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BIRTH AND THE DIVISION OF LABOR:
THE MOVEMENT TO PROFESSIONALIZE NURSE-MIDWIFERY, AND ITS
RELATIONSHIP TO THE MOVEMENT FOR HOME BIRTH AND LAY MIDWIFERY

A CASE STUDY OF VERMONT

by

Regi Teasley

Dissertation
In partial completion of
the requirements for the degree of Ph.D.
Michigan State University

1983

ABSTRACT
BIRTH AND THE DIVISION OF LABOR: THE MOVEMENT
TO PROFESSIONALIZE NURSE-MIDWIFERY AND ITS RELATIONSHIP

TO THE MOVEMENT FOR HOME BIRTH AND LAY MIDWIFERY.
A CASE STUDY OF VERMONT

By
Regi Teasley

This is a study of the changing social organization of
the work of birth attendance. I examine the process by which
a profession (obstetrics) emerged and achieved hegemony,
dominating an extensive division of labor. This relationship
was subsequently challenged by several social movements which
politicized birthing practices and critiqued physician hegemony.

This is a case study of Vermont; the primary source of
data is interviews with nurse-midwives, lay-midwives, physi-
cians and others. This material was supplemented by an
informal content analysis of state newspapers as well as an
extensive review of historical, sociological and medical
and nursing literature which enabled me to locate the processes
studied both historically and nationally.

Drawing on Larson's (1977) neo-Marxist analysis, I examined
the processes by which nurse-midwives attempted to profes-
sionalize within a highly articulated medical division of
labor.

This study focuses on conflicting claims to occupational

jurisdiction and the processes by which a client revolt (the

home birth movement) and client reform movements (in-hospital
birth reform) alter the work terrain, creating new opportuni-
ties for emerging occupations (lay-midwives and nurse-midwives)
and resulting in conflicts over the division of labor. It
also examines the process by which segments of the dominant
profession (colleague-centered physicians, especially obste-
tricians) resist or attempt to co—opt challenges to their
'monOpoly while other segments (client-centered physicians,
especially family practitioners) augment client revolts and
align themselves with emerging occupations.

I concluded that within the hospital, the institutional
matrix of the dominant profession, nurse-midwives have located
a market which is inherently subordinate.

Acceptance of this location in the medical division of
labor would assure that nurse-midwifery would never achieve
one of the primary goals of professionalization: autonomy
in practice. At the same time, the growth of nurse-midwifery
practice in the obstetrician headed "team" has the effect of
undercutting an independent market for midwifery services.
This effectively places CNMs in hospital practice in market
competition with lay-midwives and nurse-midwives in indepen-
dent practice.

Potential directions of occupational trajectories and

interoccupational relations are suggested.

The industrialization

of love, of birth,

this is the last besieged castle
the last tower
and of this particular war

this is the last hour

the great, pink walls
of this genetic treasure cave
are being shaken
and this will be the final city
ever taken.
Judy Grahn. "Like a Woman

in Childbirth Wailing."
The Queen of Wands.

 

Only now, we name ourselves....

we know ourselves to be made from
this earth. We know this earth is
made from our bodies. For we see
ourselves. And we are nature.

Susan Griffin.
'Woman and Nature

 

ii

ACKNOWLEDGMENTS

I wish to thank the members of my committee, Elianne Riska,
Barrie Thorne, Marilyn Aronoff, Kevin Kelly, Bill Ewens and
Jim.McKee.

My colleagues in the Anthropology/Sociology Department
at Hobart and William Smith Colleges saw to it that I remained
employed while completing this work and I thank them for their
support.

Thanks are also due my parents, sister, and grandmother
who offered ongoing encouragement.

Linda Ficcaglia, who typed this dissertation, helped me
immensely; her work speaks for itself.

My deepest appreciation I extend to my sisters in the
women's community whose empathy and generosity enabled me to
complete this undertaking. I am particularly indebted to
Martha Waters, Judy and Alice Saul and Susan Smith.

Finally, I thank the people I interviewed for their
willingness to take the time and the risks to speak openly
about their lives and work. I hope that this study assists

them in their work.

iii

TABLE OF CONTENTS

Introduction and Methods of Study . . . . . . . 1
The Politicization of Childbirth . . . . . . . .20

The Professionalization of Allopathic Medicine
and the Medical Division of Labor . . . . . . .46

The Development and Rediscovery of Nurse-
MidWifery O O O O I O O O O O O O O O O O O O O 84

The Early Development of Nurse-Midwifery
in Vermont . . . . . . . . . . . . . . . . . . .120

Out-Of-Hospital Birth Reform: The Home
Birth Movement . . . . . . . . . . . . . . . . .142

In-Hospital Birth Reform: The Provider-Oriented
Movement to Reassert Hospital Birth . . . . . .198

Nurse-Midwives and Negotiations Toward
Professionalization. . . . . . . . . . . . . . .242

Summary and Conclusion . . . . . . . . . . . . .273
Appendices . . . . . . . . . . . . . . . . . . .287

Bibliography . . . . . . . . . . . . . . . . . .324

iv

Table
Table

Table
Table

Table

6.4

7.1

LIST OF TABLES

Vermont Births by Location and Year.

Comparison of Education of Women Giving
Birth at Home with General Population of

Birthing Women in Vermont by Year.

Vermont Births by Attendant and Year .

Home Births by Area of Residence

and Year . . . . .

Numbers of Births for Selected Hospitals

and At-Home by Year

158

161

172

I90

207

Chapter I

Introduction and Methods of Study

Introduction

This is a study of the changing social organization of
the work of birth attendance. It focuses on conflicting
claims to occupational jurisdiction arui the processes by
which client revolts (the home birth movement) alter the
work terrain, creating new opportunities for emerging occupa-
tions (lay-midwives and nurse-midwives) and resulting in
conflicts over the division of labor. It also examines
the process by which segments of the dominant profession
(physicians, especially obstetricians) resist or attempt
to coopt challenges to their monopoly while other segments
of the profession (especially general practitioners) augment
client revolts and align themselves with emerging occupations.

This case study of the movements for home birth, lay-
midwifery and nurse-midwifery in Vermont points to more
general processes in the changing organization of work and
occupations. It addresses Larson's (1977) assertion that
a division of labor is dynamic and results from both larger
societal transformations and collective responses to them.

It examines the manner in which occupational collectivities
pursue strategies aimed at locating and monOpolizing turf

in a division of labor by acquiring both "license and mandate"

l

from the state for the exclusive performance of their
services (Hughes, 1964). Occupations' claims to this

status derive in large part from their assertions of unique
expertise. The ability of emerging occupations to success-
fully claim expertise requires that they either discredit
the dominant profession's claims to a monopoly on relevant
knowledge or persuade it to delegate a portion of its exper-
tise and related task performance. The role of an activated
clientele may be pivotal in enabling emerging occupations

to gain state sanction for their claimed expert status
(Kronus, 1976).

Larson (1977) notes that occupational collectivities
engage in a process of unification, standardization and,
typically, credentialing in an effort to create a specific
commodity which is both useful and salable. At the same
time they endeavor to construct a market for their specialized
skills and services (the commodity). Emerging occupations
may be aided in this process by client revolts which redefine
both the object of the service (e.g., pregnancy and child-
birth as normal processes) and the nature of the skilled
assistance it requires (e.g., supportive, non-interventive
care). This may have the effect of creating a new market
for the services of new kinds of occupations. However,
Larson suggests that some markets may be Vinherently sub-
ordinate“ because of the structures in which they exist.

Thus while an occupational collectivity may monopolize

specialized work it cannot be an autonomous profession since
its relationship to its market is controlled and mediated

by institutions or organizational collectivities to which

it is structurally subordinate. An examination of this
question enables me to ask if it is reasonable to speak of
the process of "professionalization" by an occupational
group (nurse-midwifery) which is structurally subordinate

to the dominant profession.

