Midwifery; a David and Goliath Tale

The story of midwifery in America is a classic power struggle for women’s rights, respect and choice; a tale of the clash of women’s culture and values with the male dominated spheres of science, medicine and finance. It is an ugly story laced with racism and class war fare. This struggle continues to walk the halls of political power and sits in insurance industry board rooms today.
It began as the eighteenth century was drawing to a close and the science of medicine was on the rise. Men for the first time began to move deeply into the privacy of the birth room, a place that in most cultures around the world is traditionally populated almost exclusively by women. This slow and determined encroachment into what had previously always been a woman’s world began the battle.

Before men became involved American midwives had always held a place of respect within their communities. Their skill at helping women during the birth process was of vital importance to all in the community. Women were encouraged to stay mobile as long as possible during the birth, the pain of the process was recognized but not believed to be insurmountable, the passage of time was noted but there were no standardized graphs labors had to abide by, and women utilized up-right physiologically sound positions for pushing a baby out.


When male doctors took over this all changed. Pain relieving drugs were used as an inducement to have doctors attend women’s births. These medications changed the balance of power forever; stripping the woman’s innate abilities. She became an object to practice medicine upon; someone who needed her baby delivered to her like a pizza instead of using her own physical power to bring her baby forth. Soon untested scientific “theories” blended with necessities created by using pain medications and women were routinely being cut and babies were being pulled out with forceps.

As the prestige of the medical profession rose, so did their power. In the end it came down to dollars and cents. In order to corner the market doctors began a campaign to stamp out midwifery. First they created a belief that birth was a medical event which could only be safe if attended by a physician. Doctors traveled in the upper circles of society. They convinced bankers, lawyers and other prominent society men to avail themselves of the best that the science of modern medicine could offer for their wives by using a physician. Men controlled the medical schools and women were not allowed to attend so female care providers slowly began to die out. In the early twentieth century not satisfied yet, they convinced the government to begin a propaganda campaign slandering midwives as dirty, illiterate, and ignorant. Eventually only poor women or newly arrived immigrants were still turning to midwives for care.


Meanwhile another huge shift in health care in our country was taking place. Hospitals were on the rise, with their bureaucracies, standardizations, schedules and sanitization of birth. Women were told it was best when labor began to leave their homes, where they had some control, and travel to a hospital, where they had no control. Hospitals lead to the immediate separation of the newborn from its mother and scheduled feedings. These disruptions in the process along with the drugs created babies who could not suck effectively, needing to be force fed from bottles. Soon the women of America thought their bodies were so defective they couldn’t even breastfeed their own children. Meanwhile the practice of midwifery was outlawed in most states.


But it’s hard to hold good women down. It is hard to stop women from answering the call to serve women; especially women in need. In the 1920’s nurses began to step forward to get additional training in the skills required to help low income women, the rural and urban poor. These were women who couldn’t pay doctors and hospitals, therefore providing them care did not threaten the medical establishment’s monopoly. They eventually founded specialized nurse midwifery schools and associations. From this branch was born the certified nurse midwife. In the 1960’s couples living on communes had turned their backs on many forms of the “establishment”. These female rebels began to birth their babies at home with the help of other women in their communities. The daring women who answered this call eventually became highly trained homebirth midwives. It took courage to be a midwife, to practice midwifery without a license. Not only could you lose everything, your home and your practice, you could be thrown in jail. In our county one traditional midwife was brought up on charges and convicted in 1982. Over time this branch of midwifery also adopted standards for training, created associations and worked hard to become legal once again. In California the legal battle culminated in 1993 in the creation of a system to license out of hospital midwives but it took 4 more years for the first group of midwives to be licensed by the state medical board.


All midwives are still fighting for the right to work as autonomous, respected members of the birth provider community. Whether they are CNMs who have made the choice to work in a doctor’s practice under his supervision because even if they could find a company willing to cover them medical malpractice insurance is prohibitive, or the LMs who can’t get insurance company’s to reimburse their clients for basic care the struggle continues. The California Medical Board is currently reviewing whether to change the language in the regulations governing LMs to allow them to order the life saving medications and tools they need to attend birthing women. And so the struggle continues.


