legitimizes it as a health care choice and integrates it into the health care system, or if birth professionals cannot support women in their maternity care choices without fear of legal sanction. The birth professional with whom the mother in that case, Anna Ternovszky, fought for the right to give birth is Hungarian doctor-turned-midwife Ágnes Geréb. Despite the Court’s decision, the Hungarian government kept Ágnes on house arrest for three years for allegations associated with her support of out-of-hospital birth. The state finally released her under the strict condition that she was forbidden to talk to any pregnant woman.
The evidence is conclusive that achieving global targets for the reduction of maternal and perinatal mortality will require health care teams that include doctors, nurses and midwives (NICE 2014). There is a growing call for, and movement toward, partnership and integration of midwifery and medicine in the care of pregnant women (IFGO et al. 2015). The picture of partnership and integration between medicine and midwifery is, however, a patchwork across Europe, across the United States, and around the world, in both law and practice. The maternity care system, with strong, supported midwifery professionals who work with reliable backup from emergency obstetric providers, has the lowest intervention rates and the best outcomes (BBC News 2015). Systems without a supported midwifery profession, or where midwives’ ability to provide midwifery care is severely circumscribed, increasingly resemble cesarean section assembly lines (Barros et al. 2011). The human right described in Ternovszky is not yet a reality for most women around the world. On July 21, 2016, the commissioner for human rights for the Council of Europe acknowledged receiving “disturbing reports of human rights violations in the context of maternity health care,” and referenced both the Ternovszky holding and recent conclusions by the UN Committee on the Elimination of Discrimination Against Women (CEDAW) regarding the “need to ensure … respect for women’s rights, dignity and autonomy during deliveries, expressing concerns in particular at reports that childbirth conditions and obstetric services unduly curtail women’s reproductive health choices” (Muižnieks 2016).
Despite the best intentions of maternal health policy makers and providers to move toward the integration of midwifery in maternity care schemes and systems, such integration will be slow in coming without an overriding essential framework of equality and respect between the professions of medicine and midwifery. The fact that the idea of equality between doctors and midwives seems radical is a testament to how entrenched are the systems that have established medicine’s dominance over midwifery. The current status of midwives, and the relationships between medicine and midwifery that underlie integration, cannot be understood without recognizing the systemic inequality between obstetric medicine and midwifery, awareness of its historical roots and a commitment to dismantling that inequality.
A Brief History
Since time immemorial, women have attended each other in childbirth. Some women developed such skill and expertise that they became the community midwife. Midwives often tended to the full spectrum of women’s reproductive cycle and general community health care needs. Midwives held the knowledge of the local herbs and culturally-rooted practices associated with fertility, healing, promoting health and minimizing the risk of pathology. It was for their knowledge of the herbs for contraception and abortion that midwives were defined as the primary target for the European witch hunts (Heinsohn and Steiger 2004). The torture and execution of midwives over three centuries led to the loss of that knowledge and a population explosion that fueled many wars and the colonial settlement of the “New World.” With the midwives’ knowledge of contraception went their knowledge of female sexuality and gynecology, including how to support women in childbirth. After the witch hunts, male doctors stepped in to attend women in childbirth, at first only in emergency cases, but then as the main providers for childbirth, a shift “promoted by the authorities but disliked by women” (Ibid., 23).
Up to the late fourteenth century midwives were entitled to practice without regulation. From this time onward [they] were downgraded from qualified and independent female healers … to mere assistants of the physician [who was] lacking any experience in obstetrics because through the Middle Ages no male was allowed to practice in gynecology. (Ibid., 22)
Midwifery as a profession continued on in Europe, but it was defined in law and practice as subservient to the medical profession. The relationship between the female profession of midwifery and the male profession of obstetric medicine reflected the entrenched sex inequality of the time. Just as the state enforced men’s economic and legal dominance over women, the state enforced medicine’s dominance over midwifery, and ultimately, its control over maternity care.