Background

 

In the 1960's and 1970's in the United States, the
convergence of several social movements on the issue of
health care created an environment in which birthing prac-
tices came to be critically evaluated and the professional
power of obstetricians challenged. In this context, two
major strategies developed which aimed at birth reform and/or
the creation of birthing alternatives. First, within the
medical system, childbirth educators and a few medical care
providers worked to reform hospital birthing practices and
to prepare birthing parents for hospital births. Second,
outside the hospital, some birthing parents began to create
their own alternatives, especially home birth. Increasingly,
a new health care provider, the lay-midwife, aided by a few
defecting physicians, attended them. As this phenomenon
began to spread among physicians' white, middle-class,

paying clientele, organized medicine sought to eliminate it.

Another occupation, the nurse-midwife, emerged in this
changing context of childbirth practices. As I will suggest,
the nurse-midwife is somewhere between these two strategies
of birth reform and birthing alternatives and incorporates
elements of each. Like the more medically-oriented child-
birth educators (such as Lamaze prepared childbirth instruc-
tors), nurse-midwives seek to professionalize in order to
improve their status, facilitate their autonomy and to
carry out their reform-oriented approach to childbirth and
the care of pregnant women. They have endeavored to locate
a suitable niche in the medical division of labor. But,
like lay-midwives, nurse-midwives, although under physician
control, are more client-centered than the vast majority of
obstetricians and they encourage client involvement and
participation.

Begun in the 1930's and originally serving the under-
served, nurse-midwives deve10ped with independence and autonomy
remarkable for a nursing specialty. By the 1960's however,
nurse-midwives were largely being drawn into the physician-
dominated, hospital-based medical division of labor to meet
projected obstetrician shortages. Their numbers and their
schools began to expand, as did their salaries, and their
claims to a special contribution to health care began to
shift someWhat. Still, the framework from which they dev-
eloped was nursing, a care-giving, rather than a cure-provid-

ing occupation. In addition, the early influence of British

midwifery in their shcools, afforded them a view of child-
birth as a normal event. Thus, latent tensions between
nurseamidwifery and obstetricians, which were minimized when
nurse-midwives functioned relatively authonomously (with
physician back-up) serving "marginal populations," began
to emerge as nurse-midwives worked more closely with obste-
tricians to whom they were structurally subordinate.
Meanwhile, lay midwives and home birth parents, pursued
a strategy of deprofessionalization in order to create viable
birthing alternatives outside the hospital. The challenged
obstetricians' claims that the hospital was the only safe
place for birth and physicians the only safe attendants (or
supervising attendants). In contrast to physician-oriented
childbirth educators, the home birth movement generated more
independent-minded childbirth educators who included in
their courses critical perspectives on hospital birth as
well as preparation for home birth. This movement thus
developed both an ideology in which childbirth was recon-
ceived and a strategy for realizing its goal of alternative
birth. In so doing, it significantly altered birth reform.
Thus, the period of the 1960's and 1970's was a time of
particularly dynamic change in the social organization of
birth and birth attendance in the United States, though
there was also strong medical resistance to fundamental
change. In this context, I chose to focus primarily on the

occupation of nurse—midwifery since it both changed its locus

of work during this period and increasingly became wedged
between the client revolt and the medical profession's
response to it. While the home birth movement critiqued
hospital birth and created alternatives to it (including
potential competitors for the turf of nurse-midwives),
organized medicine sought to shape nurse-midwifery to fit
into the obstetrician-headed team.while attempting to eradi-
cate home birth. Meanwhile, a few general practitioners
broke ranks with the medical establishment and used their
professional status to support home birth and lay-midwifery.
Nurse-midwives carefully sought to make the most of this
turn of events by continuing their professionalization efforts
while regarding themselves as birth reformers and client-

centered practitioners.

Methods of Study

 

In order to understand the interplay of these elements
and actors on a smaller scale, I undertook a case study of
Vermont. The case study is not a method best suited to
observing either the organized actions of a profession's
leadership or national trends in birth reform, but it was
the method best suited to my purposes. What the case study
can illuminate is the manner in which relatively complex
social processes play out in a particular social context
over a specific period of time. It is an approach which

constitutes, ...a way of organizing social data so at to

preserve the unitary character of the social object being

studied" (Goode and Hatt, 1952: 331).

This study is exploratory, aimed at understanding a
complex of events and actions rather than testing present
hypotheses. It also embodies elements of social history.

As an examination of social movements in an arena of work,
this study sheds light on the reasons, and the methods by
which individuals worked in collectivities to either promote
or block social change. Thus, I chose to study a small pop—
ulation of actors in a clearly delineated area, (the state
of Vermont), over a relatively short period of time, (1970-
1980). This enabled me to examine in detail events which,
in the larger sweep of historical research and social theory
are typically overlooked or obscured. Such complex social
phenomena leave few artifacts and rapidly metamorphose into
new forms. A "snapshot" such as this study, may be able to
represent some of the relationships and directions of motion.

Vermont is an attractive study site for several reasons.
Nurse-midwives have worked in the state in various capacities
for over ten years, however, their position in actual practice
is still being negotiated. Legislation enabling the practice
of nurse-midwifery is of relatively recent origin and legis-
lation concerning lay-midwivery practice has been discussed
at some length in the state legislature in the past few years.
During the period examined by this study, the practice of
lay-midwifery was extra-legal (outside the legal system).

The movements for home birth and lay-midwifery had recently

been active in the state. In addition, this study site had
the advantage of allowing me access to four different settings
in which nurse-midwives practiced. The final focus of my
research shifted to northern and central Vermont since my
entree to southern Vermont was restricted. However, the
activities in the area under study were relatively removed,
particularly for the nurse-midwives, from those in the south.

I chose Vermont as a study site primarily because it
afforded me entree. A friend ofudne was a practicing obste-
trician/gynecologist in one of the study sites. This physi-
cian provided me with initial contacts among the lay-midwives
from whom I acquired additional names creating a snowball
sample. (This particular physician seemed to have a rela-
tively unique, if not wholly neutral, position in the diverse
population of subjects interviewed. At no time did I sense
that this physician's sponsorship inhibited either access to
subjects or the candidness of the interviews.) I obtained
the names of the nurse-midwives from the American College of
Nurse-Midwives.

I interviewed ten nurse-midwives including all the
practicing nurse-midwives in the northern two-thirds of the
state and two nurse-midwives who worked as instructors of
nursing. In addition, I interviewed five practicing lay-
midwives (two of whom referred to themselves as "birth
attendants") and two former lay-midwives. Midwives them-
selves estimated a population of eight to ten midwives (more

if birth attendants were included) in the area of the state

studied and my sample included most of the central actors.

To round out my study, I interviewed four physicians, two
childbirth educators and two home birth parents who were

also health care workers. This last group of interview
subjects was chosen because they were important actors in the
processes under study, they had special access to information
or a favorable social location which enabled them to achieve
an overview.

Interview subjects did not neatly fit into the categories
of home birth mother, nurse-midwive or lay midwife, etc.

This indicates the complexity of the process of social change
in which these actors were involved and suggests their
"careers" in these movements. For example, one former lay-
midwife was a childbirth educator while another was applying
to medical school. Some of the nurse-midwives were also home
birth mothers or former childbirth educators.

While my focus throughout the research was on nurse-
midwifery, I also interviewed most of the central actors in
the home birth movement. Unfortunately, I was never able to
contact a "lay" midwife in the southern portion of the state.
She was actually a Canadian-trained nurse-practitioner who
could not legally function as a nurse-midwife in the United
States and she was a key actor intfluapromotion of lay-mid-
wifery legislation.