This year on May 5th, the International Day of the Midwife, the women and their families who have been cared for so well for so many years by our community’s midwives will gather in Mission Plaza to honor 41 courageous, tireless, and caring professional women. The Birth & Baby Resource Network along with the co-sponsors of this year’s Birth & Baby Fair wish to invite you to join us at 10:30 for this historic event in the annuls of San Luis Obispo women’s rights.


Participate in BBRN’s on-line Midwifery Project at: www.bbrn.org.
Learn More about the History of Midwifery:
A Midwife’s Tale; Martha Ballard her Diary by Laurel Thatcher Ulrich
Motherwit; an Alabama Midwife’s Story by Onnie Lee Logan
Listen to Me Good; the Life Story of an Alabama Midwife by Margaret Charles Smith
Birth Matters; a Midwife’s Manifesta by Ina May Gaskin
A Short History of Midwifery: from Midwife Info an independent internet resource 
I am a Midwife, a movie trailer by the Midwives Alliance of North America
Fiction with Midwifery themes:
The Midwife's Apprentice by Karen Cushman
The Red Tent by Anita Diamant
Midwives by Chris Bohjalian

A Midwife's Story by Penny Armstrong and Sheryl Feldman

A Sign on a Door

“Because the Physicians at Aspen Women’s Center care about the quality of their patient’s deliveries and are very concerned about the welfare and health of your unborn child, we will not participate in a “Birth Contract”, a Doula Assisted, or Bradley Method delivery. For those patients who are interested in such methods, please notify the nurse so we may arrange transfer of your care.”

A photo of this sign has been posted on the internet and has created a stir in the pro-natural birth community. Wow! So here is a hospital being completely upfront with their beliefs: natural childbirth is less safe, laboring moms and dads do not have the right to make their own choices during the birth process regarding the safety of their babies, and they can not bring into the process any outside professionals who do believe in the safety of natural birth. As a doula I am both shocked and glad they are being this straight forward. Many hospitals and medical professionals share these same beliefs but they are not so open about it. The women in Aspen who take a tour of this facility before they make a choice about where to birth their babies can decide for themselves if the philosophy of birth expressed here is a good match for them. Luckily I was able to find one other hospital in the Provo Utah area where the Aspen Women’s Center is located so women do have a choice.

At the root of this sign are two men, Dr. Robert Bradley and Dr. Fernand Lamaze but to understand why a sign like this would end up hanging on a door in a maternity ward it is helpful to look at a little history. Perhaps one of the worst times for birthing women in this country occurred during the era when doctors stopped going to their patients and medicine became more centralized. Driven by the discovery of germs to be feared and a culture that was turning away from individualization and toward efficiency, hospital protocols turned birth from a family event into the business of birth. Culturally women were trained to acquiesce to male authority figures and so they passively allowed the process of birthing babies to be taken over, fathers were excluded, rigid hospital routines were followed and male doctors dominated the scene.

Then the Sixties arrived and with it the women’s movement, hippies and the protest era. Into this powerful mix walked Dr. Bradley and Dr. Lamaze to spearhead the “natural” birth movement here and abroad. Although their “methods” differed they both believed two things; the sensations of birth can be handled without pain medication and a husband’s help is vitally important to the process. Through their books and training of out of hospital birth educators they changed maternity care in this country by creating consumers, moms and dads, who demanded changes. Fathers went from being completely excluded and made to sit anxiously waiting in a separate room to being required to be an active participant at their child’s birth. Women showed doctors it was possible to experience labor without being rescued by pain medication; birthing in up right positions became possible and labor beds which convert into a variety of positions were adopted. Babies who weren’t drugged in labor could latch-on and nurse immediately after birth and did not need bottles and formula; La Leche League and the breastfeeding movement began. Now hospitals have lactation consultants on staff. Women who had not received medications and/or surgery could immediately begin to care for their infants and rooming-in became the norm; only infants who need special care go to our local nurseries now so they look like ghost towns. None of these changes were begun from within the system they came about through consumer demand on the system, although all along the way nurses, certified nurse midwives and a few doctors listened to their clients and ultimately were the ones to bring about change within the system.

