Citation
Piercing the veil

Material Information

Title:
Piercing the veil the marginalization of midwives in the US
Creator:
Goodman, Steffie
Publication Date:
Language:
English
Physical Description:
xiii, 367 leaves : ; 28 cm

Subjects

Subjects / Keywords:
Midwives -- United States ( lcsh )
Maternal health services -- United States ( lcsh )
Maternal health services ( fast )
Midwives ( fast )
United States ( fast )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 342-367).
General Note:
Department of Health and Behavioral Sciences
Statement of Responsibility:
by Steffie Goodman.

Record Information

Source Institution:
University of Colorado Denver
Holding Location:
Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
71753070 ( OCLC )
ocm71753070
Classification:
LD1193.L566 2006d G66 ( lcc )

Full Text
PIERCING THE VEIL: THE MARGINALIZATION
OF MID WIVES IN THE US
Steffie Goodman
B.A., Colorado College, 1976
M.S.N., Yale University, 1992
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
Health and Behavioral Sciences
2006
by


This thesis for the Doctor of Philosophy
degree by
Steffie Goodman
has been approved by
Date


Goodman, Steffie (Ph.D., Health and Behavioral Sciences)
Piercing the veil: The marginalization of midwives in the US
Thesis directed by Professor Stephen Koester
ABSTRACT
The purpose of this study is to examine the demise of two prominent
midwifery services that recently experienced significant changes to their professional
status in order to perform a critical analysis about the marginalization of midwives in
the United States. This investigation also illustrates existing problems with the
political economy of maternity care in the US and makes specific suggestions for
improvement. There is ample evidence that demonstrates the high quality cost-
effective care associated with a midwifery model. Despite all the evidence, midwives
attend seven percent of births, compared to 50-75% of births in other developed
countries. The US spends more on health care than any other developed nation, has
worse benchmark indicators for the nations health, and has over 45 million uninsured
costing over 50 billion dollars. Recently, multiple midwifery services in major US
cities experienced practice closures or changes, exemplifying the problem and
offering an opportunity to examine the marginalization of midwifery in the 21st
century. A qualitative case study of the changes that occurred within two prestigious
midwifery services in New York City was undertaken. Purposeful critical case
sampling methods were utilized. Multi-sited in-depth interviews were conducted with
physicians, midwives, administrators, nurses, staff, lobbyists, and liability insurance
carriers. Further triangulation of data collection was done through the analysis of
relevant archival sources and documents. Multiple methods of data analysis were
utilized, including constant comparison of data, within case, and cross case patterns
of analysis. Each case is reported with a detailed analysis of findings along with a
discussion of market, state, and cultural forces that shape the professionalization and
marginalization of midwifery in the US. Concluding remarks summarize the
phenomenon of the marginalization of midwifery and discuss ways to pierce the veil
that keeps midwifery from mainstream medicine. Strategies for practical and
theoretical models are presented to lead modem-day midwifery into the mainstream
of medicine in the US where it belongs.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication.
Signed
Stephen Koester
m


DEDICATION
This work is dedicated to those who appear to be still, yet move with the swiftness of
light; who seem to be calm, yet know how to release fear into the wind and guide
the energy of waves; who know how to listen so they can hear each speck of falling
sand and drifting snowflake; who gather together the forces of birth with joy and
serenity, through darkness and light; who give of themselves from the depths of their
being. So that souls connected may stay connected as they embark on the journey of
being mother and child. This work is dedicated to the midwives (Krysl, 1989).


ACKNOWLEDGEMENT
Many thanks goes to many folk for their instructional, directional, and emotional
support received during the production of this thesis: the brilliant, articulate
participants who so graciously shared their thoughts and insights with me, despite
incredibly busy lives; Jean Scandlyn, in whom I have found a mentor, for her support,
her unique being, and her immense contribution to the work and the writing; Susan
Erikson, for the wonderful work she does, her excellent contribution in helping
understand the meaning and depth of a of political economy perspective, her strength
and vocation; Craig Janes, for his ability to be master in all areas, his capacity to
articulate his expertise, to share his wisdom and provide guidance; Steve Koester, for
his profound and unwavering enthusiasm and support for my project, and his
masterful knowledge in qualitative work; and Eugene Declerq, for agreeing to be a
final reader when he doesnt know me at all, for he is unquestionably an expert in this
area and I have always had a tremendous regard for his work and passion. I would
like to give special thanks to the Ortho-McNeil/ ACNM Foundation and the W.
Newton Long Foundation for their gracious awards which helped fund this project.
Finally, gratitude and enduring love goes to John, Emrys and Emiel, for their ever
present faith, pride, trust, and secure belays. They are the light.


CONTENTS
Figures.....................................................................xi
Tables....................................................................xiii
CHAPTER
1. The Destiny of a Profession
Introduction and Significance of the Problem............................1
Evidence of Marginalization of Midwives in the US....................7
Finding Voice: The Personal Becomes the Political......................13
Purpose and Aims.......................................................14
Question............................................................15
Aim.................................................................15
What is a Midwife?.....................................................15
2. Knowledge That Counts
Professionalization of Medicine and Midwifery in the US................23
A Brief History of Medicine and Midwifery in the US.................24
Professionalization Theories and Application to Midwifery..............39
Social Closure......................................................40
The Choice to Professionalize as Nurses.............................42
The Importance of a Distinct and Unique Identity....................46
vi


3. Smoking Jaded Expertise
Marginalization Theory.....................................................50
Cost of Marginalization of Midwives in the US............................59
4. Research Design and Methods
A Qualitative Case Study Analysis..........................................63
Unit of Analysis...........................................................66
Sampling Methods...........................................................66
Data Collection Procedures.................................................68
Data Collection Instruments................................................70
Data Analysis..............................................................70
Rigor, Credibility and Generalizability of the Study.......................73
Research Participants......................................................74
Limitations................................................................77
Preliminary Study..........................................................80
Reporting the Cases........................................................81
5. A Gala Celebration of Fifty Years of Midwifery
The Emperor Has New Clothes................................................83
The University Midwifery Service, 1989-2003................................83
Power and the Discourse of Risk and Safety..............................123
Vll


6. Piercing the Veil
The Case of the Birth Center.................................................128
7. Money, Politics, and Birth
Political Economy of Maternity Care..........................................152
Big Business of Health Care...............................................156
The Politics of Getting Paid..............................................157
Early 20th Century Market and State Forces................................160
Time for Social Change....................................................163
Evolution of Modem Midwifery Practices....................................166
8. The Paradox of Money and Birth
Market Forces................................................................169
Strategies for Economic Success: Medical Model............................171
Maximizing Billing Practices..........................................171
Minimizing Competition.................................................181
Strategies for Survival: Midwives.........................................194
Struggling to Survive..................................................194
Increasing Autonomy....................................................196
9. Fragile Relations: Politics and Midwifery
Macro Politics...............................................................198
Micro Politics...............................................................210
VUl


10. The Culture of Birth
A Compelling Influence....................................................221
Medwifery............................................................242
11. Professionalization of Midwifery
Midwifery and Nursing.....................................................245
Midwifery and Medicine....................................................255
Midwifery and Midwives....................................................266
12. The Canary in the Mineshaft
Who Wins, Who Loses?......................................................275
Final Thoughts on the Marginalization of Midwives.........................278
Practical Model...........................................................289
Theoretical Model.........................................................300
Political Economy and Midwifery........................................303
Discourse of Power and Midwifery.......................................307
Building Identity and Unity............................................307
APPENDIX
A. Introductory Letter to Potential Participants...........................311
Letter to Potential Participants..........................................312
Follow up Letter to Participants..........................................314
B. Response Card from Participants.........................................316
C. Participant Information Sheet...........................................318
ix


Participant Information Sheet..........................................319
D. Human Subjects........................................................321
Human Subjects Consent Form............................................323
E. Question Guide........................................................326
Question Guides for Participants.......................................327
F. Analytic Codes........................................................333
Axial Codes, Within Case, and Cross Case Tables........................334
G. Permission For Reprinted Information..................................338
REFERENCES..................................................................342
x


FIGURES
Figure
1.1 Infant mortality rates in selected developed countries, 2003, OECD Health Data
Set, 2005 ..................................................................5
1.2 Health care spending in USD per capita, selected developed countries, 2003,
OECD Health Data Set, 2005..................................................6
1.3 % midwife attended births in US, 2003, National Center for Health Statistics. ...10
1.4 Percent midwife attended births in US, 1976-2003....................11
1.5 Save the midwives rallies, Chicago, Washington, DC, 2003............11
2.1 Comparison of maternal mortality rate per 10,000 live births in developed nations,
1899-1950..........................................................32
2.2 Mary Breckenridge and FNS midwives, 1925, Kentucky..................35
3.1 A model to show boundaries between midwifery and obstetric models of care...54
3.2 The circle of safety for mothers and babies..............................55
3.3 Facility charges by site and method of delivery, 2003.....................60
4.1 Nested layers embedded in case study analysis.............................69
5.1 A time line of history and events applicable to the case of the AP.......87
5.2 Structure of midwifery services at the Community Hospital.................91
6.1 Time line of history and events, Birth Center.............................132
7.1 Caravan of buses to the Farm.............................................163
xi


7.2 A comparison of obstetrical birth and holistic birth......................164
12.1 Health care reform........................................................290
12.2 Midwifery model flow chart................................................292
12.3 Ratio of midwives to physicians in practical model.......................294
12.4 Maintenance of professional needs with practical model....................294
12.5 On-going evaluation of evidence based research...........................299
Xll


TABLES
Table
1.1 Birth and infant mortality rates, health care spending in USD and as % GDP by
country, 2000-2003, OECD Health Data Set, 2005...........................4
1.2 Summary of findings of exemplary midwifery care in peer reviewed journals.8
3.1 A comparison of obstetrical and midwifery models of care..................56
4.1 Table format used to organize text by codes...............................72
4.2 Type of participant per case..............................................74
5.1 Birth, infant, neonatal mortality rates, WH, NYC, 1997-2004, New York Health
Department Statistics....................................................98
5.2 Risk characteristics of women giving birth in New York City, Manhattan, and
Washington Heights, 1997-2003 per New York Health Department Statistics. 100
12.1 Theoretical constructs of market forces shaping midwifery service.............303
12.2 Political forces that shape midwifery service.................................304
xm


CHAPTER 1
THE DESTINY OF A PROFESSION
Introduction and Significance of the Problem
...I underscore my belief that midwiferys unique strengths will overcome the
innumerable perils that threaten our profession today.. ..Our challenges are
many, but they are far from insurmountable. We must not give up... we
cannot despair. The destiny of our profession is in our own hands. We must
work together to convince the public, the legislators, the third party payers,
the insurance industry, and the medical establishment that midwifery care is
not only scientifically-based... but that our hallmarks can set the gold
standard for safe, competent and humanistic health care for all women. ... As
long as we remain strong and united... and stand up for our beliefs in the
interests of the women we serve... we can overcome any obstacles that
confront us and assure that midwifery will prevail... .Let us take heart in the
sage advice that Mary Breckinridge offered us 77 years ago and take heart,
even though the trail is hard in the blazing (Shah, 2003). Presidential address
to the ACNM 48th Annual Meeting, June 2, 2003, Palm Desert, CA
The presidential address to the American College of Nurse Midwives
(ACNM) 48th Annual Meeting given June 2, 2003 acknowledges the problems and
challenges that midwives in the United States (US) face in order to practice despite
the benefits, which include safe and satisfying outcomes for women and infants and
immense cost savings for health care systems. The impetus for this study is to
understand the innumerable perils that midwives face today in the US by revealing
1


some of the political, economic, and cultural factors that contribute to the
disappearance of services. Specifically, this study explores the details of recent
changes in two prominent and influential midwifery sendees in a large city in the US.
This issue is an important one in the context of health care in the US in the
21st century, where skyrocketing costs, limited access, and quality of care are grave
concerns. The US spent 1.9 trillion dollars in 2004, which is sixteen percent of its
gross domestic product (GDP) (Smith, Cowan, Heffler, Catlin, & the National Health
Accounts Team, 2006). This compares to an average of nine percent among the 22
developed nations listed in Table 1.1, all of whom have a lower infant mortality rate
(IMR) when compared to the US (Organization of Economic Cooperation and
Development, 2005a). In addition, the US currently has 48 million uninsured people,
costing over 43 billion dollars (National Coalition on Health Care, 2004b; Stoll et al.,
2005). The US relies on competition among insurers and providers to both finance
and provide health care in an efficient manner. Yet, we spend more on health care,
have limited access, and worse benchmark indicators of health, such as IMR, low
birth weight rates, maternal mortality rates, life expectancy rates, and rates of obesity
leading to chronic diseases (Docteur, Suppanz, & Woo, 2003; National Coalition on
Health Care, 2004a). All of these facts are evidence of the problems with our health
care system related to cost, access, and quality of care.
Maternity care is an important window through which to look more closely at
these issues. Childbirth constitutes the fourth largest category of health care
2


