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Against the Licensing of Midwives A review and personal essay, copyright © by Jeannine
Parvati Baker. The following appeared in Nurturing
Magazine, issue Number 6. 
Having always allied myself with the "political" aspect of life (and here I prefer Webster’s first definition of politics, i.e., practical wisdom), midwifery’s movement to define itself from this perspective is fascinating to me. Like many of us, my first introduction to the politics of
midwifery came many years ago when I found myself pioneering
natural childbirth and freedom of choice as regards to place
and style of birthing in my own community. It didn’t
take long until the students became educators and members
of the helping professions themselves and lo and behold, we
had a community who initially defined itself as non-medical
servants of the birthing process. Whenever a group gathers,
a certain acceptance of the body politic that forms is most
useful. Ours was typically feminine in the sense that we followed
no Robert’s Rules of Conduct; adopted no patriarchal
persona in terms of goals, and steadfastly remained true to
the model of a support group, a friendship circle, rather
than a guerilla task force. And so it was with some chagrin that my next encounter with
the politics of organizational midwifery was such a challenging
experience. Here I am speaking about the California Association
of Midwives meetings where half of the time was earmarked
for education purposes and the other half labeled as political.
As if the two are, in essence, so different. The responses
to the education half of the meetings were overwhelmingly
positive. The feedback about the political half was quite
mixed to say the least. Take a group of self-proclaimed anarchistic feminists and
put on hierarchal mode of communication and just see what
is expressed! Confusion, anguish, frustration. Of all the
struggles people are undergoing to reclaim power of choice
over our own health, the midwifery movement must be true to
the feminine. And this means down to the very foundation of
our concepts and the structures which invariably issue forth
from within. As Star so lucidly expresses in A Birthing Renaissance,
the means is the ends. He makes a basic rhetoric for the feminine
in politics which carefully presents the issues all groups
must face but which is often overlooked in our need to define
and defend ourselves from the dominate health care industry.
This is the most eloquent statement against licensing standards,
and in essence, elitism, I’ve yet to read. Here I finally
understood my embarrassment at C. A. M. meetings when the
talk turned "political." And by reading Star’s
proposal for the Health Responsibility System, I gained clarification
for my intuitive reluctance to lobby and proselytize the midwife’s
position. Right at the beginning, Star designates the crisis at hand,
not only for midwives, but for all participants in the renaissance
of the individual’s freedom of choice. "Since the
means determine the ends, political structures must be designed
correctly in order to produce results consistent with goals."
From here, the author methodically guides us through our options:
1) Midwifery will develop enough support to fight for licensing,
based on monopoly. 2.) Midwives will develop an alternative regulatory system,
based on freedom of choice. The second path calls for a structure "based on a fundamental
shift of the state’s role from protection – through-
restriction to freedom – through education." (Page
2) As my basic philosophy recognizes the goal of educating myself
out of another profession (i.e. ideally my role as midwife
shall become obsolete once each and every birthing family
can do it themselves) the second alternative is consistent
with this. Midwives are more akin to educators than licensors.
It makes sense to organize in the mode we eventually want,
now, rather than adopt a style antithetical to this in order
to get what we want sometime in the future. "Licensing
destroys individual autonomy in health care by usurping the
power to heal, and completely substitutes professions and
institutions for our own abilities and responsibilities."
(Page 18) If our stated goal is for the parents’ acceptance of
their responsibility in terms of homebirth, how does a framed
license fit into this? "Licensing offers certain advantages as a tradeoff for
conformity to the principles and political structures of established
medicine. Previous health movements, which won licensing ultimately,
traded their identity and independence for the economic and
political advantages of licensing. Will this happen to midwifery?"
(Page 23) The benefits of licensing seem irresistible. The state approval would:
Tantalizing, eh? Star refutes each of these showing us the pitfalls - the entrapment of state – funded schools, for example, inherently/necessarily will serve the dominant set of values. But beneath this, a larger concern finds me, and that is the issue of whether or not being legal means being like doctors. I’ve observed this phenomenon in the feminist movement – a "phase" where being equal to men meant, for many sisters, being LIKE men. We all understand how "midwives" and "doctors" are complementary roles. One of the reasons most midwives never saw the need for malpractice insurance, for just one example, was that we don’t come to parents like Gods. We make it clear that there are no guarantees in birth and need no piece of paper on the wall to prove or assume any more than a partnership with the parents in the birthing process. The images of two Gods are germane at this point. As in all
good stories, the mythic backdrop is what moves it onward.