As my research in the state continued, I came to realize

the importance of other actors and managed to interview some

10

of the most active among them, including childbirth educa—
tors and a defecting physician. If I had had more time, I
would have more thoroughly sought out general practitioners
since at least a few of them either attended home births

or covertly supported the practice. For example, two or

the layamidwives I interviewed worked as physician's assist-
ants with physicians sympathetic to home birth. Also, inter-
views with staff nurses would have improved my understanding
of hospital birth reform.

I chose the method of Open-ended in-depth interviewing
(ranging from 1 to 2% hours) in order to elicit subjects'
interpretations of events and social relationships, in their
own words. Much of my interview schedule was comprised of
informational questions interspersed with questions about the
respondant's opinions.

Since both the claims of occupations and the challenges
raised by a clientele in revolt concern, among other things,
the social construction of reality, interpretation of events
and the terminology used to describe them is particularly
important. The quite specific nature of many of the questions
asked helped to draw the subjects into the material. The
fact that I asked a few major questions in many different
ways, allowed the respondant‘s perspective and interpreta-
tion of events to emerge. Toward the second half of the
interview, even those subjects who indicated initial wariness

appeared to be quite candid. In addition, in analyzing the

11

data, the several interpretations of events and relation-
ships both created a composite picture and enabled me to
sort out collective perspectives.

Most of the interviews with the nurse-midwives were
conducted in their offices during work or lunch hours. Two
nurse-midwives I interviewed at home, one because it was
unavoidable (she had cair trouble and apologized for my
inconvenience) and another, the nurse-midwife in independent
practice, because she chose to and in any case did not have
an office. A third interview began at work and continued
through the lunch hour at the nurse-midwife's house. In
contrast, most of the interviews conducted with lay/independent
midwives took place in their homes, though I met one at the
physician's office where she worked and spoke with her during
lunch at a restaurant.

The location and nature of the interviews suggested to
me different kinds of practice. Not surprisingly, the
nurse-midwives spoke with me in locations which increased
the social distance between us while the lay-midwives spoke
with me admist their home clutter. Interestingly, the nurse-
midwives who chose to meet me at their homes were both influ-
enced by alternative birth orientations, and were sympathetic
to home birth. The conversations with them were more like
the casual interviews with the lay-midwives in their homes.

I experienced a similar situation with my interview of the
defecting family practitioner who had been engaged in home

birth. The social distance was minimized and an easy rapport

12

was readily established.

In retrospect, while this method proved to be much more
time-consuming than other methods (for example, mailed
questionnaires) it did provide detailed and grounded infor-
mation--and a gestalt--which was relevant to the questions
this study asked and which could not have been otherwise
obtained. In addition, since much of my interest concerned
complicated relationships, and differences, between and among
subjects and groups, as well as material which subjects
might regard as sensitive, I decided that actual on-site
interviewing would be the most appropriate method.

I began conducting interviews using a structured inter-
view schedule and I continued to use it as a framework for
the interviews. However, as I began to grasp the larger
complex of events associated with birthing in the state, as
well as the subtleties of the relationships, I was more
able to direct the interview to the specific expertise and
awareness of the particular subject. It was for this reason
that I chose to interview some subjects with special or
unique expertise and information in the last phase of inter-
viewing. Interviewing was begun in June, 1980 and was com-
pleted in September, 1981. A few subjects were re-contacted
to check information or to discuss developments in their
situations or practices.

My ability to anticipate issues in home birth and birth

reform was enhanced by my earlier field work in childbirth

13

education. This research, which I did in Lansing, Michigan
in 1979, increased my familiarity with medical, birth reform
and home birth terminology and concepts. In addition, these
experiences improved my understanding of the issues of
concern among those elements of birth reform and alternative
birthing. I also became a member of NAPSAC (the [Inter]-
National Association of Parents and Professionals for Safe
Alternatives in Childbirth) and read its newsletter. In
1980, I attended NAPSAC's eastern regional conference in
Williamsport, Pennsylvania, and, during the course of writing
the dissertation, I attended the NAPSAC-sponsored Alternative
Birth Crisis Coalition Conference in Washington, D.C. in
1982. I also assembled and examined an extensive collection
of home birth and birth reform literature.

To gain greater familiarity with nurse-midwifery, I
reviewed the literature in the "new health professions"
(cf. Bliss and Cohen, 1977) including the "expanded role
of the nurse" (Teasley, 1978). I also attended a conference
on nursedmidwifery education in Philadelphia in the spring

of 1981 and regularly read the Journal of Nurse Midwifery.

 

These experiences helped me to both get a feel for
the issues and the movement participants' vernacular and to
locate the case study within the larger social movements
and national scene.

While I was not an objective observer, neither was I

clearly a partisan. I shared with birth reformers and home

14

birth parents the critique of professional hegemony but my
loyalties were split. After all, my sponsor who facilitated
my entree and supported my work was an obstetrician, a pro-
gressive person and a dear friend. In addition, my inter-
views with nurse-midwives included frank discussions of the
problems of "professional women" in which I participated
gratefully. At the same time, the independent midwives in-
cluded "outsiders" by virtue of their work who understood
and empathized with my marginal status as a lesbian. In
some ways, my own ambivalence worked to my benefit, when a
few of the interview subjects asked me, after my introduction
to the interview, which side I was on, I could honestly
explain my ambivalence. This satisfied them, and they seemed
to appreciate that I was not about the business of testing
some hypothesis on them or gathering up confirmation for some
preconceived argument. Nonetheless, I did encounter some
resistance from a few interview subjects. A few people eyed
me critically, as an academic, I might be university--and
thus professionally-oriented. Some resented the fact that I
was watching them participate in their lives and offering

no aSSistance. I felt considerable ambivalence about this
myself. In addition, as a lesbian with no children of my
own, I felt very ambivalent, and even somewhat ridiculous,
moving about in actively and overtly heterosexual circles
abounding with babies. Hopefully, my profound marginality

in these circles did not obscure my vision; it did provide

15

me with a source of detachment.

Confidentiality is of particular importance in this
study even though as one subject quipped, "Half of the state
of Vermont is keeping a secret from the other half." Some
of the information I obtained would place respondants in an
awkward position. However, this seems to be because the infor-
mation would have to be formally acknowledged and dealt with
rather than because the information is truly secret. Further,
since virtually everyone who has a central stakeixlthis infor-
mation has already been interviewed, it seemed fruitless to
attempt to obscure the state about which I was reporting.
Because the study pOpulation is small, every effort has been
made to obscure the identity of the subjects who revealed
truly "inside" information. Some sensitive issues I have
chosen to avoid altogether.

I used several other sources of information about the
situation in Vermont. One of the midwives with whom I spoke
supplied me with copies of the proceedings of hearings before
the Health and Welfare Committee of the Vermont House of
Representatives concerning the licensing of lay—midwifery
practice. In addition, she shared with me an extensive
collection of clippings from state newspapers pertaining to
home birth, lay—midwifery and birth reform. Other information
was obtained through correspondence or telephone interviews
with other actors involved in important events or from

whom particular important pieces of information could be

l6

acquired or checked. From the Vermont Public Health Depart-
ment, I obtained copies of their annual publication of vital
statistics as well as information about locations of hospitals
and numbers of obstetrical beds. The State Board of Nursing
Practice provided me with information on legal guidelines

for nursing practice. A physician passed on to me a letter
from the State Board of Medical Practice (Appendix )

which I later consulted for a position on medical support

for birthing alternatives.

While I brought to the study previous field research,
familiarity with the literature on professions and social
movements and training as a medical sociologist, I have sought
to generate sufficiently varied and in-depth information to
allow issues to emerge from the data. Glaser and Strauss
(1967) suggest a method of analyzing data which is aimed at
generating explanatory frameworks derived from the location
of emerging patterns within the data.