expenditures and is the most common reason for hospitalization in this country
(Keefe, 2003). In addition to health care costs incurred with the four million births
that occur per year, access to and quality of care are major concerns. For example, the
US has higher infant and maternal mortality and low birth weight rates than many
other countries in the world, with large disparities in outcomes for vulnerable
populations (Arias, MacDorman, Strobino, & Guyer, 2003; Keefe, 2003; J. A. Martin,
Kochenek, Strobino, Guyer, & MacDorman, 2005). The infant mortality rate for the
US ranked below 26 other developed nations for the year 2001 and below 27 other
nations in 2003 (J. A. Martin, Kochenek et al., 2005; Organization of Economic
Cooperation and Development, 2005b). Overall estimates for 2005 show that the US
ranks 43rd out of 226 nations for infant mortality, followed only by developing
nations (Central Intelligence Agency, 2005). Most recent reports on outcomes
indicate that in 2004, the US had a higher number of preterm deliveries the highest
rate reported since 1981 when comparable data was first collected; a higher number
of low birth weight babiesa rise of sixteen percent since 1990; and rising cesarean
section rateswhich have risen over 40 percent since 1996 (J. A. Martin, Kochenek
et al., 2005). Each of these findings reflects a rise in poor outcomes for mothers and
babies and contributes significantly to the skyrocketing costs of health care. Table 1.1
shows birth rates, infant mortality rates, US dollars spent on health care per capita,
also expressed as percent of Gross Domestic Product for developed countries for
3


years 2000-2003 (Arias et al., 2003; Organization of Economic Cooperation and
Development, 2005b).
Country # Births 2000 Birth Rates 2000 IMR 2003 IMR 2000 IMR 1999 Health Spending per capita, 2003 Health spending %GDP 2003
Iceland n/a n/a 2.4 n/a n/a $3,115 10.5
Singapore 46,631 11.3 n/a 2.9 3.5 n/a n/a
Hong Kong 54,134 8.0 n/a 3.0 3.1 n/a n/a
Japan 1,190,560 9.4 3.0 3.2 3.4 $2,139 7.9
Finland 56,742 11.8 3.1 3.8 3.9 $2,118 7.4
Sweden 90,441 10.2 3.1 3.2 3.4 $2,594 9.2
Norway 59,229 13.2 3.4 3.8 3.9 $1,695 10.3
Czech Republic 90,715 8.9 3.9 4.1 4.6 $1,298 7.5
France 778,900 13.2 3.9 4.4 4.3 $2,903 10.1
Spain 386,450 10.2 4.1 4.4 4.5 $1,835 7.7
Portugal 118,551 11.8 4.1 5.6 5.6 $1,797 9.6
Germany 743,500 9.0 4.2 4.4 4.5 $2,996 11.1
Italy 538,999 9.3 4.3 4.6 5.2 $2,258 8.4
Switzerland 73,176 10.1 4.3 4.9 4.6 $3,781 11.5
Belgium 114,883 11.2 4.3 5.2 4.9 $2,827 9.6
Denmark 66,232 12.4 4.4 4.6 4.2 $2,763 9.0
Austria 77,558 9.6 4.5 4.8 4.4 $2,699 7.6
Australia 248,861 13.0 4.8 4.9 5.7 $2,280 9.3
Netherlands 201,461 12.6 4.8 5.1 5.2 $2,976 9.8
Greece 117,140 11.7 4.8 5.4 5.5 $2,011 9.9
Ireland 54,239 14.3 5.1 5.9 5.5 $2,386 7.3
UK 679,284 11.4 5.3 5.6 5.8 $1,232 7.7
Canada 331,051 10.8 5.4 n/a 5.3 $3,003 9.9
Israel 136,390 21.7 n/a 6.2 5.8 n/a n/a
NZ 56,605 14.8 5.6 6.1 5.6 $1,886 8.1
Cuba 138,718 12.4 n/a 6.2 6.4 n/a n/a
USA 4,058,814 14.7 7.0 6.9 7.1 $5,635 15
Table 1.1 Birth and infant mortality rates, health care spending in USD and % GDP
by country, 2000-2003, OECD Health Data Set, 2005
4


Figures 1.1 and 1.2 show bar graph comparisons of infant mortality rates (deaths in
the first year per 1000 live births) and health spending per capita in US dollars for
selected high income countries (Organization of Economic Cooperation and
Development, 2005b).
Outcomes: National Infant
Mortality Rates,OECD 2003
Source: OECD Data 2005.
Figure 1.1 Infant mortality rates in selected developed countries, 2003, OECD Health
Data Set, 2005
5


6,000
5,635
Country
Figure 1.2 Health care spending in USD per capita, selected developed countries,
2003, OECD Health Data Set, 2005
These statistics are staggering when one realizes that the US spends over twice per
capita than countries that have an infant mortality rate that is nearly half that of the
US.
Although different kinds of midwives practice in this country, the reference of
midwife in this proposal will exclusively refer to certified nurse midwives or
certified midwives (CNMs/ CMs) (Rooks, 1997; Tritten & Southern, 1998). The case
of CNMs/ CMs is explored because: 1) they have clearly written delineation of core
competencies; 2) they are educated through accredited educational programs; 3) they
have a psychometrically defensible, research based national certification exam (that
6


can only be taken after successful completion of a formal education program); and 4)
they have some consistency in licensure that is recognized and accepted in every state
in the US. Furthermore, state and federal laws mandate reimbursement for services
and CNMs/CMs are able to practice in all settings including hospitals, freestanding
birth centers, and homes.1
Evidence of Marginalization of Midwives in the US
In many ways, the history of midwifery in the US is a unique case in that
midwifery was exiled from mainstream medicine, or marginalized, in the early 20th
century compared to other industrialized countries (Loudon, 1992). The important
point for the purposes of this study is that midwives are underutilized in the US.
There is extensive evidence that demonstrates that the midwifery model results in
excellent maternal and infant outcomes, is cost-effective, and offers satisfying
experiences for women (Blanchette, 1995; Greulich et al., 1994; Jackson et al., 2003;
MacDorman & Singh, 1998; D. Oakley, Murray, & Murtland, 1996; Rooks et al.,
1 See explanation regarding formal education and certification of CNM/CMs in section entitled What
is a Midwife? There are also direct-entry midwives (DEMs) in the US. Education, regulation and
licensure of DEMs is determined by individual states. They attend births at home or in freestanding
birth centers, whereas CNMs are able to attend women in hospitals, freestanding birth centers, and at
home. For further description of DEMs, see Bourgeault & Fynes 1997; Tritten and Southern, 1998;
Rooks, 1997; and Lay 2000.
7


1986). The potentially confounding factors of risk and socioeconomic status have
been controlled in many of these studies (See Table 1.2 for summary).
Author, Year, Journal Summary of Study Summary of Findings
Greulich, et al., 1994 Journal of Nurse Midwifery 30,000 births attended by CNMs 7% intrapartum transfer of care; 4% cesarean section rate; no maternal or neonatal deaths
Blanchette, et al., 1995, American Journal of Obstetrics and Gynecology Comparison of low risk CNM service to low risk obstetrical service CNMs 13% cesarean section rate; Obstetricians 25.4% c/s rate; No difference in perinatal outcomes
MacDorman & Singh, 1998, Journal of Epidemiology and Community Health Analysis of US birth certificate data 1991, controlled for SES and risk status Compared to obstetricians CNMs had 33% less neonatal mortality; CNMs had 31 % less low birth weight babies; CNMs had 19% lower infant mortality rate
Jackson et al., 2003, American Journal of Public Health Prospective study funded by US Agency for Health Care Research and Quality Midwifery care resulted in less time in the birth facility, fewer c/s, assisted vaginal births, episiotomies, and less technical interventions with comparable outcomes
Rooks et al., 1986 New England Journal of Medicine Prospective study, 11,866 births in freestanding birth center Antepartum transfer rate 18%; intrapartum transfer rate 15%; cesarean section rate 4.4%; neonatal mortality rate 0.7/1000; Safe and cost effective to deliver in FSBC
Oakley et al., 1996 Obstetrics and Gynecology Restrospective analysis of 1,200 women No differences in prematurity and low birth weight; physicians had higher rates of complications.
Table 1.2 Summary of findings of exemplary midwifery care in peer reviewed
journals
In an extensive meta-analysis of the midwifery literature, Raisler (2000) looked at 23
studies published in 30 journals comparing midwifery and physician care. Many
studies used sophisticated statistical methods to account for confounding variables
and some articles were published by physicians. All the studies reported that CNMs
8


used fewer interventions, technology, and medications, and that women were more
likely to have a spontaneous vaginal birth with outcomes as good as, if not better than
those of physicians (Raisler, 2000). Additional studies have been published further
documenting the excellent outcomes accorded to nurse midwives (Haire & Elsberry,
1991; Heins, Nance, McCarthy, & Efird, 1990; Mann, 1981; D. Oakley et al., 1996;
Piechnik & Corbett, 1985; Platt, Angelina, & Quilligan, 1985; Schimmel, Hogan,
Boechler, Difelice, & Cooney, 1992; Slome et al., 1976; Visintainer et al., 2000).
But access to and utilization of midwifery care does not reflect what one
would expect to see based on the evidence, though over the past three decades, there
has been significant growth in the profession of midwifery. According to the National
Center for Health Statistics, a federal agency, in 1976 certified nurse midwives
attended one percent of births in the US. This figure rose gradually to three percent in
1987, five percent in 1994 and seven percent in 1998. The latest figures from 2003,
are at 7.6 percent, showing little growth (US Department of Health and Human
Services, April 5, 2004). It is true that over the last three decades, there has been a
six-fold increase in the number of midwife-attended births in the US, but the numbers
remain puzzlingly small in comparison to evidence demonstrating safe and cost-
effective care. Midwives in the United States only attend seven percent of births
compared to 50-75 percent of births in other developed countries (ACNM, 2003a;
McCool & Simeone, 2002; Paine, Dower, & O'Neil, 1999; Reale, 2002; WHO, 1996).
See Figures 1.3 and 1.4 (National Vital Statistics System, 2006). The state where both
9


of the cases used in this investigation were located boasted one of the higher rates of
midwife-attended births in the nation12.2 percent of births in 1997; but by 2002
that rate fell to 9.7 percent according to the citys Department of Health and Mental
Hygiene (Perez-Pena, 2004). It is estimated that 2003 figures will be lower still
because of the multiple practice closures found in the city (Perez-Pena, 2004).
QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS
Percentage of Births Attended by Midwives United States, 2003
In 2003, approximately 8,0% of births were attended by midwives, more than double the 1990 rate
ot 3.9%. In six stales (Alaska, Georgia, New Hampshire. New Mexico, Oregon, and Vermont), rates
were at least twice as high as the national rate.
SOURCE: National Vital Statistics System, Natality File 2003. Available at http://www.cdc.gov/nchs/
births.htm.
Figure 1.3 Percent midwife attended births in US, 2003, National Center for Health
Statistics
10


1976 1987 1994 1998 2002 2003
1%
3%
5%
7%
7.6%
7.6%
Figure 1.4 Percent midwife attended births in US, 1976-2003
Many examples of midwifery practice closures exist. By December 2002, only
obstetricians were delivering babies in Austin Texas hospitals because physicians
unilaterally refused to sponsor CNMswhich is required in most if not all hospitals
in the US (Edwards, 2003; Pleticha, 2004; Stamberg, 2004). Yet other midwifery
practice closures can be found as recently as 2003 in New York City, Washington
D.C., Baltimore, Chicago, Denver and other cities in the US (ACNM, 2004; Edwards,
2003; Farley, 2003a, 2003b; O'Donnell, 2003; Perez-Pena, 2004; Pleticha, 2004;
Stamberg, 2004). Women all over the country have marched and protested with
banners that read, We Want Our Midwives!, Save Our Midwives!, and
Midwives Save Lives! due to multiple midwifery practice closures (See Figure 1.5)
(reprinted with permission) (ACNM, 2004; Farley, 2003b).
jmtuxtUrt Jarfmte Ayi>icc tfaifim cm VMfccn. U'fldfM!. tBiii i)fhT mi&njcry BipfVfTeil lultn to ifas&n at S ra£v tot tin4 litoitthfoim i>1
DC
Figure 1.5 Save the midwives rallies, Chicago, Washington, DC, 2003
11


All of these practices provided care to indigent populations and showed excellent
perinatal outcomes.
In summary, it is difficult to understand the marginalization of midwives in
the US given that:
1. The medical establishment increasingly demands evidence-based practice
standards and midwifery has a sound base of evidence supporting excellent outcomes;
2. Consumers, legislators, and health care providers decry the skyrocketing
costs of health care and midwifery clearly provides a cost-effective alternative to
hospital-based physician care; and
3. Birth is an event imbued with personal meaning for women and their
families and studies have shown that midwifery offers a highly individualized,
personalized and unobtrusive form of care through this life event.
The recent changes within the two long-standing midwifery services studied here
exemplify the problem and offer an ideal opportunity to examine the details of the
marginalization of midwifery in the 21st century and the politics of birth in the United
States. Furthermore, inherent to and embedded within this question are considerations
of the political economy of health care delivery in this country. With over 45 million
uninsured people in the US, we are facing a health care crisis. We must consider all
feasible high quality, cost effective ways of addressing the nations health care needs.
The results of this study demonstrate that in the context of our present day
health care system, what happened to midwifery services in both cases analyzed
12


makes economic sense. It makes less sense, however, with respect to the health and
best interests of mothers, babies and the health care of a nation. A paradox exists that
must be reconciled. It is this paradox that I begin to unravel in my study.
Finding Voice: The Personal Becomes the Political
Part of the motivation for this project was about finding voice (Richardson,
2000). There are ample examples in the feminist and civil rights literature of people
making the personal the political and taking action to make changes (Hamisch,
1969; Richardson, 2000). Finding my making the personal the political voice drives
this projectit provides both reason and grounding for the research.
I have been a midwife for over 25 years and have accumulated extensive
experience with professional marginalization that, at times, became exceedingly
personal. This particular research project allows me to transform the personal into the
political. If, as Margaret Lock asserts, politics has to do with the ways in which power
is concentrated, disseminated and articulated among individuals and institutions, then
this project is about the transformation of power via a revolution of facts, ideas and
experiences (Lock, 1998). Over time, I was able to understand that although they felt
extremely personal to me, my experiences were not isolated; they were, in fact,
shared by many midwives all over the country. Ultimately, this discovery led me to
this project.
13