Despite the knowledge and skills that traditional midwives have always used to serve their communities, there were medical emergencies that could arise in childbirth that they could not solve. Antibiotics, anti-hemorrhagic medicine, assisted and surgical deliveries and other medical technologies can prevent many of those deaths, and access to such technologies has saved many lives and massively reduced maternal and neonatal loss since their invention. But the terms on which these tools were offered to women, in the US and in many other places, created new forms of risk as all women were asked to place themselves in the care of medical professionals for pregnancy and birth, whether or not they needed medical treatment. Only the Netherlands developed its maternity care system on a model that saved life-saving medical technologies for the event they were actually needed. In the Dutch birth system, healthy women give birth at home with midwives, saving doctors and hospitals for medical backup. In the US and in other industrialized nations, state authorities worked in partnership with medical associations to push the female population to give birth in hospitals, under the care of doctors (Fisch 2012). Midwives were often disempowered both as professionals and as citizens, not only on the basis of sex, but also race, immigration status or caste, in different combinations in different places and times (Sadgopal 2009). After black midwives safely delivered generations of babies from both enslaved and free women in the United States, they were degraded through racist propaganda schemes to move women into the hospital, even as women of color in the US had insecure access to hospital care. In developing maternity care systems around the world, community midwives have been blamed for bad outcomes in communities that exist in extreme poverty and lack access to emergency medical treatment and were sidelined or left out of plans for development. Maternal health development schemes have long treated indigenous and traditional midwives as ignorant and their contributions as worthless. Thus, midwives’ knowledge of culturally-specific, locally-rooted healthy birth traditions can become extinct over a couple of generations, while the women of their community are subjected to unsustainable modes of treatment imported from the developed West. When there are no more midwives, and women can’t or don’t want to go to the hospital, many women are left without any health care support for pregnancy and childbirth.
To prevent the deaths that can occur if women have midwifery support but lack access to emergency obstetric services, systems of medical monopoly ask all pregnant women to come into the hospital to give birth. The obstetric focus on medical intervention and the anticipation of pathology has resulted in standards of interventionist care that make it all but impossible for a healthy woman to simply squat down and give birth to her baby. Technology’s “trends” have changed over the last century of Western obstetrics, from forceps deliveries of babies from women under general anesthesia in the 1930s and 1940s, to women on twilight sleep and physically restrained in the 1950s and 1960s, to epidural and episiotomy deliveries, to the modern era of the cesarean delivery. What has not changed much is the passivity of the birthing person in these processes and the virtually indoctrinated belief in these interventions as “necessary,” even when research proves otherwise.
As the rates of c-section skyrocket to the point where the majority of babies are delivered by surgery in many systems, and women increasingly report abuse and human rights violations in childbirth, the global maternal health community is starting to acknowledge that this system of care is not working. In the developing world, women are being sent back to villages with insecure water sources and fresh cesarean wounds. In places without community midwives and with insecure access to medical facilities, women are left with no care at all, especially in marginalized communities. In the last few generations, midwifery has risen up again as a profession in places where it was eradicated. Regardless of how they are trained and where they work, midwives face powerful structural and systemic barriers. Doctors decide if midwives are allowed to practice in the hospital and if so, how they practice. The state decides if midwives are allowed to practice outside the hospital, often regulating midwifery practices in a way that imposes medical standards on them and prevents them from providing genuine midwifery care that upholds their client’s human rights. In some places, midwives are still fighting for the recognition that midwifery is indeed a profession. Everywhere, midwifery is underfunded, and in many places, financially unsustainable. Although it is well known that women need midwives, women in many places aren’t getting midwives.
Different but Equal
Midwifery and medicine have overlapping but distinct visions of pregnancy and childbirth. Midwifery frames pregnancy and childbirth as normal physiological life events, with the potential to become a pathological medical event. Medicine frames pregnancy and childbirth as medical events that, by definition, can only be safely managed through medical treatment. The integration of these two paradigms requires understanding of their differences and a willingness to work together despite them. The differences between the professions should not prevent the recognition of both as necessary (and equal) partners in the care of the pregnant population. Equality doesn’t require that two groups be exactly the same in order to be treated equally. Equality means that the differences between two groups do not make one group superior or give it the right to dominate the other.
The recognition of doctors and midwives as equal and complementary partners in reproductive health care requires respect for their relative fields of expertise. Midwives are the experts in physiological birth. They know how to work with the female body to help women give birth to their babies, including in cases of complex physiology like vaginal breech and twins. Doctors are the experts at using medical treatment to fight pathologies and manage medical crises. They go to school for many years to learn the complexities of pharmacology and the intricacies of surgery. It should be noted, though, that all the years of education and residency that doctors go through do not train them how to support physiological childbirth. Obstetric doctors and nurses openly acknowledge that they may never see a woman give birth without intervention in either training or practice. As obstetric medicine increasingly relies on surgical delivery, midwives are often the only maternity care providers a woman can find who know how to support vaginal birth, let alone physiological birth, especially in the case of breech delivery.
Although the subjugation and elimination of midwifery were historically built upon sex inequality, racial inequality, class and caste inequality and colonial power, like most systems of domination and inequality, it eventually became primarily about capital. Obstetric medicine is a multi-billion dollar industry whose stakeholders include not only providers but hospitals, pharmaceutical companies and insurance companies. Providers themselves are convinced that doctors are superior to midwives and have the authority to determine when and how midwives will practice. At this point, those power dynamics can play out in encounters between doctors and midwives regardless of the sex or race of the providers involved. Obstetrics as a profession may be majority female in some places, but gendered systems of dominance have always been perpetrated by females as well as males. Without a consciousness of power dynamics and a determination to not exploit their power position, female doctors can, and unfortunately sometimes do, use the power of their role to dominate midwives as well as patients.