Here are some of the changes I have seen in San Luis Obispo in the twenty years since I became a doula. When I was pregnant with my son there were two hospitals to choose from in San Luis; General Hospital which was known for being more pro-natural birth and Sierra Vista which had just gone through a dramatic physical renovation to create less “hospitally” looking rooms where a mom could stay throughout her time in the hospital. You had two choices of care providers who supported a natural birth, Dr. Lickness or the Certified Nurse Midwives working for Dr. Johnson and Dr. Richards. Kathleen Huggins had published her “Nursing Mother’s Companion” and begun the Breastfeeding Warm Line which dramatically increased our county’s breastfeeding rate. Did you want to try to birth vaginally after a cesarean? Talk to Dr. Clutter; eventually all the doctors in town would “allow” a woman to try for a V-BAC. At General Hospital the nurses worked hard to achieve the World Health Organizations “Baby Friendly” status and later with the help of the nurse midwives, Linda Seeley, Midday Johnson, and Lisa Winnick, and Dr. Spalding they began doing water births. At French hospital the nurses have worked with the anesthesiologists to find a level of medication which will give adequate pain control and leave the mom able to be more of an active participant during pushing. Sierra Vista increased the level of care they could provide seriously ill newborns so moms and babies can stay together in the county instead of being flown to bigger hospitals. Many beliefs about standard safety procedures have changed too, such as, when I had my son I was continuously on the baby heart monitor but now even the American College Of Obstetricians and Gynecologists agree that fifteen minutes out of every hour is adequate for picking up a baby who’s in trouble. Doulas became more common in the county and I personally felt more accepted as part of an over all team working to achieve the most positive births possible for my clients. Each of these changes and many others started small, one doctor saying yes or nurse saying I’ve never seen that done before but if it’s what you want. . .

None of these changes happened without push back from the established system. The stakes are high. The business of birth is big money. The fear of litigation is all too real. My birth class clients have had doctors throw their birth plans across the room. I sat in a doctor’s office and heard him tell my doula client that “natural” birth was all very well but it wasn’t optimal. Both our hospitals currently refuse to “allow” women to birth in water. Now because of space issues dads aren’t always able to stay with moms and babies after their births at our hospitals. I listened to a birth professional tell a group of women that Bradley classes teach women not to trust their care provider but I believe it is a birth educator’s responsibility to teach women to trust themselves and to trust birth and it is the care provider’s responsibility to foster a trusting relationship with their client. Sierra Vista asks doulas to sign a paper agreeing to do little else than bring ice chips and hold a woman’s hand. These days many women don’t want to actually feel birth, our society is too accustomed to medicating our pain away. Add to that our culture’s obsession with scheduling our lives and we get inductions and planned cesareans. Meanwhile our hospitals’ cesarean section rates are climbing as is our premature birth rate as too many babies are being “scheduled” to be born too early.

So this sign on a hospital’s maternity ward door doesn’t surprise me but it does sadden me to see that the things women and their partners, nurses, doctors and midwives have worked so hard to achieve in moving birth in our country toward a more humane, family centered experience grounded in the belief that women are created with the power in them to birth their babies is being eroded.

Jennifer Stover
Labor of Love Childbirth Preparation & Doula Services
www.slolaboroflovedoula.blogspot.com

Informed Consent

Recently I missed a birth. I am a doula. I help guide women and their partners during pregnancy, labor and birth. I had been hired by a woman pregnant with her second child to insure that this time she would be informed of any procedures or options by the nurses and doctors during her birth so that she could make her own choices. This time, she wanted to be listened to and respected during the birth process.

But this birth, as often happens, had its own story to write. Her labor came so fast and furious there was barely time to get to one of our local hospitals before the baby zoomed into the world. I was left “doula-ing” via speaker phone as I raced down the road. I heard the baby’s first cry as I exited the freeway in Templeton five minutes from the hospital.

When I walked into their room, Mom and Dad were ecstatic as the doctor quietly finished sewing a minor tear and moved on to another woman in labor down the hall. The baby looked great. Mom looked great. Then I noticed she had an I.V. of medication running into her. I asked my mom what it was. She said it was her saline lock. I said no you are hooked up to an I.V. of medication. We looked at the nurse who calmly told us it was Pitocin and that it was standard protocol at the hospital for all moms. I was shocked. My mom looked shocked. Where was the informed consent?