I believe that my years of midwifery experience bring many advantages to
conducting this research, including the ability, indeed, the willingness, to challenge
my own perspective in order to find out the truth about why midwives are
marginalized and underutilized in this country. I think it is a question that must be
askedfor the well-being of women, newborns, and our broken health care system.
In this case study, my intention is to gather information that will enrich and ultimately
strengthen our understanding of the reasons for the marginalization of midwives in
the US in an effort to promote changes that will ultimately benefit women and
infants.
Purpose and Aims
The purpose of this study is to examine in close detail the demise of two long-
standing midwifery services in a major city in the US that experienced significant
changes to their professional status during the summer of 2003 to critically analyze
the factors that contribute to the professional marginalization of midwives in the
United States. The overall goal of this investigation is to illustrate some of the
existing problems within the political economy of the maternal child health care
system and to make some specific suggestions for improvement. The overall question
driving this investigation and aim of the study are the following:
14


Question
Given that there is ample evidence documenting the safety, cost effectiveness
and satisfaction with midwifery care, what factors contribute to the underutilization of
midwives in the US?
Aim
The aim of this study is to understand why two long-standing midwifery
services were either closed or experienced significant changes in their practices in
order to understand the process of professional marginalization of CNMs in the US.
This aim was accomplished by conducting in-depth qualitative interviews with
midwives, staff, administrators, doulas, childbirth educators, liability insurers,
lobbyists, and physicians from two long-standing midwifery services that have
experienced practice closure or restrictions.
What is a Midwife?
Certified nurse midwives (CNMs) and certified midwives (CMs) are trained to
provide care to women throughout their life cycle, from the onset of menses through
the menopausal years, with a particular emphasis on providing care to women during
15


pregnancy, birth and the postpartum period. Traditionally, CNMs enter the profession
of midwifery through nursing school education programs, where they receive a
Master of Science degree, usually in nursing, with an advanced practice specialization
in midwifery. Graduate programs follow undergraduate degrees, thus nurse
midwifery education is generally a six or seven year course of study. Certified
midwives (CMs) are educated in the same manner as CNMs, however they do not
have a nursing degree prior to graduate education in midwifery. CMs are an attempt
on the behalf of the ACNM to promote the independent profession of midwifery.
However, in 48 states in the US, midwives must be CNMs in order to practice. There
are only two states where CMs can practice in the same manner as CNMs: New York
and Rhode Island, where midwives are licensed to practice under a Midwifery
Practice Act, instead of the Nurse Practice Act (D. R. Williams, 2005).
Philosophically, CNMs and CMs believe that every individual has a right to
safe, satisfying health care with respect for human dignity and cultural diversity. They
support womens rights to self-determination, and their goal is to provide women
with information so that they can be active participants in all aspects of their care and
the decision-making process. Midwives believe in the normal physiologic process of
pregnancy and birth and strive to support and enhance these processes through
education, high quality continuity of care, minimal intervention in normal processes
and working collaboratively with physicians and other members of the health care
system to optimize care and outcomes for women and their families (ACNM, 1989).
16


Governance of midwifery in the United States varies from state to state. In 42
jurisdictions, midwives are governed by the State Board of Nursing, Advanced
Practice Nurse regulations and guidelines, and the Core Competencies and
Standards for the Practice of Nurse Midwifery promulgated by the American
College of Nurse Midwives (ACNM, 2003b). In 23 states, midwives cannot practice
unless they have a Masters degree. Approximately 35 of 45 educational programs are
situated in schools of nursing. The fact that midwives are primarily licensed and
regulated by boards of nursing and educated in schools of nursing creates an
interesting dilemma for the profession with respect to their identity. From a
regulatory and educational perspective, it is easier and more cost effective for states
to group advanced practice nurses and midwives together for uniformity and
consistency. Although this simplifies some issues for the state and for midwives, it
also creates some problems (Reed & Roberts, 2000). Being licensed and regulated
under the Nurse Practice Act has implications for midwifery education programs, 80
percent of which are located in schools of nursing, which limits who can become a
midwife and who can get a job if they have an unconventional education or degree
(Burst, 2005).
The authority to prescribe medications is another issue for midwives.
Although midwives in 50 jurisdictions are granted some sort of prescriptive authority,
this authority is restricted in over 20 jurisdictions with limitations that are not
evidence-based, such as being unable to write prescriptions for controlled substances,
17


requiring a written collaborative agreement with a physician, taking additional
coursework beyond midwifery training, having a certain number of supervised
clinical hours, or requiring physician permission before writing a prescription (Reed
& Roberts, 2000). Other areas that states regulate include educational requirements
for licensure, liability insurance, and third party reimbursement by Medicaid,
Medicare, managed care companies, and other types of insurance. State laws and
regulations must be considered, since they may hinder or promote midwifery practice.
Midwives bring great value to health care systems if properly utilized, as can
be seen in other western industrialized countries, such as the Netherlands, Great
Britain, Japan, Sweden, and New Zealandall countries that boast a high rate of
births attended by midwives and the lowest infant and maternal mortality rates in the
world (DeVries, Benoit, van Teijlingen, & Wrede, 2001; Strong, 2000). There are
other significant differences between the health care and political economies in these
countries and the US. For example, all but the US have universal health care and
smaller, more homogeneous populations (except for the UK). With universal health
care, the cost, accessibility and quality of health care delivery are all closely
intertwined, and midwives have a crucial role to play (Geyman, 2003). It is in the
close analysis of some of these programs in other countries that the value of
midwifery can be ascertained (DeVries et al., 2001; Loudon, 1992).
Contrary to what was happening in the US during the early part of the
twentieth century, in the UK there was broad agreement that midwives provided the
18


ideal structure for maternity care (Wrede, Benoit, & Sandall, 2001). Midwives have
encountered opposition in the UK over the years, particularly during the middle part
of the twentieth century when there was a shift towards hospitalization and
medicalization of birth, resulting in fragmented and dehumanized care for women and
a loss of autonomy for midwives (Mander & Fleming, 2002). But accountability
issues within the National Health Service regarding escalating costs of health care and
equitable resource allocation led to significant changes and increasing governmental
support for midwives in the later half of the twentieth century. Attention was once
again focused on continuity of care for women, choice on type of provider and
location for birth, and womens involvement in decision-making processes regarding
their bodies during pregnancy and birth. This resulted in increased autonomy for
midwives, more cost effective and efficient care for the government and greater
choices for women (Wrede et al., 2001). Midwifery in the UK is strong (albeit
struggling), state funded, and state supported. Midwives are university educated and
attend the majority of births.
In Sweden, there is a clear state commitment to offer its citizenry equitable
and high quality health care in the form of universal coverage. In fact, outcomes are
basically the same across race, ethnicity and class, unlike in the US where infant
mortality rates for African American infants are over twice what it is for Caucasian
infants (Nelson & Popenoe, 2001). In Sweden, essentially all women give birth in the
hospital setting with midwives (Nelson & Popenoe, 2001). Although women have
19


equal access to high quality care, they have fewer choices given to them since they
cannot choose the type of provider for their care. However, the model is based on a
strong midwifery philosophy because it is cost effective, efficient, and of high
quality. Critical to the success of midwives in Sweden is that few conflicts exist
between physicians and midwives. This lack of conflict occurs because midwives and
doctors in Sweden work together as a team to complement each other as opposed to
competing with each other for clients (Hogberg, 2004). The midwife as primary birth
attendant, along with her noninterventionist attitude, is the indisputable norm of
Swedish women, physicians, and the state. This is in contrast to the high rates of
intervention in the standard obstetrical model of care in the US.
Midwifery in the Netherlands is strong and provides a model for other
countries (DeVries, 2001). Midwives attend the majority of births and enjoy
autonomy and support from the state and health insurance companies (Sandall,
Bourgeault, Meijer, & Schuecking, 2001). In fact, the state and private insurance
companies remunerate obstetricians only when their services are indicated by the
condition of the mother or fetus. A discussion of what constitutes appropriate
consultation accounts for lengthy meetings between professionals. The Dutch
experience demonstrates that consensus on major issues is effective when there is no
power structure or professional hierarchy dominating the discussions, and all
professionals are on equal footing (Sandall et al., 2001). The Dutch government
issued a long term policy on maternity care stating that all women should be cared for
20


by a midwife or general practitioner unless there is a medical indication for obstetric
care. They also reinforced the absolute need for cooperation between professions and
institutions. The role of midwives in the Dutch health care system is actively
protected by the state and midwives feel their professional status is secure.
In every analysis, where midwifery remains an important part of the health
care system, a nationally recognized value is placed on access to high quality, cost-
effective health care, and the state plays a key role in legitimizing and protecting the
jurisdictional claims of the midwife (Sandall et al., 2001). The US system is founded
on a market-based economy, where competition over resources, status, and power is
encouraged between professionals in a hierarchical system. The lack of a coherent
public policy regarding health care is problematic for the US, where costs for health
care are exorbitant and benchmark indicators for health are abysmal, particularly in
the area of maternal child health. Lack of state control over health care policy
produces irrationality in equitable access to effective services. Cost-effective care is
often eschewed in favor of costly-ineffective care. The minor role played by
midwifery in maternal health care in the US is a striking example of such
irrationality.
To shed light on the causes of such irrationality, this study examines how the
profession of midwifery is situated within the political economy of the predominant
biomedical model of obstetrics and how that has affected midwifery practice.
Examination of the challenges that midwives face in order to practice take into
21


consideration the rationalization of the boundaries used to define obstetrical and
midwifery practices, which are inherently and philosophically different. In addition,
an analysis of the history and professionalization of midwifery is considered. Finally,
an examination of the two case studies lends itself for a detailed discussion on the
political economy and cultural analysis of birth and the discourses that surround it.
My goal is to begin to pierce the veil that allows the obstetrical model to disguise
what is best for mothers and babies at the time of birth. In the context of a health care
system that is in crisis, this is an analysis that is long overdue.
22


CHAPTER 2
KNOWLEDGE THAT COUNTS
Professionalization of Medicine and Midwifery in the US
There will be a midwife problem as long as there is a midwife, and there will
be midwives as long as there is an element of ignorance and superstition in the
population (Rucker, 1923).
My own feeling is that the great danger lies in the possibility of attempting to
educate the midwife and in licensing her to practice midwifery, giving her
thereby a legal status which later perhaps cannot be altered. If she once
becomes a fixed element in our social and economic system, as she now is in
the British Isles and on the Continent, we may never be able to get rid of her...
The fact is.. .that we can get along very nicely without the midwife, whereas
all are agreed that the physician is indispensable. It thus seems the sensible
thing to do is to train the physician until he is capable of doing good
obstetrics, and then make it financially possible for him to do it, by
eliminating the midwife and giving him such other support as may be
necessary (Ziegler, 1913: 32-33).
These quotes reflect the attitudes of physicians throughout the early and
middle parts of the twentieth century. The marginalization of midwives in the US is a
complicated and nuanced story replete with multiple countervailing pressures,
conflicts, and competing influences. It has to do with the history of the
professionalization of medicine and midwifery in the early part of the 20th century,
23


the development of authoritative knowledge and medical discourse, the political
economy of health care, and marginalization theory.
A Brief History of Medicine and Midwifery in the US
Paul Starr tells the complex story of how the profession of medicine obtained
sovereignty in the US in the early part of the 20 century (Starr, 1982). He opens his
book, The Social Transformation of American Medicine, by saying The dream of
reason did not take power into account (Starr, 1982: 1). The story begins with a
description of the profession of medicine in the late 19th and early 20th centuries,
when a disorganized and disorderly group of questionably credible practitioners
eventually gained authority over medical knowledge and became a self-governing,
supremely powerful entity. It is the story of how the profession of medicine achieved
solidarity in order to resist forces and competitors that threatened their social and
economic position. Ultimately, it is a story about the contradictions between
professionalization and the rule of market, between the dream of reason and the
dream for power, which, according to Starr, is long-standing and unavoidable.
Importantly, Starr documents the social, political, and economic processes that gave
the physician socially-granted and legally-sanctioned control over medical
knowledge. Writing in the context of physician control over birth, Jordan puts it
simply: The power of authoritative knowledge is not that it is correct but that it
24


counts (Jordan, 1997: 58). The story is one about how medicine successfully and
authoritatively came to possess knowledge that counts. In large part, the
marginalization of midwives is one casualty of the professionalization of medicine.
According to several authors, the consolidation of medical authority occurred
early in the 20th century following the publication of the Flexner Report in 1910
(Beck, 2004; Borst, 1995; Jordan, 1997; Starr, 1982; J. W. Williams, 1912). This
report reflected the findings of a study done to examine the quality of medical
education in the US, which was found to be poorly funded, inconsistent, and
deficient. As a result of this report, medical funding was allocated towards the
provision of higher quality allopathic medical education and ultimately led to the
closure of programs that were deemed inappropriate. Some authors suggest that the
Flexner Report was instrumental in ensuring medical sovereignty for conventionally
trained physicians and that the majority of these physicians would be white, middle to
upper class, and male (Ehrenreich & English, 1973; Wertz & Wertz, 1989). There is
another important aspect to the Flexner Report. Flexner, or rather the physicians that
seized upon this report, sought to craft authority and control competition by linking
medical authority to the rapidly developing biomedical sciences. The rise of medicine
is thus coeval with the hegemony of the biological sciences. Things not strictly
scientific (i.e., humane care) were a casualty of this process. Midwifery, associated
with more humane care, was seen as competition and thus discounted knowledge.
25