However, I regard this suggested methodology as an
ideal type and think that few, if any, researchers are actually
able to "face the data alone," free of preconceived expecta-
tions which color their vision. Nonetheless, I have attempted
to allow patterns to emerge from the information I gathered.

I have also endeavored to avoid forcing the data into pre-
viously developed and perhaps ill-fitting frameworks.

I came to this research with hunches about the complex
of events I was studying. I had derived these from my exami-

nation of theorists such as Larson (1977) and Freidson (1970a).

17

Thus, the method of data analysis which I used might best
be described as the grounded modification of theory (Glaser

and Strauss, 1967: 2).

The Organization of the Study

 

Subsequent chapters provide an overview of the broader
social movements of which these examined in the case study
are particular versions and moments. While I am not suggest-
ing that Vermont represents a microcosm of national trends,
it is a useful vehicle for understanding a part of the
social processes which make up the national whole. Those
characteristics which are unique to Vermont, or make this
case special, indicate the varied circumstances under which
changes in birthing practices and the development of the
professionalizing occupation of nurse-midwifery occur.

In chapters two through four, I lay the ground-work for
the case study which follows in chapters five through eight.
In chapter two, I describe the manner in which,after the
ascendence of allopathic medicine and the elimination of
the lay-midwife, several social movements converged on the
issues of health care, politicizing childbirth and its
organization.

In chapter three, I examine the historic process by
which allopathic medicine achieved professional status and
came to dominate the medical care system. This enables me

to consider both the general process of professionalization

18

as well as the specific situation in which allopaths' achieve-
ment of professional status conferred upon them the ability

to mold and dominante subordinate occupations in an expand-
ing medical division of labor.

Chapter four consists of a brief history of nurse-
midwifery in the United States focusing on its development
and efforts to professionalize on the margins of an increas-
ingly obstetrician-dominanted medical division of labor.

I note broader changes in the medical division of labor which
resulted in medical efforts to draw nurse-midwives into
hospital-based obstetrical care. In chapter five, I take up
the case study describing the manner in which nurse-midwives
were drawn into the medical division of labor in Vermont.

The movement for home birth and lay-midwifery is addressed
in chapter six. Here I consider the goals and strategies of
the movement, actually a client revolt, and the emergence
of lay-midwifery as an occupation. I focus on the manner in
which this movement has altered the social environment of
birthing in Vermont.

In chapter seven, I consider the manner in which Vermont's
obstetricians responded to growing lay criticism and attempts
at intervention (birth reform) or innovation (home birth).
Obstetricians and hospitals attempt to reassert normative
hospital birth through conservative birth reform while some
other physicians tried to create progressive and substantial

changes through birth reform. Having looked at changes in

19

the social organization of hospital birth, in chapter eight
I examine the manner in which nurse-midwives negotiate for
professional status in these altered contexts. Finally, in
my concluding chapter, I consider the way in which the
findings of the case study shed light on questions about
changes in the division of labor and the social organiza-
tion of childbirth.

It is my hope that this case study, located within the
larger social movements and historical context, will enable
the reader to feel, as I do, a closeness to these people—-
mostly women--who are actively engaged in making history
in a crucial social realm, the social organization of
childbirth. They are negotiating and struggling to change
their social world and they do so with little fanfare, day

by day.

Chapter II

The Politicization of Childbirth Practices

Introduction

 

Childbirth practices in America have become contested
terrain both within and without the medical establishment.
At least two social movements have actively and explicitly
challenged the professional hegemony of American obstetri-
cians in the press, the courts and in daily life. These
activities by the Feminist movement and the Home Birth move-
ment, met with the active response by obstetricians to re-
assert their hegemony, have made problematic a sphere of
social reality which was previously taken for granted. The
organization of childbirth has become politicized; it has

become a social problem.

Birthing as a Social Issue

 

In the United States, during the first half of the
twentieth century, childbirth increasingly became regarded
as a medical event, typically referred to as a "delivery."
As allOpathic physicians usurped birth attendance from lay
midwives, they both reshaped the social meaning of the event
and gradually altered both its location and the social rela-
tions of the participants. By the 1950's and until the

relatively recent past, both the place of birth and the

20

21

appropriate attendant were virtually undisputed and alterna-
tives were largely unavailable. There weretnwanotable excep-
tions to this trend. For many generations, "granny" mid-
wives and, since the 1930's a handful of nurse-midwives,
have served poor, minority and/or isolated populations (Litoff,
1978: Lee and Glasser, 1974; Cox, 1973; Mongeau, et a1., 1961;
Maternity Center Association, 1956). Among the middle classes,
birth reformers have, since the mid-1900's, sought more
"natural" hospital deliveries, calling for the option to have
births in which the mother was "awake and aware” (Karmel, 1959;
Read, 1944).

In recent years, the appearance of consensus about child-
birth and birthing practices has been replaced by a heated
and thorough-going debate concerning almost all aspects of
childbirth, especially the role, status and autonomy of the
woman giving birth and the person(s) attending her. To better
understand this change we need to consider the larger histor-
ical scene, since some of the actors previously involved, as
well as some ideological positions, are reappearing, if in

altered forms.

Historical Overview and Reinterpretation

For most of the 19th century, the (lay) midwife was the
typical birth attendant for the vast majority of women, as
indeed she has been for centuries. Even after the turn of
the century, midwives held their ground against competitors,

continuing to attend at least 50 percent of all births in

22

the U.S. However, by the late 19th century the rise of
allopathic medicine had begun in earnest and by the time of
the Flexner Report of 1910, the "men midwives" (physicians)
were edging out (lay) midwives. This occurred first among
the middling and upper classes and later among the working
and poorer classes as well (though less completely). Allo-
paths, especially obstetricians, eventually restricted or
eliminated their female competitors through legislation and
licensure, though public relations campaigns were also impor-
tant. Midwives' numbers not only declined dramatically as
their practices were legally restricted or outlawed, they
also became geographically restricted. Fully 80 percent
were reported living in the South by 1930 (Litoff, 1978:

58; 141). They were allowed to persist on the fringe of the
health care system because they provided services to those
Wh om physicians could not or would not serVe.

Recent literature has re-examined and challenged the
mainstream.history of this period which is typically related
from the perspective of the now dominant medical establish-
ment (Shryock, 1936). The new scholarship challenges the
interpretation that the historical transformation in birth—
ing practices and birth attendance constituted an evolution-
ary process in which progress occurred as the skilled experts
(obstetricians) replaced untrained and inept caregivers
(midwives). These studies have taken up issues of power,

inequality and social conflict, which they see as crucial

23

factors in this shift to medical control of birthing. It

is important to observe, and should not be surprising, that
as the current social and political climate in this area
changes, the interpretation of the history which preceded it
is re-examined.

An instructive example of this historical reinterpre-
tation is Litoff's (1978) examination of the ideological and
political struggle between physicians and lay-midwives and
their supporters prior to the development of medical hegemony
in birth attendance. For the first three decades of the
20th century, a lengthy and heated debate took place between
pr0ponents and opponents of midwives. (Though the impact
would be far-reaching, the actual contest was largely con-
fined to legislatures, public health offices and medical
societies.) Physicians typically called for the elimina-
tion of the midwife on the grounds that, due to her ignor-
ance, she was responsible for the high rates of infant and
maternal mortality which plagued the U.S. Further, they
asserted that her status as common birth attendant had the
effect of degrading the prestige of obstetrics as she
inappropriately competed for some patient populations.