Let us invoke the great twins Apollo and Artemis. The firstborn,
Artemis, immediately upon birth, turned around and delivered
her brother Apollo. He is noted as the God of Medicine among
many other things, she the Goddess of the Ecstatic Dance,
a virgin huntress. Yet, she was the first midwife and is reported
to also be the first herbalist who would attend human and
animal mothers during birth and speak to them in their own
tongue. A group of plants carry on her name, the "Artemisians"
of which mugwort is most often used by practicing midwives
even today. That the Greeks held the midwife and the doctor
in the image of twin gods says a lot to me. Again, the message
here is not to be like doctors and impress our parents with
state approval, but to be their twin, midwiving our brothers
into an enlightenment of the Health Responsibility System.
"If the means for regulating midwifery are similar to
the structure which regulates the medical professions, midwifery
will grow in established medicine’s image." (Page
40) AB 1896 will help define me as a lay, lay midwife. This somewhat
tickles the member of my psyche I’ve come to recognize
as "the outsider", but it does dangerous disservice
to tenets of midwifery as an art. In Star’s words, it
will "stifle its creativity due to: requirements for
a vague ‘collegial relationship’ with a doctor,
the exclusion of nonlicensed persons from midwifery, a bureaucratic
and centralized midwifery practice board, rigid protocols
and standards, endless rules and regs, excessive educational
and birth experience requirements, malpractice, and other
restrictive aspects of licensing." He says that the "loss
is actually a boon" if this bill is defeated. (Page 41) How? "Controls like these, whether they are called regulations,
standards, protocols or protections, work to limit parents’
freedom of choice to the current dominant viewpoint."
"…Fears of malpractice or license revocation could
lead a midwife to rearrange her actions to primarily protect
her own interests, and secondarily the rights of the family
she is assisting." (Page 42) "Physicians faced with
an abnormal situation often feel compelled to perform interventions
in order to protect their own interests… this process
is not intentional or even conscious; it is built into the
very fabric of the licensing structure. The means determine
the ends. Physicians cannot avoid it, nor shall we."
(Page 43) I will refer the reader to A Birthing Renaissance for the details for the proposed alternative to what I call masculine-based politic. The Health Responsibility System contains an intricate checks and balances system and answers every question I had about elitism, dominance, diversity, cooptation, rights in conflict, consumer advocates, community review, client feedback, voluntary certification, practitioner’s Audited Statistics and Informed Choice. It is perhaps the last two items, which I might mention briefly. For "statistics," the very concept and use/misuse of them is one of my favorite topics. Being a radical relativist, I view the abstraction of our experience into number as a possible dangerous game. Statistics are our most potent myth-builders and it has been shown that numbers can be manipulated to prove or disprove any theorem. What is crucial, if we as midwives opt to play the statistics game, is to always be alert to what vested interest collects the data and most importantly, what are the "objective" criteria? Just what do we deem, out to the complex subjective experience we call birthing, to single out as necessitating quantification? How many vaginal tears or post partum hemorrhages or…? Where is the categorical imperative to collect statistics for non-medical crisis or choices? (Crisis means "choice" in Greek.) Shall we also note how many of our mothers experience multiple orgasms during birth and/or see God as reflective of our midwifery expertise? We are quick to award merit to intact perineums as some sort of proof of competency, but how many of us acknowledge the importance of creating a climate which can best be described as a challenging, yet safe, psychic environment for a mother to know the birthing as a profound rite of passage? This is embarrassingly showing my prejudices, and yet, this
is exactly my point. All statistics are gathered according
to the dominant prejudice of "just what IS important
to watch out for" in birth. How do we objectify the most
subjective of all human experiences? The last comment I would
like to make is on the "Informed Choice" suggestion
in the book. I have already incorporated this into my practice
and urge all practicing midwives to consider the same. In
essence, we are asked to make clear with all our parents our
practice/philosophy, education/training (both formal and informal
and apprenticeships with referrals to our teachers), all birth
experiences (including prenatal care, births observed, babies
delivered, in three categories – as observer, i.e. Hands
OFF, as an apprentice, i.e. hands ON under supervision, and
as primary i.e. responsible for care), endorsements, services
and fee (prenatal care, labor and delivery, postpartum and
emergency equipment), backup (licensed practitioner, title
and phone, emergency transport, description, and phone), accountability/liability,
community review, role (client’s responsibility, midwife’s
expectations and client’s expectations of midwife, written
by client), practitioners Audited Statistics, documentation
of informed choice, community review, ending with the midwife’s
signature and the parent’s signature and date. It is a seduction of the mind to think acquiring legal status,
licensing, hierarchical definitions of expertise and the like,
will make us more secure in the practicing of our art/work.