Midwifery could not count on the same kind of strong connection with biomedical
science. It was thus doubly doomed to marginality in the American context.
In addition to the relative importance of medical education, Starr discusses the
development of medical sovereignty and authority in the context of health care
markets, which are distinctly different from other markets where goods and services
are bought and sold at competitive prices (Starr, 1982). According to Starr, ideal
markets assume the sovereignty of consumer choice, whereas medical markets
assume the sovereignty of their professional members. Starr contends that the absence
of power is critical for markets to truly work, and he points out that medical markets
rose from power (Starr, 1982). According to Starr, medical authority both stimulated
and restricted the market. It expanded the market for health care services by moving
the care of the sick out of the hands of family members and lay community members
into professional services. It restricted the market by controlling who could provide
medical services with respect to medical education, licensure, and credibility.
Essentially, the profession was successful at manipulating the market to increase the
demand for medical services and decrease or limit the supply of providers, which
helped make physicians sovereign. Medical markets became stronger as patients
became more dependent on physicians.
In addition, Starr contends that the professionalization of medicine was
successful, in part, because physicians insisted on maintaining professional autonomy
in selling their services, as opposed to allowing corporations, institutions, or
26


organizations to control them. For most of the 20th century, physicians were able to
avoid the economic threats of being employees and were able to shape hospitals and
insurance companies to meet these economic needs. In the US, unlike Europe,
physicians were able to control hospitals and who could have admitting privileges. In
Europe, physicians were employed by the state to work in hospitals and clinics, thus
cost of care, salaries, production, hours worked, and who provided care were outside
of physician control. Physicians in the US strategically positioned themselves to
maximize professional autonomy and entrepreneurial capacity, which drove up the
cost of health care and limited access to care; but then the conservation and
distribution of resources was not the concern of the profession of medicine (Starr,
1982). Having authority over medical knowledge and technology was a key
component to ensure economic success. According to Starr, consolidation of medical
authority occurred by 1931. He reports that in 1928-1931 one survey indicated that
non-physician providers provided only 5.1 percent of the health care needs for over
9000 families. Physicians had the practice of medicine to themselves (Starr, 1982).
Starr states, Power abhors competition about as intensely as nature abhors a
vacuum (Starr, 1982: 23). In his analysis, Starr notes the responses from feminists
regarding the ways in which medicine attempted to control women and their health,
thereby preventing competition from midwives:
Feminists claimed that as patients, as nurses, and in other roles in health care,
[women] were denied the right to participate in medical decisions by
paternalistic doctors who refused to share information or take their
27


intelligence seriously. They objected that much of what passed for scientific
knowledge was sexist prejudice and that male physicians had deliberately
excluded women from competence by keeping them out of medical schools
and suppressing alternative practitioners such as midwives (Starr, 1982: 391).
Once their own sovereignty was assured and physicians retained authority over
patients, hospitals, medical schools, and insurance companies, they managed to limit
and restrict licensure and credentialing of other related, competing professions, such
as chiropractics, osteopathy, midwifery, optometry, psychology, podiatry, and
homeopathy.
The idea of authoritative knowledge is central to this analysis. Authority has
to do with the knowledge with which decisions are made and actions are taken
(Jordan, 1993). As previously noted, seeking professional services for health care has
become a necessity in our culture, since the professionalization of medicine early in
the 20th century. Whereas previously medical knowledge of sickness and health used
to be commonplace in the home and lay community, the increasing advances in
medical science, such as the discovery of antibiotics, immunizations, and other
pharmaceuticals, the control of infectious disease, more complicated diagnostic
techniques, and the increasing dependence on medical technology has made health
care consumers ever more dependent on health care professionals. Such dependency,
as Starr notes, is requisite for culturally legitimate authority. Once individuals
surrender private judgment to professionals, they grant such professionals power.
Their knowledge carries weight and is seen as legitimate and official knowledge of
28


health and illness. Furthermore, authority compels voluntary obedience (Starr, 1982).
Thus authoritative knowledge is about legitimacy and obedience. Owning
authoritative knowledge is associated with owning power; it justifies giving medical
recommendations and validates taking action (Irwin & Jordan, 1987). Jordan points
out that many kinds of authoritative knowledge exist, but that when authoritative
knowledge is linked to a group with a strong power base, it readily dismisses
competing authorities, even if, as in the case of many obstetrical practices, the
authority exists without accountability (Irwin & Jordan, 1987).
Prior to the development of organized medicine, traditional midwives or
th
general practitioners attended virtually all births in the US. In the early part of the 20
century, half of all births in the US were attended by midwives, mostly immigrant
midwives in the North and African American midwives in the South (Dawley, 2003).
In the early part of the 20th century, physicians in the US decided to address the
midwife problem, including a discussion and decision about whether or not to
provide formal training and licensure and who should supervise them (DeLee, 1916;
Devitt, 1979; Emmons & Huntingdon, 1912; J. W. Williams, 1912). After a careful
study of the problem, it was decided that the profession of midwifery should be
abolished. Physicians considered them to be ignorant, incompetent, untrained, and
unclean and it was decided that they brought no value to the health care system
(DeLee, 1916). Obstetrician Joseph DeLee said, The midwife is a relic of barbarism.
In civilized countries the midwife is wrong, has always been wrong (DeLee, 1916).
29


More importantly, after a careful look at European systems, physicians in the US
realized that educated midwives competed with and took revenues away from
physicians in European countries. The medical community was determined not to let
this happen in the US (Emmons & Huntingdon, 1912). It was argued that the formal
training of midwives would lead to a double system, which would be redundant,
expensive, and unnecessary, without benefit to women and clearly a threat to the
economic health of the burgeoning field of obstetrics (DeLee, 1916; Devitt, 1979;
Emmons & Huntingdon, 1912). By 1930, midwives attended only fifteen percent of
births in the USmostly in the South (Dawley, 2003). Thus the contest between the
midwife and obstetrician, which began in the early 1900s, ended by mid-century in
apparent defeat of the midwife and triumph for the physician and a single standard
for obstetrics as suggested by Emmons and Huntingdon. This victory also laid the
foundation for the deep and unjustified prejudice against midwives that persists today
(Loudon, 1992).
One author offers a different perspective. After performing a detailed
historical analysis of documents to study the change from midwife to physician
attended childbirth in Wisconsin in the late 19th and early 20th century, Borst (1995)
suggests that the decline of midwifery in the late 19th and early 20th centuries resulted
from the failure of midwives to professionalize themselves through the development
of formal education and training, the creation of an exclusive body of knowledge, and
the formation of an autonomous profession at a time when modem medicine was
30


burgeoning. Although she acknowledges that obstetricians like Joseph DeLee called
for the elimination of the midwife in the early 20th century, and that in many respects,
the presence or absence of midwifery was somewhat related to race, class, and gender
issues associated with women and midwives, Borst faults midwives for their failure to
professionalize and claims that much of the demise of midwifery had to do with
women choosing modem medicine over traditional midwifery (DeLee, 1916, 1920).
Borst demonstrates how physicians and obstetricians made great strides in
professionalizing themselves, particularly after the Flexner Report was published in
1910. J. Whitridge Williams took on the challenge of professionalizing and reforming
obstetrics two years after the Flexner Report was published (J. W. Williams, 1912).
Nonetheless, Borst neglects to include a discussion germane to the economic and
political incentives that shaped modem medicine and the cultural changes that shaped
womens choices (Barker, 1998). Her analysis also focuses on the experiences of
immigrant midwives as opposed to the efforts of many leaders in the field of public
health who were unsuccessful in their attempts to professionalize midwifery in the
late 19th and early 20th centuries.
Contrary to popular opinion in the medical community, the public health
community advocated for the midwifery model during this same period of time. For
example, Josephine Baker, the physician appointed to the newly established
Childrens Bureau in 1908, noted that maternal infant outcomes were far superior in
Europe than in the US and wanted to know why. Figure 2.1 illustrates how far behind
31


the US was in maternal mortality rates in the first half of the 20th century compared to
other developed nations (Loudon, 1992: 152).
Figure 2.1 Comparison of maternal mortality rate per 10,000 live births in developed
nations, 1899-1950
Upon further investigation and analysis, Baker attributed better outcomes to the
midwifery model of care and the formal education of midwives in European countries
(Loudon, 1992). Multiple early efforts by public health nurses who were interested in
improving maternal infant outcomes failed to establish midwifery training programs
and services in the US (Dawley, 2003). Public funds were finally allocated by the
32


Sheppard Towner Act of 1921 to encourage the training and use of midwives in
public health, the creation of prenatal and child health clinics, education for mothers
on nutrition and hygiene, and home health care for new mothers and babies. There
were few formal midwifery educational programs at the time and none that produced
licensed credible practitioners (Reed & Roberts, 2000). With the endorsement from
the Sheppard Towner Act, three organizations that advocated for maternal child
health in the early part of the 20th century, the Childrens Bureau, Maternity Center
Association (MCA), and the Lobenstine Clinic collaborated to establish a midwifery
education program along with a midwifery service in New York City, which finally
succeeded in 1932, graduating its first class of midwives in 1933. The Sheppard
Towner Act was actually the first federally funded social welfare measure. It was
repealed in 1929 when the American Medical Association (AMA) persuaded
congress that it was too close to socialized medicine and that private practices could
provide the same services (McCloskey & Wise, 1999; Peoples-Sheps & Alexander,
2001; Starr, 1982). Using private funds, the first midwifery service was successfully
established in rural Kentucky in 1925 by Mary Breckenridge, a US citizen who
received her midwifery training in England after observing and being impressed with
the success of midwifery programs in Europe. Again with private funds, Mary
Breckenridge formed the second midwifery school in Kentucky in 1939. There were
distinct differences between the two schools and services. The Frontier Nursing
Service (FNS) midwives in rural Kentucky had more autonomy than the MCA
33


midwives in New York City because they were privately funded and they traveled by
horseback into remote areas of the Appalachian Mountains, an area where there were
few physicians. In contrast, the MCA midwives were considered a threat to the many
obstetricians in New York City, and so were placed under the direct supervision of
physicians who wanted more control over them. Physicians insisted on reviewing
charts, seeing the patients, and writing orders for care for every visit as well as for
labor and birth (Dawley, 2003). These were home birth practices, as were all
midwifery services in the first half of the 20th century. In the 1940s, inspired by the
post war baby boom, the growth of hospitals, and of insurance programs, nurse
midwifery practices and educational programs grew (Dawley, 2003). By 1950, there
were seven nurse midwifery education programs, and the professional organization of
the American College of Nurse Midwives was formed in 1955. It was not until the
mid 1950s, however, that midwives were tentatively allowed by physicians to
practice in hospital settingsthe first midwife attended birth taking place at a
hospital associated with Columbia University in New York City. Along with the
cautious steps towards allowing midwives to work in the hospital setting, Columbia
University School of Nursing established the first university-based midwifery
education program where students could obtain their clinical experience within a
university-affiliated hospital (Dawley & Burst, 2005). Thus, despite early physician
opposition, the profession of nurse midwifery had its beginnings, thanks to the
establishment of and support from public health.
34


Two forces shaped the profession of midwifery in the early part of the 20th
century. The public health perspective used evidence from other countries with better
outcomes and a midwifery model of care along with evidence of need in this country
to suggest and promote a formal midwifery model for the US. Physicians, on the
other hand, argued for a single standard of obstetrical care based on physician
delivery to promote the professional status of physicians and reduce competition from
midwives. A decision was made by the professionally organized physicians to thwart
the public health model by educating the public to expect and demand obstetrical care
(Barker, 1998). This campaign met with ultimate success, as witnessed by the fact
that over 90 percent of births in the US today are attended by physicians. Early on, it
was noted that midwives had as good as or better outcomes than physicians. Some
reflected that midwives should replace physicians, rather than abolishing the
profession of midwives (King, 1991; Kobrin, 1966; Loudon, 1992). Evidence of
excellent outcomes with midwifery care was seen very early with the evaluation of
Mary Breckenridges FNS midwifery service in 1925. (See Figure 2.2).
Figure 2.2 Mary Breckenridge and FNS midwives, 1925, Kentucky
35