After generations of medical monopoly over childbirth, the general public believes and perpetuates the inequality between medicine and midwifery. In many places, people think that being cared for by a doctor is better than being cared for by a midwife, because that’s what they’ve been always been told. In many places, people don’t even know what a midwife is, or they think that midwives are from “olden times,” and this is not an accident.
Inequality and Equality between Medicine and Midwifery
Inequality between medicine and midwifery is perpetuated in health policies, practice, law and economics. Inequality exists in practice every time a medical professional refuses to speak with and listen to a midwife during prenatal co-care or when the midwife transfers a client. It exists when medical professionals dismiss midwives’ knowledge or recommendations without due consideration. It exists when doctors set the standards of care for midwives or sit on the boards that oversee midwives’ practice while midwives don’t sit on medical boards or have any such control over doctors. It exists when doctors file complaints against midwives’ licenses over disagreements in practice, but when a midwife sees a doctor act in a way that troubles her, she doesn’t file a complaint or even confront the doctor for fear of losing backup for her clients or other retaliation. Whether women start birth with a midwife or with a doctor, they need access to emergency obstetric services in the event an emergency arises. Obstetric medicine has used its power to give or withhold emergency services to gain a monopoly over maternity care and to maintain dominance over midwives.
Inequality exists in law, when the laws themselves, and the administration of those laws, reflect the cultural attitude that doctors are superior to midwives and treat midwives differently to medical professionals. When midwives are subject to criminal prosecution for allegations that would only expose a doctor to a civil lawsuit or a licensing complaint, the law imposes a powerful inequality between the professions. Midwives have recently been jailed or sentenced to prison for allegations associated with out-of-hospital birth in Germany, Cyprus and Portugal, and they have been subject to criminal investigations and prosecutions in the US and Australia. The essential claim in these cases, as in so many legal actions against midwives, was that the women should have been in the hospital and that it was the midwives’ fault that they weren’t. In medical malpractice terms, they are charged with failure to diagnose the need for medical treatment and failure to intervene by sending the women to the hospital, often being held legally responsible for their clients’ informed decisions to not go to the hospital. Doctors generally, and obstetricians in particular, are frequently accused of failure to diagnose and intervene in legal actions by the bereaved parents of stillborn babies, and yet they do not face criminal prosecution or prison for those allegations. The different legal processes to which doctors and midwives are subjected for comparable allegations of negligence, and the different impact that those processes can have on individuals and on the professions, enforce prevailing substantive inequality between the professions. This can make it dangerous or even impossible to be a midwife.
Inequality exists in economics when doctors are rich, while midwives are poor. The valuing of, and compensation for, midwifery services should appropriately recognize their contribution to maternal health, enable midwives to continue in the field and develop experience and skills and construct midwifery as a stable profession that enables a woman to support her family, as doctors are able to support theirs. In nations where midwifery and medicine still are largely gendered professions, investment in midwifery as a strategy for meeting the Sustainable Development Goals has the effect of reducing economic inequality between the sexes while it achieves maternal and newborn health goals. Yet, in developed nations, inequality persists when insurance providers will either refuse to provide midwifery care or provide inadequate cover, which creates de facto barriers to reimbursement or limits coverage to components of bundled services. Inequality is also sustained when midwives need liability insurance in order to practice in all settings or for their services to be compensated, but liability insurance is inaccessible to them while it is available to doctors.
Underlying many of the ways that inequality can manifest is that hallmark of discrimination: disrespect. When medical providers and systems assert dominance over midwives and midwifery, they treat them with disrespect. Not listening, condescending, dismissing and talking down or rudely to people are all ways of expressing discrimination and disrespect. What does equality look like in relations between medicine and midwifery? It looks like mutual respect. In practice, it means that doctors and midwives recognize and respect each other’s knowledge and expertise and remain in dialogue to better understand and learn from each other and have equal voices at the table about maternity care policy. In law, equality requires understanding and recognition of midwifery as an independent and valuable profession and midwives as the authorities in their own standards of care. It also requires subjecting doctors and midwives to fair and equal legal oversight and acknowledging the role that the law has played historically in marginalizing midwifery and giving medicine a monopoly over maternity care. In finance, equality looks like valuing midwives’ role in maternal health care, and making sure that midwives and freestanding birth centers get paid as doctors and hospitals do.