In contrast, the midwives' supporters argued that, like
it or not, the midwife's common attendance at births was a
reality and she should receive training. At least until
some other solution was found, she should be drawn into the

nascent medical division of labor, perhaps in a manner

24

comparable to that of her British counterpart. This could
be done, it was suggested, through state licensing and
regulation. The midwives and supporters countered the
physicians' charges of midwives‘ incompetence by observing
that much of the high infant and maternal mortality rates
was the result of practices of ignorant and impatient physi-
cians, who were themselves often carriers of deadly "child-
bed fever." Kobrin (1966) suggests that such charges by mid-
wives were not without grounds. She discusses a 1912 study
of obstetrical education in the U.S. which was conducted by
an obstetrician from Johns Hopkins; he concluded that obste-
trics was clearly the weakest area of medical education.
Kobrin (1966: 353) summarizes his findings:

...the result of this neglect of obstetrics...

was that poor facilities and poor professors

were turning out incompetent products who

lost more patients from improper practices

than midwives did from infection.

Examining data on maternal and infant mortality for the
first three decades of the twentieth century, Devitt (1979)
analyzed the statistical case for the elimination of the
(lay) midwife of that period. He concluded that the mid-
wives' performance was, overall, superior to that of physi-
cians, and that physicians overcame midwives in spite of, not
because of, their statistical outcomes (see also Jensen,
1976). In spite of this poor showing, obstetricians remained

on the offensive, asserting their irreplacability by stress-

ing that the event of birth was a potentially dangerous one.

25

Claiming a special contribution to health care and demanding
that their field was of significance to the well-being of

the populace, they argued that normal births were the
exception and expertise was necessary to deal successfully
with abnormal births. Thus, obstetricians struggled to
define childbirth as a medical event for which their services
were required. Donegan (1978) argues that the shift from
woman-attended to man-attended births involved a redefinition
of the event from care-oriented to cure-oriented, in part to
justify male presence in the context of the prevailing empha-
sis on modesty for women.

Concomitantly, while the recognition of principles of
asepsis and practices of antisepsis had been central in the
obstetricians' claims to superiority in birth attendance,
these practices were only haphazardly followed. Particular-
ly in hospitals, where 50 percent of all American women and
75 percent of urban women were giving birth by 1939, and
where infections were both more likely and more potent, such
laxity was devastating (Wertz and Wertz, 1977: 133).

Indeed, much of the routinization and standardization of
Imocedures and.thus the dehumanization of medicalized child-
birth, resulted from the deadly outbreaks of puerperal fever
and physicians' struggles to cope with it while maintaining
their claim to being the woman's best attendant in childbirth.
In this context, "the medicalized posture became one of

manipulation, intervention and active combat, in the hospital

26

birth environment, (Wertz and Wertz, 1977: 137). While the
hospital which was being touted as "safer than home" for
birth actually housed potent infectious bacteria, women
were being encouraged to regard their homes as germ-ridden
(Ehrenreich and English, 1978).

Not only did obstetricians claim safer births in hospi-
tals, they offered patients less painful delivery through
the use of anesthetics. These claims and promises, coupled
with the supposed advantages of hospital delivery (such as
24 hour staffing and preparation for any calamity) helped
assure the emergent norm of hospital delivery with an
obstetrician in attendance.

Allopathic domination of birth attendance did not mark
an end to a contest over access to and control of the domain
of birth. Within the ranks of "regular" doctors, competi-
tion between the general practitioners and the obstetrical
specialists continued for decades, part of a larger competi-
tion between the generalist and specialist practitioners
throughout allopathic medicine (Stevens, 1977). Obstetri-
cians emphasized scientific medicine and cast the physician
as scientist and expert in childbirth attendance, which they
renamed "obstetrics." The rise of obstetrics, concomitant
with the rise of hospitals, and ever more closely linked to
them, thus involved not only a change in the designated
birth attendant but also in the nature of the "delivery."

The transformations in birth attendance in Britian

27

represented a struggle that pre-dated, paralleled and was
later tied to the American experience. In her examination
of the competition and conflict between physicians and mid-
wives, Donnison (1977) indicates the importance of actors'
access to and control of related technology as well as their
ideological claims to, among other things, the superiority
of their technology and their exclusive use of it. Similar-
ly, Sablosky (1976) emphasizes the use and control of forceps
in the dispute over the terrain of childbirth in America.

In both cases, male physicians controlled and employed these
technologies and inventions. In addition, they were often
charged with hasty and unnecessary intervention with their
tools, often to justify their presence and their higher
prices.

Berliner (1975) has suggested that from the outset,
allopathic medicine viewed the body as machine-like organ
systems subject to both disruption and cure from external
sources: the germs which caused illness could be best attacked
by scientifically trained physicians. Oakley (1979) observes
that a paradigm.still central in obstetrics is that of the
woman's body as machine to be maintained and "actively
managed" 'by the specially trained obstetrician, leaving post-
partal women to feel a loss of self-control and self-esteem.
The political implications of this obstetrical management and
mastery of women are obscured both by the nature of the medi-
cal intervention (which represents itself as objective) and

by dominant ideology about gender (which asserts that what

28

transpires in childbirth and the meaning given it are
"natural" rather than socially and culturally created and
thus mutable). In this way, the event of birth has been
"medicalized," claimed by obstetricians, and given a parti-
cular mechanistic/scientific form. This juncture represents
both the completion of a social andgxflitical struggle and
the rapid growth of a technology-oriented medical system.
Developments in obstetrical practices continue toward greater
‘specialization in training, testing and procedures. For
example, the rise of neonatology finds a space for a new
speciality to fit between the obstetrician and the pediatri-
cian. Additionally, increasing use of sophisticated tech-
nology and machinery and ever more active management of
delivery appears likely (Goodlin, 1979; Marieskind, 1979).
The basic transformations in childbirth practices in
the U.S. since the late 1800's may be briefly summarized.
Childbirth was first typically regarded as a natural, if
arduous and sometimes hazardous experience appropriately
attended by (lay) midwives who were women. By the second
decade of the 1900's, with the ascendence of allopathic
medicine, childbirth had increasingly come to be included
within the purview of the (white, male) allopathic physi-
cian's medical practice. Lay midwives were largely absent
from the birthing scene by the 1930's, and hospital-based
obstetric specialists employing forceps, anesthesia and,
not infrequently, surgery, had defined childbirth as a med-

ical event requiring the services of an obstetrician. They

29

had managed to gain the bulk of the market for themselves
and had become a dominant profession which regulated and

restricted competitors with the help of the state.

Social Movement and Trends Which Gave Rise to Recent Challenges

to Obstetrical Hegemony and the Politicization of Childbirth

After this lengthy process of the professionalization
of allopathic medicine, the rise of specialization and the
medicalization of childbirth, we may ask why there has
emerged a new era of debate about childbirth in America.
Such interest and activity was "overdetermined" in the sense
that several social movements came to focus on health and
health care, while economic realities of rapidly rising
medical and hospital costs created a social climate in which
medical practices were more critically examined. Partly
because the control by obstetricians was so complete in
such a fundamental area of life, particularly women's lives
social movements which were separate initially have begun to
coalesce or at least intersect on this issue. If, as Zola
(1972) and the Ehrenreichs (1978) suggest, the medical
establishment is an especially effective institution of
social control, such a convergence on this issue by groups

seeking social change is not surprising.

The Women's'Movement

In the second wave of the Women's Movement which arose

in the United States in the late 1960's, women's control of

30

their bodies--both physical and spiritual integrity and
autonomy--emerged as perhaps the central principle of Radical
Feminist theory, and it has come to represent a key activist
goal. That this focus on women's reproductive and bodily
self-control is not new is evident in Gordon's (1976) docu-
mentation of the protracted struggle for reproductive freedom
waged by women in the U.S. since the mid-1800's. Control of
reproduction was a core issue in Firestone's (1970) ovular
feminist treatise, and its centrality was reaffirmed in Rich's
(1976) more recent examination of the social construction and
degradation of motherhood (see also Fisher, 1979).