In the county where FNS started, the maternal mortality ratio was greater than
800 maternal deaths per 100,000 live births. Under the care of the midwives, the
maternal mortality ratio dropped to 68 maternal deaths per 100,000 live births,
whereas local physicians continued to have a maternal mortality ratio exceeding 800
deaths per 100,000 live births during the same period of time (Loudon, 1992). In fact,
there are compilations of statistics that show that midwives had much better outcomes
than physicians in many regions of the US in the early part of the 20th century
(Loudon, 1992). Although Breckenridges model should have been considered
exemplary and applied to the entire United States, it was essentially ignored. In fact,
the FNS experienced serious financial difficulties with the dissolution of the
Sheppard-Towner Act in 1929, when the AMA successfully lobbied against this form
of social welfare and health care initiatives. Today there is a hospital and many out-
lying clinics that are FNS owned, along with a distance-learning, community-based
nurse midwifery education program.
A study published in 1933 offers another prime example of the excellent care
midwives provided. The New York Maternal Mortality Study was undertaken by the
New York Academy of Medicine and the New York Obstetrical Society in the early
1930s in an effort to convince the public that midwives were largely responsible for
the high maternal mortality rate. The data showed, however, that over two thirds of
maternal mortality could have been prevented and that it was physicians, not
midwives, who were in fact responsible (King, 1991). Because of these unexpected
36


findings, the report was published without the permission of physicians, who
subsequently published a response to the report concluding that the findings had no
results of value (King, 1991). Instead, women were advised by their physicians and
by womens magazines such as the Ladies Home Journal that childbirth was being
lifted out of the realm of darkness and into the spotlight of new science (King,
1991). It was felt that the triumph of the medical profession over the midwifery
profession was the result of a successful campaign to educate the public before public
health programs could become firmly established in the public consciousness (Barker,
1998; Kobrin, 1966).
Another particularly remarkable episode in the history of professional
midwifery was the midwifery experiment that was conducted over a three year
period in Madera County Hospital in California during the 1960s. Midwives managed
most of the births during this time, and the neonatal death rate was reduced to less
than half of what it was when obstetricians were managing the service. After three
years, the program met with extreme opposition from the California Medical
Association and was terminated. Obstetricians assumed care of the women and births
and over the next two and a half years the neonatal death rate tripled (Levy,
Wilkinson, & Marine, 1971). There are other similar midwifery experiences cited in
the literature.
In 1972, Dr. Roger Egebert, a Special Assistant for Health Policy at the
United States Department of Health, Education, and Welfare noted, It is paradoxical
37


that the United States, which does as well in training nurse midwives as any nation in
the world, lags so far behind other countries of making effective use of such highly
trained and urgently needed healthcare professionals (Strong, 2000: 127). In his
book, Expecting trouble: the myth of prenatal care in America, perinatal specialist
Thomas Strong writes at length about the restrictive and persistent policies and
regulations that have hampered the growth of both nurse midwifery education
programs and practices (Strong, 2000). It is interesting to compare the growth of the
professions of nurse practitioners and physician assistants to that of nurse midwives.
Nurse practitioner and physician assistant educational programs and certifications
have been in existence since the 1960s, which is relatively late compared to that of
nurse midwives, who had their professional beginnings in the US in 1925-1930. Yet
in 2000, there were 95,000 nurse practitioners practicing in the US, 40,000 physician
assistants, and only 8,000 CNMs (National Center for Health Workforce Analysis,
2004). One might argue that midwives are a type of specialty practice and nurse
practitioners and physician assistants provide primary care, thus there is a greater
need for them. Yet the same investigation showed that the vast majority of nurse
practitioners and physician assistants went into specialty practices and do not provide
primary care (National Center for Health Workforce Analysis, 2004). Furthermore,
midwives are trained to provide primary care to women from menarche through
menopause.
38


There is extensive evidence and documentation that suggests a historical,
cultural, political, and economic basis for the present day professional
marginalization of midwives. What is difficult to understand, is how this
marginalization can persist in the 21st century, in the face of all the evidence that
supports midwifery care as being as good as if not superior to obstetrical care,
alongside the increasing economic, social and statistical health care concerns in our
country. Once again, reason does not necessarily take power into account.
Professionalization Theories and Application to Midwifery
The history of midwifery in the US demonstrates some of the problems that
midwives encountered with professionalization, how the profession has situated itself
in society, and perhaps even more important to its viability, within an accepted health
care system.
Many theories exist on professionalization. Trait theory provides one of the
earliest explanations for professionalization and suggests that several characteristics
must exist in order for a group to be considered a profession, such as an accepted
body of knowledge, a code of ethics regulating the profession, a formal education and
training process, and licensure and regulation, all of which apply to the profession of
midwifery (Caplow, 1954; Rutty, 1998; Welsh, Kelner, Wellman, & Boon, 2004;
Wilensky, 1964). However, licensure, a code of ethics, and a body of knowledge are
39


not sufficient; the process of professionalization is not so simple. Power struggles and
social and historical conditions influence the success of or barriers to
professionalization and trait theory obscures their relative importance and influence
(Friedson, 1970; Saks, 1983; Welsh et al., 2004). Other scholars suggest that
professionalization is defined by trait theory and by a process of social closure, where
dominant groups, or stakeholders have power and control over market conditions that
protect their interests in the face of competition from outsiders (Saks, 2000,2001;
Welsh et al., 2004).
Social Closure
The professionalization of medicine that occurred in the early part of the 20th
century is a fascinating story of struggles and successes, at times helped along by
silver bullets and other potent discoveries that catapulted medical opinion into
medical authority (Starr, 1982). But it was difficult to predict the future, so medical
practitioners did everything they could to protect the domain of medicine. Becoming
masters of social closure was one such strategy. Social closure provides a more
realistic picture of the actual struggles that midwifery and other professions have had
during the process of professionalization. But it is unclear from the history of
midwifery why midwives allowed themselves to be marginalized, why they did not
organize as midwives did in Europe to lobby for and promote their profession. Most
40


of the midwives were poor, oppressed, dealing with issues relating to gender, race and
ethnicity, and lived in a time when women could not vote. The phenomenon of social
closure was relatively easy against such a disempowered group. Later, as the
professionalization of nurse midwifery began, the process of social closure was
already in place and difficult to change.
In one study, conducted in Ontario, investigators interviewed established
health care providers to elicit opinions on the professionalization of complementary
health care providers into the health care system. Findings showed that stakeholders
were in fact reluctant to endorse the professionalization of potential competitors and
that they developed three strategies to prevent entry of these competitors into the
market and to protect their stake (Kelner, Wellman, Boon, & Welsh, 2004a).
Established health care providers claimed that they were concerned with the lack of
evidence-based research to document the safety and efficacy associated with
complementary medicine, despite the fact that they did not hold themselves to that
same standard; they opposed government spending to fund research and education;
and they did not support integration of complementary health care providers into the
health care system. Kelner et al. write, These strategies serve to protect the dominant
position of medicine and its allied professions, and to maintain existing jurisdictional
boundaries within the health care system (Kelner et al., 2004a). A major problem
authors identified was that judges or administrative gatekeepers were also
competitors, who were clearly advocating for their own economic sustainability. This
41


is a similar situation for midwives who depend on physicians, who are also their
competition, in order to practice. The process of professionalization is a challenge
when faced with the strategy of social closure.
The Choice to Professionalize as Nurses
Professionalization has to do with how the profession receives both legal and
social recognition and respect, which may be measured in terms of how it is regulated
by public policy and law, how it is reimbursed for its services, how well the service is
utilized, and how fairly the profession is treated within the system. All of these
concerns are controlled by mechanisms both internal and external to the profession of
midwifery. Midwifery has a long history of struggling to become accepted by
professionals in the world of mainstream medicine.
Lynch (2005) suggests that midwifery aligned itself with nursing in an effort
to legitimatize itself. Some experts agree:
Nurse-midwifery has grappled with its origins. The autonomy that midwives
had was sacrificed for credibility and access to the health care system. Nurse-
midwifery was started against rancorous opposition. The profession was
allowed to come into being only attached to nursing and under the auspices of
medical supervision and control. It is necessary to understand the context
within which nurse-midwifery developed to understand the compromises
made at that time, which still affect the profession today. It is clear that the
early promoters of nurse-midwifery, while understanding that nursing and
midwifery were two different professions, also understood that to survive and
thrive, nurse-midwifery had to make itself acceptable to the mainstream health
care system (i.e., nursing and medicine).... Calling nurse-midwifery a clinical
42


specialty in nursing retained health care system access and acceptance at a
time when the word midwife conjured up, albeit unfairly, derogatory images
(Burst, 2005:129). [Emphasis is original].
Many midwives have questioned this strategy of seeking legitimacy by becoming
medical experts. Juliana van Olphen Fehr expresses her objections to this strategy in
the following remarks:
Many midwives in these situations have said to me, At least we have our foot
in the door. My question to them is: What door? Is it the door to a medical
model described by [in the article by] MacDorman and Singh, whose infant
mortality rates are higher than those of midwives? (MacDorman & Singh,
1998) Whose politics are fraught with fear, competition, and insecurity? I
dont want my foot in the door of the medical model. I dont want to cross
over that threshold. Rather, I prefer to live on the edge, the margin where
midwives have always existed.... Here, the midwifery model emanates (van
Olphen Fehr, 2001:40-41).
Although staying true to a midwifery model is a valid and compelling argument, if
midwives remain on the fringe, they are less likely to become mainstream
practitioners.
There is a distinct group of midwives who would like to see professional
autonomy for the profession of midwifery. They note that the strongest most
autonomous models of midwifery around the world are the direct-entry models and
further note that the only groups that disagree with this model are the physicians
and nurses associations who want to exert control over the profession of midwifery
(Lynch, 2005). Moreover, this group wants to know who is representing midwifery in
hospitals, state legislatures and educational settingsis it nurses, doctors or
midwives? If midwives see themselves as independent practitioners, then another
43


profession should not represent them; they should represent themselves. These
questions are being asked because this group often wonders how nursing has
benefited the profession of midwifery, which is clearly in trouble (Lynch, 2005).
Others feel strongly that the reason to be associated with nursing has to do
with the tremendous respect, recognition, and acceptance attributed to the nursing
profession. To them, nursing provides an important professional umbrella since
midwifery is such a small and relatively young profession with a dubious professional
history and reputation. The debate regarding whether midwives should enter the
profession via nursing or be a direct-entry profession remains on-going and is divisive
to the profession.
Nurse midwiferys origins came from public health nursing in the early part of
the 20th century. Even so, one of the earliest dilemmas that the profession of
midwifery faced was its relationship with the profession of nursing. On the one hand,
being part of the nursing profession legitimatized the profession that was so recently
disparaged. But, on the other hand, it also led to problems for midwives from the very
beginning related to state licensure, regulations, education, and socialization. Perhaps
more critical is the factor of professional socialization. In the US, midwives are
treated as midlevel practitioners, grouped with nurse practitioners, nurse
anesthetists, and physician assistantsall considered physician extenders, that is,
working within the body of knowledge of medicine (Rooks, 1997). Midwives,
however, practice midwifery, and although some overlap exists, they do not practice
44


from the middle of the realm of obstetrics. Thus some midwives contend that they
should be able to practice with more autonomy with respect to licensing, billing,
obtaining prescriptive authority, hospital privileges, and physician backup (Rooks,
1997). Further, as stated in the Pew Health Professions Commission Task Force on
Health Care Workforce Regulation, Medicine is the only profession with state
practice acts that cover all of health care services. With this exclusivity, little or
nothing exists that can be added to the medical act and medicine has no incentive to
delete anything (Pew Health Professions Commission Task Force on Health Care
Workforce Regulation, 1998). This means that medicine has a monopoly over
anything that might be defined as the practice of medicine, including delivering a
baby, writing a prescription, or ordering a lab test. Other practitioners can initiate
these activities only if they are under the direct supervision of a physician, which
limits the professionalization of, in this case, midwifery (Reed & Roberts, 2000).
Although the Standards for the Practice of Nurse Midwifery loosely define the
relationship between midwives and physicians as one of consultation, collaboration,
and referral, state regulations may be more restrictive, in part because of the way
medical practice acts are written to protect physicians (ACNM, 2003b; Pew Health
Professions Commission Task Force on Health Care Workforce Regulation, 1998).
Only eleven states have no supervisory language in their regulations for midwives
(National Center for Health Workforce Analysis, 2004). The relationship between
midwives and physicians is paramount for midwives. How state laws interpret this
45


relationship, for example, is the criterion that the Joint Commission of Healthcare
Organizations uses to determine if a midwife should be able to be an independent
practitioner, thus able to be eligible for admitting privileges at a health care facility
(Reed & Roberts, 2000).
Socially, it is unclear whether midwives have achieved respect and
recognition based on consumer choice of provider for care. The vast majority of
women still seek out physician care. Since obstetricians far outnumber and essentially
control midwives in this country, this preference could be about accessibility as much
as confidence or preference for a particular model of care.
The Importance of a Distinct and Unique Identity
In addition to legal and social recognition and respect, professionalization has
to do with the ability of the profession to identify a distinct and unique identity and
model of care and to uphold its values and vision. It is critical that the profession
avoid being redefined and molded by others in order to be accepted. Midwifery is a
minority profession in our health care system and, as such, often finds itself trying to
fit into a system that is not set up to support it the way it supports physicians and
nurses. This often results in redefining midwifery practice in the context of the
dominant culture of medicine. For midwifery, it has been difficult to achieve all three
items crucial to professionalization: legal respect, social respect, and as a strong self-
46


identity. Midwifery is often touted as being based on women-centered care, evidence-
based care, and continuity of care. But in the real world, the stresses of being an
outsider can be intense, and some of those values and vision are lost in actual clinical
practice, perhaps in exchange for the legal and social acceptance in the hierarchy of
medicine.
There is some suggestion that professionalization may alter a profession
(Bourgeault & Fynes, 1997; Lay, 2000). When professionals organize into collective
groups, they often find they have greater occupational power. This may come at the
expense of individual autonomy, however, if the individual does not conform to the
expectations and standards as set forth by the larger group. Some believe that obeying
the rules compromises midwifery care and leads to medwifery, a more medical
model of midwifery. In order to maintain their distinct professional identity, their
mother tongue, midwives need to have a clear understanding of their professional
struggles and know how to manage them (Zeidenstein, 2000). In the real world, no
one teaches this variety of professional integrity to midwives and thus like the shock
that many babies experience as they are bom into bright lights, senseless noise, and
unfamiliar hands, a new midwife may be bom into professional shock (Zeidenstein,
2000: 85).
Midwives have long struggled for a sense of belonging in the health care
system in the US, for a sense of legitimacy. This ambition is selfless in many
respects; midwives can only serve mothers and babies if they have access to them. If
47


midwives are seen as mavericks, or non-conformists, unconventional providers, they
will never be able to get close to enough women to have an impact. In a way, this
desire to fit in has created a dilemma for the profession because of somewhat opposed
belief systems on the one hand, and the need to use similar language when talking
about pregnancy and birth so that they can be seen as being as knowledgeable and as
good as other kinds of providers on the other hand. As noted in Table 3.1, the
midwifery and obstetrical models differ in terms of their boundaries, beliefs,
philosophies, experiences, and training. The challenge then is for midwives to find a
way to be considered mainstream and yet hold on to their unique belief systems.
Many midwives have worked hard to find ways to blend the best parts of obstetrical
and midwifery models to meet the needs of women they serve. It is also important to
recognize the important role of discourse and how it can be artfully used to further
legitimatize the profession of midwifery (Foley & Faircloth, 2003). Authors Foley
and Faircloth (2003:169) point out, Midwives, often under attack by the medical
profession, the media, etc., might feel a need to legitimate their profession and its
activities.... [Discourse from] the medical model, that is most often construed as
antagonistic to the practice of midwifery, becomes a requisite resource for building
the case of legitimacy.
The concept of medwifery has resulted from the way in which the medical
profession successfully took control over maternity care in this country and redefined
pregnancy and birth as pathological processes despite evidence to the contrary.
48