Building respect and equality between medicine and midwifery will require investing in communication and building relationships. In order to evolve toward collaborative care teams, maternity care providers must prioritize time to simply sit and talk, with open ears and mutual respect, not only within hospital teams but between those who work in hospitals and those who serve women to give birth at home, in birth centers or in rural clinics. The quality of communication and trust between these professionals determines whether critical collaborative care moments go well or go poorly, and in an obstetric emergency, this can mean the difference between life and death. Integrated maternity care systems promote mutual respect between doctors and midwives as collaborative professionals, which enables the transparency and continuity of care necessary to optimizing safety and quality of care.
The need for integration based on equality is urgent, as perinatal studies for out-of-hospital birth have made clear that the systems that fail to respect the human right expressed in Ternovszky do not prevent the perinatal deaths associated with homebirth; they cause them. In the maternity care systems that respect and integrate midwives and uphold women’s human rights in childbirth, planned homebirth is as safe as planned hospital birth (De Jonge et al. 2014). In the systems where medicine still has a strong monopoly hold over childbirth and refuses to integrate midwifery, and the state enforces that monopoly instead of women’s human rights, the result is that more babies die (Wax et al. 2010).
The only ethical and professionally responsible conclusion to draw from studies showing higher perinatal deaths in non-integrated systems is to work to improve integration, not to work to drive out-of-hospital birth and midwifery further underground. We know by now that it doesn’t work to tell women that they are “not allowed” to make personal reproductive health care choices. Women make their reproductive choices for reasons that are unique to their own circumstances and history, whether the “authorities” like those choices or not. When the state supports medical monopoly over childbirth by driving midwives underground or refusing to recognize out-of-hospital birth, or when states subject out-of-hospital midwives to unique legal persecution, the result is the following:
- A lack of transparency between doctors, midwives, and their clients during prenatal care.
- A lack of transparency and communication between midwives and their backup professionals during labor.
- Emergency medical service providers who lack the training and equipment for homebirth transfers but don’t respect the midwives enough to let them help.
- Communication breakdowns between midwives and hospital staff during transfer.
- Punitive neglect of the birthing women who transfer in from midwifery care.
All of the above lead to perinatal, and even maternal, deaths that could have been prevented with timely medical treatment. Because violating Ternovszky causes perinatal death rather than prevents it, no state government can honestly claim that it pursues a legitimate public health aim by failing to integrate out-of-hospital birth. As attorneys working on cases involving homebirths, we have seen a pattern of cases in which preventable deaths occurred as a result of these factors of non-integrated care. In each case, the blame and fallout for these dysfunctions was laid squarely on the shoulders of the midwives. Focusing blame on the midwife diverts attention from the system dysfunctions and power dynamics that cause the bad outcomes. Systemic issues are sidelined, and the career and skills of another experienced midwife are laid to waste.
The need for equality and mutual respect between different kinds of midwives is a topic for another article. There is a role for all midwives in maternity care, from the traditional or indigenous midwife, to the independent professional midwife and the hospital nurse-midwife. If the contributions of traditional community midwives were valued and included in the development of maternity care, we would see a flourishing biodiversity of healthy birth practices, across cultures and ecosystems, with relative uniformity of standards of care for medical backup.
It is time to put an end to the hierarchical, monopolistic maternity care systems that were constructed on socially and economically discriminatory systems of sex, race, caste and colonial oppression. These systems and today’s c-section assembly lines do not optimize maternal and newborn health. Integrated systems with strong midwifery professions as the first line for maternity care, in partnership with and with reliable backup from medical professionals, are the most effective, and most efficient, strategy for optimizing the health of mothers, babies and communities. Health care systems are shifting from the old hierarchical models toward team-based, patient-centered care, which is often called “woman-centered care” in the maternity context. This shift reflects a movement away from the vertical model of care, in which doctors were at the top and everybody else (including the patient) was below them, to a model in which the patient is at the center of a team of care providers, who are working on a horizontal plane, as equal and complementary partners, to provide care as needed for each individual. This transformation is achievable but only with recognition of the role of power and entrenched inequality in the construction and dynamics of the current system. It is ultimately the responsibility of the democratically elected governments to impose justice and equity for its childbearing constituents.
The radical implication of Ternovszky was that it required the state to dismantle legal and systemic inequality between medicine and midwifery and to restrain medical monopoly over maternity care. Given the centuries that went into constructing the status quo of that monopoly, it is not surprising that this human right is not yet a reality. But the human rights framework makes it inevitable. Governments are obliged to move toward more perfect recognition and protection of human rights, even when doing so is inconvenient to prevailing interests. The evolving global awareness of human rights in maternal health care hold the potential to direct a new approach toward optimizing the systems of support in place for pregnant women and babies.
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- BBC News. 2015. “C-Section Rates ‘Vary Widely’ Across Europe.” BBC News. Accessed August 31, 2016. bbc.com/news/health-31766715.
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