The focus for control of reproduction has been primarily
on access to and safety of contraception, abortion, and
gynecological care; in addition, the movement challenges
professional and male control of medical care and information
and the sexism women face as both patients and providers
(Dreifus, 1977: Scully and Bart, 1977; Waldron, 1977;
Barker-Benfield, 1976; Fee, 1975; Lorber, 1975: Ruzek, 1975;
Ehrenreich and English, 1973b; Frankfort, 1972; Hole and
Levine, 1971: 278-304, 355-362). With the 1971 publication

of the movement pamphlet Our Bodies Ourselves, widely dis-

 

tributed and later published by a mainstream publishing
house, (Simon and Schuster), the issue of pregnancy and
childbirth began to enter the feminist agenda and the

Ehrenreich and English pamphlet (1973a) Witches, Midwives

 

and Nurses neatly tied together themes of Radical Feminism

 

31

with childbirth and healing and further politicized both
birthing practices and the role of women as birth attendants
(see also Corea, 1977: 209-261).

Deprofessionalization and (female) lay control of
health care are central goals of the women's health move-
ment, which grew out of the larger women's movement (Ruzek,
1978). This activist health movement, which has mushroomed
since the early 1970's, focuses on women's physical health
and aims to dramatically alter the content and delivery
of health care through a two-pronged approach. First,
activists work to educate women about their bodies, especial-
ly their reproductive organs, via self-help groups: this is
coupled with a critique of the medical establishment and
medical practices. Second, feminists have created autono-
mous clinics, the Feminist Women's Health Centers, which pro-
vide health care (focusing on reproduction) and educational
services. These clinics are organized and run by (lay)
women who structurally seek to deprofessionalize medical
care by hiring physicians to perform restricted technical
services (Health Center Staff, 1977; Women's Community
Health Center, 1977; Mareiskind, 1975; Mareiskind and Ehren-
reich, 1975). The feminist movement for self-help in health
care has its roots most immediately in the second wave of
the Women's Movement in the U.S., but it must be understood
within a broader self-help tendency and tradition in the U.S.
This tradition has deep historic roots and has manifested

itself in a variety of ways.

32

Self Help in Health Care

 

In spite of the dominance of allopathic physicians in
American health care, the movements for self-care have per-
sisted (cf. Levin et al., 1979: Howell, 1978). The Popular
Health Movement of the 1830's and 1840's actually managed
to turn back the allopaths' first major effort at hegemony
by championing populism in health care. Since colonial
times, self-help has been a watchword in American culture
and it persists as a countervailing theme to professionalism
and the authority of expertise (cf. Risse, et al., 1977:
Beecher and Stowe, 1870). Recent versions of self-care
such as diets of natural foods, vitamin therapies and inter-
est in alternative healing techniques may be an outgrowth
of the counter-cultural movement of the late 1960's. This
libertarian movement sought to overcome alienation and
cultural malaise through a return both to "nature" and to
more "natural" behavior (that is, less inhibition and
greater physical and mental integration). It created a
counter-culture which persists in varied forms and which
has influenced the dominant culture. In contrast to the
counter-culture's interest in Eastern philOSOphies and arts
to promote well being, the dominant culture offers counter-
parts such as a multitude of exercise machines, sports clubs
and the immense popularity of running. Items such as the
blood pressure cuff are offered for sale with the claim of

increasing self—knowledge of one's well being: a multitude

33

of organizations compete for the emotional self-knowledge
and self-help market. (Indeed, Lasch [1978] has argued
that our culture has become narcissistic and our society
therapeutic.)

But while the self-knowledge and self-help tendency
may create new markets for gadgets and therapies, it is
double-edged and retains its (often latent) tendency to be
critical and challenging of extrinsic control. Ivan Illich
(1975) may be taken as a spokesperson for at least the more
radical elements of the movement for self-care. He asserts
that our lives have been medicalized and we have been lulled
into a physically, psychically, socially and culturally
damaging dependence upon physicians. Emphasizing that this
dependence must be stopped, he calls for what is essentially
an anarchist's vision of health care: self-care with a
restricted medical back-up. (As we shall see, the homebirth
movement puts forth a modified version of this system.)
Somewhat less radical, but more practical and influential

are the self-care journals, such as Prevention or Medical

 

Self-Care.

 

Citizen Activism: ”The Consumer Movement in Health Care

The consumer movement also aims to tip the balance of
power in medical care in favor of lay people. Such a ten-
dency is never fully absent in a capitalist society where
social power is characterized as purchasing power and the

motto caveate emptor is offered to the discontented.

 

34

The present basis for the health care consumer movement
may well have been laid in the federally—funded neighborhood
health centers, part of the Johnson administrations' War on
Poverty in 1960's (Twaddle and Hessler, 1977: 267). Programs
such as this were a respone to the Civil Rights and Black
Power movements which, among other issues, had put forth an
angry critique of the inadequate health care received by
minority and poor populations. Health centers funded by
the Office of Economic Opportunity, although eventually
scrapped by the Nixon administration, set a precedent for
consumer participation in health care delivery and provided
the impetus for further consumer activism. Activists who
demand or engineer such changes in medical care are character-
ized by Alford (1975: 191) as "equal health advocates."

(They) seek free accessible, high quality
care which equalizes treatment available
to the well-to-do and the poor. They
stress the importance of community control
over the supply and deployment of health
facilities.

While the radicalism of the 1960's may have diminished,
radical and reform movements did not terminate with the end
of that decade. Boyte (1979) examines grassroots citizen
organizing and activism.in the 1970's. Generated from
several discontented sectors of the population, this trend
is evident in a variety of organizations, such as Fair Share,
National Welfare Rights Organization, ACORN, and Gray

Panthers. Many of these organizations took up health care

as an issue of concern. Boyte (1979: 4) summarizes

35

developments of the 1970's:
...major developments merged in an increas-
ingly self-conscious citizen's movement....
A groundswell of spontaneous grassroots
activism among formerly quiescent groups of
the pOpulation--like senior citizens, farmers
and consumers--brought many tens of thou-
sands of Americans into conflict with corpor-
ate giants and government officials. And
the emergence of a coherent body of organiz-
ing and fundraising techniques resulted in
the creation of several dozen enduring,
multi-issue citizen action groups. Together,
the strands of protest constituted signs of
emerging "citizen action as a way of life."

Among those seeking reforms in health care, some have
argued that consumers' needs would best be met by better
organization and management of the medical care bureaucracy
(Roemer et al., 1975). Another position, 'market reform'
(cf. Alford, 1975L.represents a substantial and growing sector
of the consumer movement in health care. In this view, medi-
cal care is a commodity and the patient who purchases it is
the consumer; the hope for reform rests largely on the
expectation that market forces, when properly activated, will
give rise to a health care system which better meets (at
least the informed) consumers' needs. Toward this end,
activists embark on strategies of patient (consumer) educa-
tion, and the creation of reforms aimed at allowing consumer
choice among several alternatives, thereby asserting con-
sumer demand through "dollar votes." In short, physicians
and hospitals are regarded as expert (if sometimes excessive-

ly traditional or monopolistic) sources of care who are sell-

ing their services to consumers whose rights as buyers are

36

to be respected (Belsky and Gross, 1975; Freese, 1975; Gaver,
1975). Much of what transpires in childbirth education and
prepared childbirth classes constitutes consumer education
even as it also socializes participants into a more self-
controlled patient status (Rothman, 1978). Such activism is
not without effect; consumers are increasingly willing to
challenge the expertise of professionals (Lopata, 1976) even
as they have for some time consulted one another for infor-
mation about whether, when, how and where to seek medical

care via the "lay-referral system" (Freidson, 1970a).