Moreover, they were able to persuade the public and others in the health care industry
that women and infants would be safer and have better outcomes if they were cared
for by a physician in a hospital settingagain, despite evidence to the contrary
(Devitt, 1979; Emmons & Huntingdon, 1912; Freund, McGuire, & Podhurst, 2003;
King, 1991; Kobrin, 1966; Levy et al., 1971).
The full spectrum of midwifery practice sits on a continuum, ranging from
those who refuse to compromise and practice the pure art of midwifery, to those who
attempt to blend the art and science, to those who, through pressure from consumers
and medical consultants conform to the medical model, perhaps in an effort to
legitimatize their profession, perhaps because it is their experience or preference. For
some, medwifery has been one of the strategies and mechanisms through which
midwifery has been able to survive. According to these individuals, midwives use the
medical bias and gaze because it is sanctioned by modem obstetrics and provides a
niche within which midwives can function (Lynch, 2005). It also provides the
language and discourse for legitimacy (Foley & Faircloth, 2003).
The history of the process of professionalization of medicine and midwifery is
key to understanding the success of biomedicine and the marginalization of
midwifery in the US. In the context of health care in the 21st century, it is important to
recognize the ramifications of the marginalization of this important workforce that
has much to contribute to modem day health care.
49


CHAPTER 3
SMOKING JADED EXPERTISE
Marginalization Theory
Marginalization and professionalization are key concepts in understanding the
state of midwifery in the contemporary US. Much discussion of marginalization
theory has emerged from the nursing literature in the last decade as part of an effort to
define and address the health care needs of vulnerable populations or groups that
experience gender, racial, political, cultural, or economic oppression (Hall, 1999,
2004; Hall, Stevens, & Meleis, 1994; Vasas, 2005). The premise upon which this
study is based is that entire professions can be marginalized, as in the case of
midwifery. Furthermore, I argue that the marginalization of midwives increases
disparities in outcomes for vulnerable populations, limits access to care, decreases
overall quality of care, and increases costs of health careall of which are critical for
any high functioning health care system.
The pioneering work of Hall et al. (1994) regarding marginalization theory
provides key concepts and definitions that set the stage for further studies, mostly
looking at health care issues related to oppressed and vulnerable groups (Flaskerud &
50


Winslow, 1998; Stevens, 1993). The authors maintain that marginalization has to do
with characteristics, functions, and meanings of marginsthat is, borders or edges
(Hall et al., 1994). They define margins as the peripheral, boundary-determining
aspects of persons, social networks, communities, and environments.
Marginalization, therefore, is the process through which persons are peripheralized by
a dominant, central majority. It has to do with the social, political, and personal
construction of boundaries, deciding who controls and maintains these boundaries,
and who is allowed inside (Ferguson, 1990; Midgley, Munlo, & Brown, 1998). In
their initial work, Hall et al. (1994) identify seven properties that are central to the
concept of marginalization, all of which pertain to the profession of midwifery.
Intermediacy refers to having boundaries that separate a marginalized group from a
dominant group that may protect them, but may also expose them to risks.
Differentiation has to do with the marginalized groups special identity that makes
them unique, but also allows for stigmatization and frequently results in persons
being used as scapegoats. Marginalized groups have limited access to resources and
are often forced to conform to the ways of the dominant, more powerful group. They
also often feel as though they have to hide or safeguard information, resources, and
even identities or activities to protect the group. These behaviors are laden with
secrecy and often lead to the development of special survival skills because of the
constant vigilance and scrutiny experienced. Marginalized groups often use voice as a
way to express and validate experiences that differ from the dominant group, but at
51


the risk of being silenced. These features lead to enormous psychological and
emotional stress that individuals within marginalized groups feel as a result of
stigmatization and trauma. All of these characteristics apply to the profession of
midwifery, as is demonstrated in the text of this project.
Other nurse researchers have noted that in order to provide high quality care
to marginalized populations that reflects their experiences and needs, the body of
knowledge created must not be marginalized (Meleis & Im, 1999). As nurses we are
not strangers to marginalization, these authors write. The body of knowledge coming
from a marginalized group is often undervalued. Devalued knowledge is easily
marginalized (Meleis & Im, 1999: 98). They conclude that one of their jobs as
nurses is to create value in the body of knowledge that comes from nursing, make it
visible, and help inform the public so that they are aware and demand better and more
equitable care (Meleis & Im, 1999). These precepts are critical to the profession of
midwifery as well, although creating a body of evidence and making it visible has
thus far done little to change the marginalized status of midwives in our health care
system.
A discussion of boundaries is critical to understanding the concept of
marginalization. Boundaries reinforce distinctions and differences between groups.
With respect to marginalized groups, boundaries may fluctuate within the
marginalized group as some members choose to situate themselves closer or further
away from the dominant group in order to be accepted or to defend their own
52


particular identity. This movement of members from within a marginalized group
towards the central dominant group has to do with how stable power is, or appears to
be at the center, and how unstable and contested voices are at the periphery (Meleis &
Im, 2001; Vasas, 2005). Symbolic language is created at the center that becomes the
discourse of power, used to marginalize groups that may be a threat to the center, a
concept that is elaborated upon at some length in this paper. Individuals within
marginalized groups often know and understand the language of their oppressors and
use similar symbols and language to maintain their status or sense of power (Foley &
Faircloth, 2003; Meleis & Im, 1999). For example, one study investigated the ways in
which the marginalized profession of midwives represented themselves to the public
and found that this was dependent on the particular audience they addressed (Foley,
2005). In social gatherings, direct-entry midwives tried to minimize similarities
between themselves and nurse midwives, but in formal presentations, they often tried
to talk about midwifery care compared to obstetrical care, without any emphasis on
the differences between types of midwives. (Foley, 2005). Figure 3.1 illustrates
boundaries in dominant and marginalized groups.
53


Figure 3.1 A model to show boundaries between midwifery and obstetric models of
care
In the case of modem obstetrical medicine and midwifery, marginalization
occurs through the construction of knowledge, accepted epistemologies, and the
rationalization of professional and academic boundaries. The biomedical obstetrical
model has narrow, more rigid boundaries than the more expansive midwifery model,
thus it is represented by the primary boundary line articulating the inner circle in
Figure 3.1. The middle circle represents the midwifery model, bounded by the
secondary boundary lines in Figure 3.1. The marginalized elements, then, include the
constructs and concepts particular to midwifery care. The midwifery philosophy
maintains that the preservation of the physiologic process is critical to healthy
physical and psychological outcomes for women and infants. The goal is to keep the
mother and baby within the circle of safety. It is just the boundaries of the circle that
may be up for discussion (See Figure 3.2).
54


Figure 3.2 Circle of safety for mothers and babies
Some of the differences in boundaries between the obstetrical and midwifery
models have to do with the differences in philosophies, experiences, and training.
Midwives understand that the physiologic process of birth benefits mothers and
babies in many ways. They also believe in supporting and listening to women and
encouraging self-determination. The obstetrical model is based on the belief that birth
is pathological until it is over and prefers to control the process to ensure safe
outcomes. The obstetrical model views the emotional aspects of childbearing as
secondary in order to maintain control over physiology. Table 3.1 provides a
comparison of models (Davis-Floyd, 1992: 160-161).
55


Obstetrical Model Midwifery Model
Male perspective Female perspective, female centered
Woman is object Woman is subject
Cartesian mind body separation Mind body integration
Isolates uterus as working part Considers whole being
Physician is favored provider Midwife is favored provider
Fetus separate from mother/ maternal fetal conflict possible Mother and fetus connected, inseparable
Birth is means of production Birth is physical, emotional, spiritual transformational experience
Encourages multiple tests, procedures Encourages maternal intuition, decision-making regarding testing, procedures
High intervention model Low intervention model
Diagnosis of normal exists following the birth. Assumes pathological process Birth is inherently normal
Complications and emergencies are unpredictable, unpreventable Most complications and emergencies are predictable and preventable
Decreased locus of control for woman Increased locus of control for woman
Drugs to medicate mothers to decrease the pain Intolerance of pain Increase in use of technology Easier for caretakers Minimal use of drugs Acceptance that birth is intense Acceptance of pain Avoid technology unless needed Labor intensive for caretakers
Drugs to augment labor Desire to have more control over labor Allow normal labor progress Avoid unnecessary intervention Provide labor support
Women encouraged to give birth in the bed with feet in stirrups, lower part of bed removed Women encouraged to give birth in a variety of positions
Higher rates of forceps, vacuum extractions, cesarean births, episiotomies and vaginal lacerations Lower rates of surgical births, episiotomies, vaginal lacerations
Separate mothers and babies Breastfeeding, offer bottles if convenient Mothers and babies are kept together, breastfeeding encouraged
Table 3.1 A comparison of obstetrical and midwifery models of care
Obviously, there are notable differences in the values of each group, thus
different boundaries exist and conflicts arise between the two groups. Habermas
56


believes that if boundaries are to be created rationally, there needs to be dialogue
between stakeholders to resolve conflicts (Habermas, 1976, 1984a, 1984b). However,
if there are disparities in power between the two stakeholders, as in the case of
obstetricians and midwives, there will be a distortion in rationalization of boundaries,
which becomes problematic. It is difficult to have full dialogue when power
disparities exist. As a possible solution to Habermass utopian perspective, Ulrich
suggests that the best way to explore and justify boundaries between stakeholders is
through dialogue and the development of a critical and systemic assessment of
assumptions and boundaries (Ulrich, 1983). Ulrich maintains that true rational inquiry
is critical if all assumptions can be questioned and it is systemic if boundaries are
established (Ulrich, 1983). Critical thinking without boundaries may end up with the
unfettered expansion of ideas and the loss of meaning. Systemic and inflexible
thinking without questioning may end up with a hardening of boundaries where
potentially destructive assumptions remain unquestioned because of rigid boundaries
(Midgley et al., 1998). Joni Mitchell, a social activist from the music industry,
describes borderlines as a barbed wire fencestrung tight, strung tense, prickling
with pretense. She refers to those who are smoking [their] jaded expertise and
others whose convictions grow below the borderline. She says that all liberty is
laced with borderlines (Mitchell, 1994). She is referring to the conflicts that arise
when two groups of people have different ethics or values that relate to the same
issue, thereby setting different boundaries. If one group makes narrow boundary
57


judgment determinations around the issue, as in the case of obstetrical management
and stricter control of the process of pregnancy and birth, and the other group makes
the boundary judgment wider, as in the case of midwifery management of pregnancy
and birth, there will be a marginal area between the two boundaries containing
elements excluded by the first group but included by the second group. What happens
to the elements of care in this marginalized space becomes critical to the outcome of
the conflict. Either option could be potentially disastrous for mothers and babies,
whether it is a lack of or too rigid boundaries. Full discourse using evidence-based
research ought to be the solution, bringing providers, insurance carriers,
policymakers, and others into the discussion.
Douglas writes about a sacred or profane status imposed on marginalized
elements (Douglas, 1966). If considered profane, the primary boundary and its
associated ethic are reinforced and becomes the main reference for decision making.
Those ideas or people on the margins are disparaged and the secondary boundaries
are ignored. When a marginal element is considered sacred, the secondary boundary
is reinforced and becomes accepted. In many cases, social ritual and popular opinion
driven by market and political forces decide the sacred and profane. This can be seen
in the results of a study of nearly two thousand women in the northeast part of the US
in 2002 (Declercq, Sakala, Corry, Applebaum, & Risher, 2002). Researchers were
looking for the rate of intervention during labor and found that 100 percent of women
had interventions in labor, including electronic fetal monitoring, Foley catheters,
58


intravenous therapy, induction or augmentation of labor, epidural anesthesia, and
surgically assisted births. Ninety percent of women had physicians for their care and
ten percent of women had midwifery care. Most significantly, ninety five percent of
women were satisfied with their care (Declercq et al., 2002). It is clear from this study
that modern-day birth includes multiple interventions and invasive technologies that
reinforce boundaries and practices in obstetrics. Midwifery and its associated values
have been relocated within the rigid boundaries and political economy of modem
obstetrics at the expense of traditional midwifery ideals and better outcomes for
women and infants (Hyde & Roche-Reid, 2004). Much of this can be explained by
the way in which the allocation of power is determined through cultural myths and
symbols associated with childbirth in this country, regardless of lack of efficacy, a
concept that is developed in a later section.
Cost of Marginalization of Midwives in the US
Giving birth is big business in the US. Women are the major consumers of
health care in the US and childbirth is the main reason for this (James, 2000). Women
have almost three times as many health care visits as men. Womens health care
services account for over 65 percent of the nations annual medical bills and 67
percent of all hospital procedures. There are four million births in the US per year.
Nearly one third of those are cesarean births and approximately fifteen percent are
59