When did it become OK to administer a drug to someone without getting their permission? This was not an emergency when fast action has to be taken. This patient wasn’t unconscious, delirious or out of her head. She was simply having a baby. Actually she had just had her baby. She was elated, alert and aware. She was completely capable of rationally saying yes or no to a medication given as a routine at a hospital.

The nurse became concerned and offered to unhook her from the drug, but half the bag was already in her system so my client chose to allow it to finish. Would she have said yes or no if asked, “Do you want us to give you medicine that can stop any excess bleeding that might occur?” We will never know because she was never granted that right.

In a study done in 1969 Hershey and Bushkoff came to the conclusion informed consent means, “the patient has the right to know the nature of, the risks and benefits of, and the alternatives to a proposed treatment or procedure.” The United States Court of Appeals ruled in Canterbury v. Spence in 1972 that it is a fundamental concept in American jurisprudence that “every human being of adult years and sound mind has a right to determine what shall be done with his own body.” This right has been supported both federally and on a state level. Further, the American College of Obstetricians and Gynecologists first publicly acknowledged the pregnant patient’s right to informed consent in 1974. This was followed by the International Childbirth Education Association publishing “The Pregnant Patient’s Bill of Rights” in 1975. So how can it be that 35 years later birthing women, such as my client, are routinely given medications or have procedures performed on them without even telling them it is happening let alone giving actual informed consent?

Jennifer Stover
Labor of Love Birth Education and Support
jjmstover@sbcglobal.net

Women's Press Article: Birth & Baby Resource Network

There is an organization of tireless volunteers working in our community who, like those in many other “women’s” organizations, receive little recognition or fanfare as they strive to educate, support and empower young women starting families. What drives these women’s passion to reach out and share their wisdom about pregnancy, birth and early parenting? Why do they feel it is necessary to continue to struggle against the tide of our current culture?

In 1992 a group of women interested in becoming midwifery assistants and doulas met at a workshop. They shared a common goal: to make women’s birth experiences better, less medicalized and more woman-centered; more self-empowered. This meeting sparked an organization that has changed names, changed members, and changed locations over the years but has never changed its core beliefs that pregnancy and birth are normal, healthy processes that women are uniquely equipped to perform, and that women should have access to quality evidence-based care wherever they choose to birth; hospital, home or freestanding birth centers. They believe that an educated woman will make her own best choices for herself and her family and that these choices should not be made for her or taken away from her. This group is the Birth & Baby Resource Network or BBRN.

As in many other “women’s” groups, there is a coming and going of members as women try to balance the needs of their families, their lives, their work and their passions. It is always a blend of birth professionals, such as birth educators and doulas, and women young and old who were touched deeply by a birth experience and wish to reach out to others. Some had a beautiful, positive birth which touched them profoundly as women and mothers and they wish to help other women achieve the same. Some had births that left deep wounds on their female psyche from which they are still recovering and hope to spare other women. Some have never experienced giving birth but are drawn to the process as a calling; a deep, abiding woman-to-woman, sister-to-sister experience in our core.

As in many other areas of our female lives, these women are coming to see our current set of cultural beliefs about birth as being a fraud perpetrated on women by the male- dominated world of medicine and litigation. Women are drawn into the system by offers to take away their pain and promises of perceived safety. No one tells them about the risks inherent in the system or gives them an honest choice. No one really shares how empowering birth can be for a woman. This is a pivotal rite of passage for a woman and should not be directed by outside interests, such as the threat of a lawsuit, or someone else’s personal time schedule. Birth can’t be quantified, regulated, put on a timeline or boxed into someone else’s preconceived notion of how women should birth. Every woman is unique, and so are her births.

If you are interested in learning more about birth in our community or becoming a member of the Birth & Baby Resource Network visit them in Mission Plaza at their annual Birth & Baby Fair Saturday May 9 or on the BBRN website at www.bbrn.org.

Jennifer Stover
Birth Educator & Doula
Founding member & Current President of BBRN