Concern with Rising Costs and Physician Practices

 

The cost of medical care is a central issue of the
consumer movement and is a concern shared by many others.
Dramatically rising medical, and particularly hospital, costs
have been responsible for a sizeable portion of the inflation
rate as well as growing interest in cost-benefit and cost-
effectiveness analyses of medical care. Control of spiraling
health care costs is an oft-heard theme, especially within

the federal government. For example, the 1976 Forward Plan

 

for Health, after considering the sobering national economic

 

context and the dramatically rising federal outlays for health
care, concluded "until costs can be contained, Federal policy-
making in health care will be dominated by these basic economic
considerations" (Collen, 1976: 1).

Several authors have discussed related issues: the

economic impact of inappropriate priorities in health care

37

(Lave and Lave, 1970), problems of resource allocation
(Hiatt, 1975: Fein, 1968), and the structural inadequacy of
the health care delivery "system" which both creates waste
and fails to meet needs (Roemer, et al., 1975). Working from
a Marxist perspective, a number of critiques of the U.S.
health care industry have asserted, among other themes, that
the system is better equipped to generate profits than to
meet the nation's health needs (Ehrenreich, 1978; McKinlay,
1977; Navarro, 1976; Waitzkin and Waterman, 1974: Ehrenreich
and Ehrenreich, 1971). Even private industry is more criti-
cally examining the costs of medical care and physician
practices (Forbes, 1977). The facts that hospital costs are
the most rapidly rising medical costs and that obstetricians
are among the top paid physicians (Corea, 1980), are gaining
visibility as issues. In this light, assertions by some
home birth activists that up to 90 percent of all births

are essentially normal and do not require hospital confine-
ment or obstetric services contain considerable economic
import.

While costs generated by the health care industry are
closely watched, physicians' practices are ever more closely
examined and criticized. Several authors have criticized
physicians' practices, challenging the scientific basis and
application of medical practice in the past (Ehrenreich,
1974), the influence of non-medical factors in prescribing
mood-modifying drugs (Waldron, 1977), ethnocentrism among

providers and insensitive treatment of women and minorities

38

(Weaver and Garrett, 1978), and physicians' use of hormones
(Seaman and Seaman, 1977) or unnecessary surgery (Rodgers,

1975), as a "cure for women's normal anatomy and physiology.
Finally, Millman's (1977) study of the processes by which
physicians rationalize and cope with mistakes indicates the
extent of the careful scrutiny under which medicine, physi-
cians and physician practices have come (see also Bosk, 1979).

Thus, several trends and social movements have facilitated
a growing and critical interest in the practice of medicine
and the social ramifications and economic impact of allo-
path's monopoly on healing. In addition, criticism from
other quarters is emerging. While these will be examined in
greater detail in the chapters to follow, they warrant men-
tion here.

Encouraged by the women's movement, general social trends
promoting health care (rather than medical care) and the
growing need for care-giving for the chronically ill (where
there is no cure), nursing is more actively struggling to
achieve professional status and autonomy. Like subordinates
elseWhere, nurses are privy to the hidden side of medical
care and if and when they break their silence, a critical
picture of medicine is likely to emerge (cf. Duff and Holling-
shed, 1968: 66-88). Further, professionalization moves by
nursing are likely to reveal that physicians are as inclined
to protect their professional interests as they are to pro-
tect the nation's health. Meanwhile, advocates of alterna-

tive birthing practices are quick to point out that organized

39

medicine seeks to stifle most alternatives even (or especial-
ly) where they provide superior health outcomes among middle-

class patients (NAPSAC NEWS, Spring, 1981).

Birth Reform

 

There have been numerous efforts to ameliorate problems
or reform birth practices: many have concentrated on educa-
tion and training programs for prospective parents. Organi-
zations such as the International Childbirth Education
Association (ICEA), The American Society for Psychoprophy-
laxis in Obstetrics (ASPO), Lamaze prepared-birth classes
(cf. Schueler, 1976) and the Bradley method (”husband-coached
childbirth"), prepare parents for more "natural" hospital
deliveries.

Perhaps more importantly, there has been growing support
for both home birth and lay midwifery (Gilgoff, 1978; Bean,
1977: Arms, 1975: Gaskin, 1975: Lang, 1972). A relatively
new organization, which casts itself as a "prochoice" move-
ment (though it ironically seems anti-abortion), champions
home birth as a viable Option among others. Calling itself
the National Association of Parents and Professionals for
Safe Alternatives in Childbirth (NAPSAC), it has successfully
brought together at its annual conferences a wide spectrum
of people concerned about birthing practices and options.

The proceedings of the conferences are published (Stewart
and Stewart, 1979: 1977: 1976). This organization openly

challenges normative hOSpital birth as is evidenced by the

40

title of their most recent compilation: Compulsory

 

 

Hospitalization and Freedom of Choice in Childbirth. Other
pro-home birth organizations represented at NAPSAC conferences
include: The Association for Childbirth at Home, International,
The American College of Home Obstetrics (G.P.s), and The

Farm, a rural commune in Tenneseee which supports, practices
and teaches home birth attended by lay midwives, and publishes

The Practicing Midwife, a periodical apparently widely read

 

by lay midwives and by some nurse-midwives as well.

The Provider Oriented Movement to Re-assert Hospital Birth

 

Birth reformers have spent years educating prospective
parents and attempting to establish rapport with obstetricians
and hospital administrators in order to institute their
deSired reforms in birthing practices. They have finally
begun to experience some success (Forrest, 1979: Parfitt,
1977). These hard-won in—hospital alternatives in child-
birth include the acceptance by the hospital and some attend-
ing obstetricians of the (restricted) presence of the father/
coach in labor and the delivery room. Many hospitals exhibit
greater willingness to allow "rooming in," that is, extended
periods of mother-infant interaction in contrast to the
traditional rigid feeding schedule and visits of short dura-
tion. The efforts of ASPO/Lamaze-prepared or Bradley-trained
parents (including the strategy of bringing suit) have created
greater provider concern for the parents' experience of child-

birth and have, to some extent, overcome obstetrician

41

resistance to "natural childbirth" or deliveries in which

the woman is "awake and aware." Indeed, some hospitals

are now allowing fathers into the delivery room while
Cesarian sections are being performed (this is significant

as it coincides with a noticeable rise in the C-section rate
[Marieskind, 1979]). Some sections are performed under local
anesthetic so that C-sectioned mothers too are "awake and
aware." Whether or not such practices constitute meaning-
ful options or merely accommodations to the more adamant
patients remains to be seen. It is clear that such birthing
options are severely limited and vary considerably by hospital,
attending physician and the patient's and coach's strength

of will (Bean, 1977).

A birthing option repeatedly sought by reformers and
widely touted by participating hospitals is the "birthing
room." This variant hospital birth setting is typically
described as "home-like" and is portrayed as a comfortable
place staffed by caring workers in which consumers will have
a good birth experience--with a ready medical back-up should
anything go wrong. Birthing room literature sometimes
explicitly states that this alternative aims to bring those
who had planned a home birth back to the hospital (for their
own good). The birthing room is often suggested as the
antidote to the segmentalization and routinization of typical
hospital delivery since both labor and birth take place in

the same room.