surgically assisted vaginal births. This places a large burden on the health care
system. Studies suggest that midwives have four to fifteen percent cesarean birth rates
and a much lower rate of overall intervention. Figure 3.3 shows recent estimates of
facility charges for births by site and method of delivery (Maternity Center
Association, 2005) (reprinted with permission from Maternity Center Association).
Graph estimates do not include charges for anesthesia, newborns, or maternity care
providers, which add to the total cost.
$15,519
hospital hospital hospital hospital birth center
cesarean cesarean vaginal vaginal vaginal
complications no complications complications no complications
Site and Method of Delivery
Figure 3.3 Facility charges by site and method of delivery, 2003
Further cost savings could be realized with an increase in the availability and
use of freestanding birth centers. Blue Cross/ Blue Shield reported that midwifery
care in a freestanding birth center was less than 40 percent of the cost of care in a
New York hospital (Rooks, 1997). It is easy to see how the industry of birth provides
60


an excellent illustration of the problems that exist within the political economy of the
current health care system in the United States.
Part of the problem lies within the power structure and hierarchy that typifies
biomedicine in this country. Unlike other countries in Western Europe, obstetricians
in the United States dominate womens reproductive health. This authority results in
the medicalization and institutionalization of birth and a certain dependency on
technology, frequent use of interventions, separation of mothers and their newborns
and a reliance on the relatively high cost biomedical model (Robbins, 1996; Strong,
2000). It appears that women expect and prefer biomedical attention during
pregnancy and birth (Declercq et al., 2002; Weisman, 1998). It would be difficult to
argue which belief appeared earliestpopular opinion or biomedical dominance over
certain physiologic reproductive functions. Nonetheless, the professionalization of
midwifery has been affected by negative historical portraits of midwives as women
who were seen as uneducated, unsupervised, unethical individuals who refused to
comply with current knowledge and medical convention, and were felt to be
dangerous for women and newborns (Loudon, 1992; Starr, 1982). Yet the truth is that
the marginalization of midwives comes at a cost too high, as witnessed with
increasing morbidities and mortalities associated with rising cesarean section and low
birth weight rates in this country. The midwifery model of care suggests an
alternative that not only improves the health of mothers and infants, but also makes
61


economic sense. For many reasons, midwifery care should be promoted, not
marginalized.
62


CHAPTER 4
RESEARCH DESIGN AND METHODS
A Qualitative Case Study Analysis
This study seeks information to perform a critical analysis about the factors
that contribute to the professional marginalization of midwives in the United States in
an effort to improve access to quality health care for underserved populations, to
illustrate problems within the political economy of our health care system and to
make some specific suggestions for improvement. Specifically, this study attempts to
answer the larger question through the investigation of the recent closure of one and
changes within another long-standing midwifery service in a major city in the US.
Qualitative research methods using a case study approach is the overall study design.
There are many ways to think about qualitative research methodologies.
Creswell has divided qualitative inquiry into five different traditions: biography,
ethnography, phenomenology, grounded theory, and case study (Creswell, 1998).
Others do not think of case studies as a methodology, but rather a choice of what is to
be studied, i.e. the case(Patton, 2002). The case study approach is more a specific
way of collecting, organizing and analyzing data. The researcher gathers
63


comprehensive, systematic and in-depth information about each case. The analysis of
this data results in a product, called the case study. Case studies are the actual process
of analysis, the product of the analysis of the data or both (Patton, 2002). The unit of
analysis, being the case, is what drives case study analysis. This research project
lends itself perfectly to a case study design because it addresses the recent changes
within two specific midwifery services that have resulted in practice closure or
significant changes. Each service has a particularly important historical context or
story and represents two of the oldest and most prestigious midwifery services in the
country. Their recent failures carry significant implications for other practices in this
country because if these changes could happen to these influential and leading
midwifery services, then they could happen to any service. The University-Based
Midwifery Service, using a biomedical approach of midwifery care, is owned by one
of the largest hospitals in this large city and the University, which houses one of the
oldest, prestigious, and prominent midwifery educational institutions in the nation.
The Birth Center is descendent from a group that has historically advocated for
mothers and babies in the US and housed one of the first and most influential
freestanding birth centers in the US, relying on a traditional midwifery model of care.
If these services could fail, others could follow suit. The problems identified through
a case study comparison have the potential to be useful to other midwifery services as
well as to health care policymakers.
64


Holistic and context sensitive strategies are critical to case study approaches.
Maintaining a holistic perspective allows the researcher to think in new ways about
relationships between parts of the system and the whole system and the
interdependence experienced in dynamic systems (Patton, 2002). The marginalization
of midwives is best understood when midwives are viewed as a part of a complex
health care system, more than just the sum of its parts. Complex interdependencies
and system dynamics exist that cannot be meaningfully reduced to a few discrete
variables and linear, cause-effect relationships. It is important for the purposes of this
study for the researcher to understand and get a feeling for the gestalt of the whole
system to appreciate the particular changes within each specific midwifery practice.
For this reason, the project is a multi-sited research method to assemble a
comprehensive and complete picture of the social dynamic that is occurring to explain
the phenomenon under study (Marcus, 1995).
Context sensitivity is another critical strategy to be included in a case study
analysis. It places the question, problem and findings in the appropriate historical,
social and temporal context (Patton, 2002). Context sensitivity emphasizes a careful
comparative case analysis and is careful with generalizations about a topic. In this
way, one may be able to extrapolate patterns, transfer ideas, or think about possible
adaptation to new settings. The historical, social and temporal contexts found within
the question of the professional marginalization of midwifery in the beginning of the
twenty-first century are indeed critical to this research, as indicated in the literature
65


review. The particular histories of each of the cases will be important to review as
well as the overall histories of midwifery in the US.
Unit of Analysis
Stake defines the unit of analysis for qualitative research as a specific unique
bounded system (Stake, 2000). As previously stated, the unit of analysis for this
research project was the examination of two cases that led to significant changes to
midwifery services in a major US city. The selection of these services will be
discussed in greater detail below.
Sampling Methods
Case study approaches necessitate purposeful sampling methods. It is critical
that the researcher select cases strategically and intentionally. There are various
purposeful sampling strategies that one might employ. For this particular study
critical case sampling methods are used to make sure that the cases chosen are those
that most dramatically make a point (Patton, 2002). With critical case sampling, one
might be able to apply the information obtained to other cases because of the relevant
importance of each case to the whole phenomenon under study. If one might say, If
it happens to them, it could happen to anyone, or If that group is having problems,
66


then we can be sure that all groups are having similar problems, then critical case
sampling methods are appropriate. For different reasons, the cases chosen are very
important to the past, present, and particularly the future of midwifery in the US.
At each site the researcher located and sent an introductory letter to the
affected midwives from each service using the ACNM directory. In addition, similar
letters were sent to the consultant obstetricians, administrators, and support staff for
interviews. Letters were also sent to individuals involved in setting local, regional,
and national health care policy. (See Appendices A and B). A review of each of the
cases selected is presented with the actual case analysis to avoid repetition. Each
practice provided its community with a unique and important service based on
midwifery principles and was successful until recently. The changes reflected at the
University-Based Midwifery Service ought to be of concern to the whole profession,
given the longevity, prestige and influence of this service. It means that University
lost their main site for midwifery students as well, which has serious implications for
other midwifery education programs in this country. The case of the Birth Center is
critical because it represents the oldest birth center model in the US and had been
successful for approximately thirty years. If this practice could close, it may well
influence the closure of services that are similar. The success of a birth center model
is crucial to the profession of midwifery. It is incumbent upon this researcher to
uncover the reasons for their demise. The disposition of both services has broad
implications for the profession of midwifery as well.
67


Data Collection Procedures
Data collection included conducting in-depth, open-ended, informal
interviews using a tape recorder and taking detailed field notes. Interviews were
obtained from midwives, physicians, administrators, staff, doulas, liability insurance
providers, lobbyists, and members of professional organizations to create a holistic
and context sensitive picture for analysis. Interviews were conducted until the point
of saturation for each case until I was certain that I would not be able to collect any
new information because I kept hearing the same story over and over or was told that
I would not have access to certain potential respondents or information. Since the
researcher has been a midwife for over twenty years, observation played an important
role in data collection procedures. Each service has received considerable press
attention, thus all documents pertaining to the service and its respective changes were
sought out and utilized in the process of data collection. This included any email
correspondence leading to the changes. Triangulation of data was accomplished using
multi-sited interviews and secondary data.
This project involved several time intensive trips to this major city in the US
to collect data. Fifty two interviews were obtained. The researcher stayed for
approximately ten days per visit and collected as many as four to five interviews per
day in a public setting satisfactory to the participant. Each participant was asked to
read and sign an informed consent and human subjects concerns were respectfully
68


considered at all times (See Appendix D). Interviews were listened to several times
and transcribed verbatim by the researcher. I presented myself as a doctoral student
from the University of Colorado at Denver in the Health and Behavioral Sciences
Department. I explained that my dissertation topic was to investigate the reasons for
the changes within these two midwifery services. In the end, I also identified myself
as a midwife since most people were curious about my background.
These data collection procedures represent fieldwork that is organized around
a nested or layered approach that is typical of a case study (Patton, 2002). In this
study, two case studies were ultimately compared and contrasted. But imbedded
within each case, are the multiple case studies of the participants described above.
Figure 4.1 shows the nested or layered case study approach that was utilized for this
study.
Figure 4.1 Nested layers embedded in case study analysis
69


Data Collection Instruments
In general, data collection instruments consisted of open-ended interviews
where participants were asked to talk openly about their experiences with the
particular service and the topic in general, with an emphasis on the changes that
recently occurred within the service, regardless of the participants respective
profession. The interviewer had a question guide available if necessary, but only
referred to it if the individual being interviewed was having difficulty talking about
the issues. When talking to politicians, issues around public policy were focused on
as opposed to some of the other issues. See Appendix E for question guide details.
Data Analysis
This research project utilized an inductive method of data analysis. Inductive
research is considered theory building, allowing the researcher to examine a specific
case in order to learn more about other cases. The researcher uses cases to consider
the implications and importance of the bigger question (Strauss & Corbin, 1998).
Specific cases offer properties and information about the size, scope, and magnitude
of the problem that allows the researcher to move from description to
conceptualization and from the specific to the more general or abstract (Strauss &
Corbin, 1998). In this case, the researcher used a computer assisted manual process of
70


constant comparison of data to begin to understand the phenomenon being
investigated. The method of constant comparison of data encourages the immediate
application of findings, where data collection and analysis occur simultaneously. The
method of constant comparison serves to promote an open-minded investigation and
avoids staying within the limits of existing knowledge or personal experience. Codes
emerge directly from the text without the use of any pre-established codes. In this
way, the researcher is able to avoid preconceived ideas about the issues, since the
themes appear inductively. As text is read and re-read, meaning units are found and
codes are assigned to each meaning unit. Codes are compared, rearranged and
grouped together to form broader categories of codes and to allow themes to emerge.
An attempt to use literal coding is used in order to stay as close to the participants
words as possible. However, as the process of constant comparison unfolds,
descriptive or interpretive codes are also utilized, where the researcher attempts to
capture the meaning of the participants words.
Data analysis was done concurrently as data was collected. This assisted the
investigator in data collection. The analysis of the data began with an analysis of each
of the individual case studies, that is, with an analysis of each of the individual
interviews. This process began with the transcription of interviews, repeatedly
listening to audiotapes and re-reading transcribed interviews, extracting themes and
correlating quotes for each individual interview. Following the coding by hand of
each interview, tables were constructed in Microsoft Word that allowed the
71


investigator to arrange data and quotes by source, code, actual text and investigators
comments (See Table 4.1).
Source Code Text Comments
Table 4.1 Table format used to organize text by codes
Initial tables were constructed for the two individual cases and a third one for
the secondary data set. Then a within-case pattern analysis developed from each
individual interview to provide the data for the larger case, which then provided the
data for the next layer. For example, in the case of the Birth Center, the interviews for
each midwife were transcribed and analyzed and then compared and contrasted with
the other interviews obtained from other midwives. This was done for interviews
obtained with physicians, administrators, staff, etc. Then, all of the interviews from
each of the groups was compared and contrasted to provide the case study for the
Birth Center. The University-Based Midwifery Service was handled in the same
manner.
Finally, a cross-case pattern analysis was utilized to compare and contrast
each of the cases to provide the final case study report addressing the themes that
arose from this research project that were factors contributing to the marginalization
of midwives in these services. Tables were again constructed using Microsoft Word
to organize data by source, code, actual text, and investigator comments into the more
general topics and themes relating to market, state, and cultural influences that shape
72


the marginalization of midwives. The results of the analysis follow after looking at
profiles of participants. Please refer to Appendix F for a list of axial codes, and within
and cross case analyses.
Rigor. Credibility and Generalizabilitv of the Study
Case study approaches often have an internal form of rigor built into the study
design, particularly if the data is collected in a multi-sited manner, as in the case of
this study, since it provides rival explanations for the problem (Yin, 1999).
Triangulation and multi-sited interview methods using different data collection
methods, such as interviews, newspaper stories and participant observation as well as
the utilization of different sources also provide credibility for the study (Patton,
2002). In addition, triangulation of qualitative methods was accomplished through
constant comparison of data, within case, and cross pattern case analyses.
Stake reminds us that case studies contribute to the social construction of
knowledge that builds general but not necessarily generalizable knowledge (Stake,
2000). He contends that naturalistic cases often parallel actual experiences and that
the reader will understand things as if they had the experience or they might
recognize the experience as similar to one they have had, thus, again, increasing
knowledge. As was already noted in an earlier discussion, these two cases could not
be more different from one another. Yet the analysis led the researcher to very similar
73