For those of us for whom midwifery is the only source of livelihood,
the issue I’m about to present may be problematic for
you, for there is the complex of survival and identification
which having all one’s eggs in one basket, so to speak,
evokes. So, let me speak directly from my own experience and
what I’ve observed with some of my friends over many
years. I’ll approach the issues first as phenomenological,
i.e., at face value, and then proceed into a realm more invisible
to the eye, the world beneath the surface for which my formal
training as a psychologist serves me well. It is apparent to me that many of the mistakes in our practice come from "spreading oneself too thin." From going to one birth after another with little no time for rest and integration/refection of the previous experience. This is an aspect of the "heroic frontier midwife" as I like to call this character. Ten years ago, when there was no one doing homebirth preparation and primary care, I was also attracted to this image. Then once seniority is attained, which is an entrapment of the ego to which I’ll address myself in a few minutes, the pitfall is thinking that since we’ve had the most experience, we really are the best person to attend births in our community. And so, we accept many more births than we can actually bring our full, calm, healthy and clear self to each time. My midwife friends have more regrets and lessons around this issue of exhaustion than any other– jut like the overworked obstetricians do. Now, as rules just focus the energy, I adopted on early in my calling which works well for me. One rule is not to accept more than one birth per moth. This eliminates the likelihood of women laboring simultaneously. It is obvious that I do other things to support my three daughters and self, which all complement the practice of midwifery. I teach natural childbirth classes, pre-natal yoga, and conscious conception/fertility awareness workshops. In this way I see the parents in a variety of settings and get to know them in addition to our prenatal/postpartum caring sessions. Again I see my role as a midwife mainly as educator. My operant goal is to have the parents feel as if they could birth their baby all by themselves. And I pray that in a generation or two I will be out of a job! Now to focus on the issue of number of births as a criteria for status, which most honestly is, and not necessarily as a sign of expertise. Once we’ve done our 100 births or whatever the dominant value system has deemed the magic number, there becomes a collusion amongst the in-group to maintain this dominance. It smacks of primate, patriarchal, linear consciousness! Monkey minds must’ve thought this up. The QUALITY of one’s experience in birthing is what is vital, not mere the quantity. And who can judge this? Which leads me to main point– only each and every midwife, for herself, can truly know when she can assume primary care responsibility. It comes at different moments in all our paths. I’m not meaning to discount the power of the peer group acceptance. The support of our sister midwives is a blessing. But, all good midwives need to look within to really know whether they are able and willing to be accountable in this role and be clear about their own standards of practice. The standards hopefully undergo refinements as we travel our paths as midwives. Let us be careful not to impose our standard and the underlying systems of belief upon one another. The best we can do is to live our own standards as purely as we can and let our example shine and teach sister-midwives. So I propose we accept the absurdity of our apprentice midwife,
freshwomen – midwife, junior – midwife, senior –
midwife grading system in good humour and place it within
a perspective of "hazing." This is a popular sorority
we are in. However communities choose midwives, other midwives
don’t. There’s a calling which every woman answers
from within, that, if she is true to her Self, is also manifested
in the world and the birthing community creates her position
in midwifery. Let’s not forget this in the drama of our
clique. It’s a powerful club, no doubt, and yet a trick
for the heroic ego to feel as if we are better than any other
sister. I intuit that Star’s Health Responsibility System
gives back the power to the parents and will be the greatest
service for our spiritual unfolding as practicing midwives. * This article retyped by Jill McDanal |