conclusions regarding the political economy that shapes the professional
marginalization of midwifery. Thus, I contend that a close examination of these two
critical cases is indeed helpful to the overall analysis of the problem.
Research Participants
In this section, information will be provided regarding research participants
and secondary data obtained for this analysis. See Table 4.2.
CNM MD Admin RN CBE Educator AC NM Policy maker Insurance
Birth Center (34) 9 2 7 4 2 3 3 2 2
University Midwives (24) 9 2 3 0 0 3 3 2 2
Table 4.2 Type of participant per case
I did not have any convenient contacts that gave me an easy introduction into
the University-Based Hospital. I sent out introductory letters with stamped self
addressed cards for easy replies to all the midwives, department of obstetrics, and
administrators associated with this service (See Appendix A). The midwives names
were obtained from the ACNM service directory. A few were returned to sender with
wrong addresses. I also sent email inquiries out to the same midwives since their
email addresses are included in the service directory. Initially, I received tentative
74


responses from six out of approximately thirty five midwives (See Appendix B). One
midwife informed me that there was nothing wrong with the midwifery service at the
University-Based Hospital and she did not understand why I was conducting this
study. Persistence prevailed and I was able to obtain three additional midwife
interviews. The Dean of the School of Nursing initially said she would be available
by phone and then declined even a phone interview, stating she was too busy. The
chair of the Obstetric Department at the Universitys School of Medicine declined to
participate as well, wishing me luck with my project. The chair of obstetrics at the
Community Hospital did not respond to multiple queries as well. The Senior Vice
President at the Hospital in charge of women and childrens services never responded
after several attempts to reach her, as was the case for the person in charge of public
relations. I was able to find several public statements issued by all of these
individuals and used them in the analysis of the secondary data. The University-
Based Hospital system was difficult to penetrate. What I did find out explains why it
was so difficult.
Of the eighteen individuals interviewed within the University-Based Hospital
system, the average age was 48, with a range of ages between 36 and 76 years old.
There were two males and fifteen females interviewed. This group of individuals was
highly educated, with three who were doctorally prepared and three others who were
working towards this advanced degree. The rest were Masters prepared. The salary
range was between $41,000- >$100,000, with a mode in the range of $71,000-80,000
75


per year. Professional experience was also extensive in this group, ranging between
eight to fifty years, including clinicians, administrators, educators, researchers, and
people who had extensive experience working internationally.
In 2003,1 attended a special lecture with a well-known anthropologist from a
prestigious university in the city where these cases were located. This lecture was part
of the Distinguished Anthropologists Series at the University of Colorado at Boulder.
During an opportunity to speak with her, I told her about my dissertation research
project and she suggested I contact a student of hers. This was a young woman who
sat on the board of a non-profit organization that quickly formed with the demise of
the Birth Center in an effort to create a new freestanding birth center in this large city.
I connected via email with this woman and she assisted me in sending introductory
letters to the staff of the birth center. Within days of sending this letter out, I was
inundated with responses from people who were willing and excited about
participating in this study. Due to scheduling difficulties, time restraints, and personal
matters (such as child care issues and transportation), I was not able to interview all
of those who agreed to participate in my study. Using a snowball sampling method, I
was able to find out names and contact information for board members, physicians,
and administrators from some of the people I interviewed initially and from the
World Wide Web. Several of the people from the hospital that owned the birth center
to whom I sent letters of inquiry, emails, and phone calls did not respond to any of
my queries. This included a few board members, insurance agents, and individuals in
76


the public relations department for the hospital. The head of the Obstetrics
Department did respond by returning the card I included in the original letter I sent
out. The return response only said that he refused to participate in my study. In the
end, I collected interviews from twenty seven participants: nine midwives, four
nurses, two physicians, two childbirth educators, seven administrators or board
members, and three educators. All but two participants were female. Ages ranged
between 32 and 80 years old, with an average age of 46 years old. Twenty out of 24
participants held a Masters degree, three were doctorally prepared and one had a
Bachelors degree. Salaries ranged between $31,000-40,000 up to over $100,000 per
year, with a mean and mode of salaries falling between $61,000-70,000 per year.
Essentially all interviewed had extensive clinical or professional experience, ranging
between five and fifty years, with an average of seventeen years of professional
experience per person.
Finally, I interviewed two people involved in policymaking, two liability
insurance providers, and three individuals who were part of a professional
organization.
Limitations
There were many limitations associated with this study. Since the two
midwifery services were closed in the summer of 2003, it was somewhat difficult to
77


locate participants to interview. In addition, a significant amount of time had elapsed
since the two practice closures, thus memories of what happened may have faded or
changed over time. Some participants were not willing to candidly discuss what
happened.
The most significant limitation in this study has to do with the fact that some
crucial voices are missing because they refused to participate in the study.
Specifically, the voices of the Hospital and Obstetrics Department associated with the
hospital from the University-Based Midwifery Service and some hospital
administrators and obstetricians from the hospital associated with the Birth Center are
conspicuously absent.
Nader (1972) encourages anthropologists to study up. There is a certain
urgency, she suggests, to understand those in power because of the ways in which
they shape and control our lives. However, the author also acknowledges the
difficulties one encounters when studying up with respect to access, attitudes,
ethics, and methodology (Nader, 1972). My experiences reflected the difficulties with
respect to access. The powerful do not want to be studied, Nader says. It is dangerous
and even precarious to be powerful and one must be cautious with what one says.
They must control information, maintain a certain secrecy. And they are conveniently
very busy (Nader, 1972). The absence of these critical voices is troublesome and does
not allow me to present a completely balanced case analysis for either of the cases. I
did do a thorough investigation of the secondary data in order to be able to report
78


what they were saying to the media and elsewhere, but I was unable to speak directly
with some potentially important sources. Their silence speaks volumes. But it is
difficult to objectively analyze silence and their absence remains a definite weakness
of my study. I worried that I was not persistent enough in trying to encourage them to
participate. One researcher aptly notes:
Some field workers identify so completely with the underdog that they are
unable to make effective contacts with those on the top level of the social [or
political] hierarchy (Powdermaker, 1966: 291).
Since I am a midwife, I worried that I might not have been persistent enough in my
queries, even though I sent two letters with stamped addressed cards for return,
multiple phone calls and emails. Living in Colorado and not anywhere near this large
city was a further limitation, since it meant I was not there to be as persistent and
available as I would have liked.
Clearly, investigation of only two cases out of the many practice closures does
not provide the researcher with substantial information about what is happening in a
general sense. However, for the purposes of this study, it is not practical to investigate
additional sites. In addition, it would be useful to compare these cases to similar
services that remain in practice to more fully understand the process. However, any
service could be functioning one day and be told it was going to close the next day.
This has something to do with the fragility and political nature of midwifery.
79


Preliminary Study
A preliminary study was conducted, the intent of which was to carry out
personal qualitative interviews with individual midwives to determine if they have
had personal experiences with professional marginalization. These preliminary
interviews served to inform the larger study which investigated the changes within
two midwifery services in a large city in the US. The themes that emerged from these
in-depth interviews were used to develop a more comprehensive understanding of the
issue of professional marginalization of midwives in the United States. The personal
narratives of individual midwives ultimately helped to promote understanding of how
extensive and widespread the problem is.
The analysis of the qualitative interviews led to a division of the findings into
two main frameworks: (1) reflections about internal and personal experiences about
how each midwife coped with feelings of professional marginalization, and (2)
reflections about external forces that have influenced their experiences of professional
marginalization. In the development of the first theme, common ideas emerged that
focused on the various personal choices each midwife made to deal with work-related
stress and the sense of personal power or powerlessness they experienced. With the
emergence of the second theme, midwives talked about the relationships they had
with physicians, health care systems, nurses, and other midwives; nurse midwifery
80


education; practice styles and being marked by the health care system as a rogue
provider.
It is clear from the interviews conducted for the pilot study that midwives
perceive and experience extensive professional marginalization in this country which
has a serious impact on the ways in which they practice and even the locations where
they are allowed to practice. Given the plethora of evidence that suggests that
midwifery care is safer, more efficacious and more satisfying to women than
physician care, with outcomes that are far better, it is time, in the 21st century, for our
health care system to take a serious look at how midwives can be better utilized and
given more autonomy to practice. Mothers, babies and whole communities have
much to gain from these changes.
Reporting the Cases
It is my hope that the voices of those interviewed in this project will help
bring these issues to the fore. The following chapters provide in depth analysis of
what I was told by participants. Chapters five and six will report findings from each
individual case. Chapters eight through eleven will report findings from the cross case
analysis.
Secondary to issues of confidentiality and anonymity, I have chosen to use
pseudonyms for the actual cases and to purposefully omit identification of the voice
81


of the speaker in chapters five and six, where I present the individual cases. In
chapters eight through eleven, where I present the cross case analysis, I have
identified the speaker, with the exception of the section entitled Micropolitics, since
the potential for identification of the voice was greater. However, in these later
chapters, the voices are identified as from case one or case two, as opposed to from
Community Hospital or the Birth Center, in an effort to further protect identification
of my respondents. The reader will thus be able to have a sense that the cross case
analysis is constructed from both cases, even though they will not necessarily know
which case the speaker was from. In some instances, the voice will be someone who
had some history or involvement in both cases. These voices will be identified as
(voice 1,2) as opposed to (voice 1) or (voice 2).
82


CHAPTER 5
A GALA CELEBRATION OF FIFTY YEARS OF MIDWIFERY
The Emperor Has New Clothes
The University Midwifery Service. 1989-2003
May 4,2005 began the gala celebration of fifty years of midwifery at a
respected and esteemed university in a large city in the US. There was a special
unveiling for the premier of an exhibit of still photographs taken from the infamous
film produced in 1953, entitled All My Babies, which portrays the life of an African
American midwife and the midwife tradition that existed in the segregated South in
the first half of the twentieth century. This classic film was commissioned to be used
as a training film for other midwives in the South by the Georgia Public Health
Department. The Dean of the School of Nursing and the Dean of the School of Public
Health from the University unveiled the exhibition, with speeches in support of the
Universitys long-standing tradition of midwifery. The Dean of the School of
Nursing was quoted as saying:
83


Midwifery practices provided a vital safety net when segregation and poverty
made access to medical and hospital care impossible for women of color.
Legendary midwives across the South were known in their communities for
their compassionate caring. And today, the compassion, caring and support
that midwives provide to women and their families during and after birth are
the reasons that so many women in this country continue to seek out their
services. [Our] School of Nursing has paved the way for professional nursing
since the turn of the century and continues to lead the field as the foremost
institution for advanced practice nursing (University School of Nursing,
2005).
The following day, several renowned guest speakers were engaged, including Helen
Varney Burst CNM, MSN, FACM, Professor Emeritus from Yale University, Kitty
Ernst CNM, MPH, Mary Breckenridge Chair of Midwifery at Frontier School of
Midwifery and Family Nursing, and Ruth Watson Lubic, CNM, EdD, FAAN,
FACNM, President and CEO, Family Health and Birth Center speaking on Lessons
Learned: Modem Midwiferys History; and special guest Faye Wattleton, President
of the Center for the Advancement of Women. The focus of this multi-faceted event
was to celebrate the Universitys role in paving the way for midwifery in the US.
Fifty years ago, in 1955, the University began the first university-based midwifery
education program and allowed the first midwife attended birth in a hospital setting in
the US.
Ironically, the University continues to pave the way for midwifery in the 21st
century. Exactly two years prior to this gala celebration of midwifery, midwives
employed by the University and the hospital had been told that they could no longer
attend births at the Community Hospital owned and operated by both of those
84


institutions. There was no mention of this at the gala celebration of midwifery at
the University. Participants in my study responded to this celebration of midwifery:
Isn't it something! To celebrate midwifery, to claim some part in its
beginnings, to recognize its importance and then to have a hand in its
destructionall at once! To make it so women are unable to seek out the
services of midwives right here?
It is ironic, isn't it? I feel like going with a big sign that says, Are midwives
just history at [our University]? (Or words to that effect). But it's
complicated... This may be something that the midwives in the School of
Nursing worked very hard to get and represents some kind of support by the
Dean in the School of Public Health as well. So we can't just rush in and spoil
the party.
Hence the demise of midwifery at its own institution went quietly unnoticed at its
fifty year gala politically correct celebration. The bigger and more concerning
question is how much it will pave the way for midwifery in the 21st century, given its
recent history. Several respondents commented about this concern:
I mean you did go directly to the core of the problem because [this University]
had the first midwifery education program in a university setting, it had the
first nurse midwife in a hospital, and it was the first place to get rid of them,
totally. So you know everyone is going to be kind of watching. And I am sure
it influenced Roosevelt, Beth Israel, Johns Hopkins, Georgetown, Illinoisall
of those places [where midwifery services recently were closed down]. ... But
what is happening now with the leaders in the Ivy League, I think we are in
trouble and I dont know exactly what we should do.
In the context of how midwifery is being altered in this country by the forces
that be, the many forces that be, [this] is a very sad and important example. ...
We were the largest midwifery service on the [name] coast, maybe in the
country as far as I know. What happens here will matter elsewhere and soon.
It is worrisome.
85


I do think that what has happened at [this service] could happen somewhere
else because a huge academic institution with a very successful and
established service found a way to essentially do away with midwifery.
As one person said, All they have to do is say, Look at [the University-Based
Midwifery Service], it is working beautifully there; it being the ruin of
midwifery.
Some background information is helpful to understand the context in which
these events occurred. Actual names and locations have been omitted to protect the
identity of participants. A time line was constructed to portray the sequence of events
(see Figure 5.1).
86


history and events associated with the University based midwifery service