42

There is a growing emphasis within the medical establish-
ment on creating, or allowing the creation of birthing alter-
natives within the hospital; such alternatives are frequently
coupled with the employment of nurse-midwives. Obstetricians
who, in the past, vociferously opposed the institution of
midwifery in the medical division of labor have begun to
look upon it more favorably (Cannings and Lazonick, 1975).
Parfitt (1977: 110-111) explains,

Nurse-midwifery was officially recognized
in 1971 by the professional organization
of the medical/obstetrics community, the
American College of Obstetricians and
Gynecologists (ACOG). The Nurse-midwife,
stated ACOG, 'ma¥ assume complete care
and management 0 uncomplicated maternity
patients while serving as a member of an
obstetrics team." (emphasis mine)

 

Thus, nurse-midwives, especially those who practice in
hospitals creating new birth settings are increasingly being
touted as the solution to the developing struggle in the
care of birthing women (Thiede, 1977). This strategy may
derive from conservative obstetricians' intentions to "oil
the squeaky wheel" by placating and thus silencing home birth
activists critical of the hospital. Some more progressive
physicians may see it as a vehicle to humanize and thus
revitalize obstetrics. In any case, institution of such
reforms, though apparently increasing, is still severely
limited. As of 1976, nurse-midwives attended only one percent
of all births in the U.S. (Rooks, 1976).

Locating the nurse-midwife squarely in the midst of

this struggle may have the effect of placing the (female)

43

nurse-midwife rather than the (male) obstetrician, in the
position of defending hospital birth and challenging lay mid-
wifery and the home birth movement. However, the willingness
of nurse-midwives to accept this role should not be assumed.
While nurse-midwives find themselves forced to take a position
in the struggle over childbirth practices, their perspective
is far from unified and at least some members aim to thorough-
ly consider the position of the home birth movement and lay
midwifery before committing themselves. For example, at the
23rd annual convention of the American College of Nurse Mid-
wives, discussion topics included birthing rooms and lay
midwifery. Further, nurse-midwives are not completely
spared criticism from advocates of lay midwifery (arms,
1976). Some argue that nurse-midwives are trained within
the medical--not midwifery--paradigm and thus may be intended
to function more as an extension of the obstetrician than
as an independent midwife who shuns unnecessary medical inter-
vention (see Rothman, 1978 for a discussion of these
paradigms).

Nurse-midwives are increasingly caught up in the debate
over home birth. Some nurse-midwives have called for a
re-examination of ACNM's policy on home birth (cf. Litoff,
1978: 144). Its 1973 policy, determined by the executive
board, endorsed only the "hospital or officially approved
maternity home as the site for childbirth..." although the

position has softened since then. The 1978 speech by the

 

44

president of the ACNM, Helen Burst, to the College included
a keen recognition of the increasingly difficult position
into which nurse-midwives were being put. After discussing
consumers' demands to have the option to determine their
birth experience, she explained,

Unfortunately, the alternatives (to

traditional obstetrical practices) the

nurse-midwife often pr0poses are fre-

quently rigorously opposed by physicians.

In a very real sense, nurse-midwives are

caught in the middle of the conflict

between the consumer and the physicians.

The nurse-midwife in spirit, heart and

philosophy, is with the consumer. But

the nurse-midwife legally and professionally

has to work with the physician, and it is

the physician who has the power in the

health care system.
She concluded her speech by asking her colleagues to be
openminded concerning the issue of lay-midwifery, and she
acknowledged the growing number of practicing lay-midwives

in the U.S. (Burst, 1978: 3).

Summagy

Both childbirth practices and attendants have changed
dramatically in the last hundred years in the United States.
Despite struggles by lay midwives and their supporters, the
ascendance of allOpathic physicians continued relatively
unabated. It culminated in a hospital-based system of
medicalized childbirth in which specialization and inter-
vention increased, giving rise to current standards of
practice which encourage "active management" of labor and

birth by obstetricians.

45

However, movements as diverse as conservative birth
reform, consumer activism and radical feminism have sought
modification and alterations in birthing practices and
provider-consumer relationships. The medical profession
has responded with strategies aimed at warding off lay
criticism.while maintaining normative obstetrician-attended
hospital births. In this context, obstetricians become
particularly interested in shaping the development of
nurse-midwifery, but evidence suggests that nurse-midwives

have their own agenda in mind.

Chapter III

The Professionalization of Allopathic Medicine and

the Medical Division of Labor

In order to more fully understand the development of
nurse-midwifery, it is necessary to examine the context in
which it began and in which it is attempting to profession-
alize. I have already briefly discussed the historical
transformation in birthing practices and birthing attendants
in the U.S. To this understanding, I must add an examination
and analysis of the structure of the medical system of care
provision, particularly the medical division of labor and
the dominance and centrality of allopathic medicine within
it. The ideological transformation of childbirth from a
family or community event to a medical event was a necessary
component of the establishment of allopathic pre-eminence
at birth. However, that in itself guaranteed neither the
new attendant's status, income nor its ability to resiSt
incursion from rivals making similar claims to medical
competence.

I shall examine the manner in which allopaths, one sect
of healers among many, were successful in their attempt to
professionalize, eventually coming to control a highly
articulated division of labor in a burgeoning and profitable

medical industry.

46

47

First, let us examine the concept of professional status.

What is its significance and what is meant by professionaliza-
tion, the process by which groups attempt to achieve it?
Several authors have taken up these questions but I will
limit my discussion to major authors whose work has the most
immediate bearing on my own. For Freidson (1970a) the crux
of professional status is autonomy. A profession is able
to determine the content of and rules about the appropriate
performance of its work, however, he notes that professions
do not invariably determine and control the context in which
the work. Or, as Hughes (1964: 78) observes,

An occupation consists, in part of a successful

claim of some people to license to carry

out certain activities which others may not,

and to do so in exchange for money, goods

or services. Those who have such license

will, if they have any sense of self-

consciousness and solidarity, also claim.a

mandate to define what is proper conduct of

others toward the matters concerned with

their work.
This license to the exclusive performance of particular tasks
derives in part from the occupation's claims. These include
assertions of a service ideal and ethical standards of
behavior as well as a monopoly on a relevant body of know-
ledge. The profession, "claims to be the most reliable
authority on the nature of the reality it deals with,"
(Freidson, 1970a: xvii). However, such claims do not trans-
late directly into professional status, since that status

is not only normative, it is also structural. The basis of

the professional status of medicine is political; the state

48

has, "deliberately granted the profession autonomy, including
the exclusive right to determine who can legitimately do its
work and how the work should be done" (Freidson, 1970a: 72).
Thus, a profession may be said to have "legitimate organized
autonomy," that is, it is essentially and legitimately free
from external, lay control and intervention.

How does an occupation arrive at this very special
status and why does the state grant it this autonomy? The
occupation itself has neither the resources nor the credi-
bility to single-handedly cause the state to bestow such
privileged status. Neither is the profession's status
necessarily the outcome of strong consumer support, although
some professionalizing occupations have benefitted from that
(Kronus, 1976). In fact, such pOpular support was noticeably
lacking for allopathic medicine during its bid for professional
status in the U.S. Early allopathic moves toward professional
status were turned back by the Popular Health Movement of the
1840's. Instead, as Freidson (1970a: 72) suggests,

A profession attains and maintains its position
by virtue of the protection and patronage of
some elite segment of society which has been
persuaded that there is some special value

in its work. Its position is thus secured

by the political and economic influence of

the elite which sponsors it--an influence

that drives competing occupations out of

the same area of work, that discourages others
by virtue of the competitive advantages
conferred on the chosen occupation and that

requires still others to be subordinated to
the profession.

49

Professionalization and Class Interests

 

Berliner (1975) takes up the issue of elite sponsorship
emphasizing the pivotal role of material support for allo-
pathic medicine's professionalization project from.economic
elites. He argues that the influential Flexner Report of
1910 marked a watershed in the allopaths' process of pro-
fessionalization because it was the outgrowth of a confluence
of interest between allopathic leadership and certain indus-
trial capitalists. Rockefeller was already enamoured with
scientific medicine and scientific medical research prior to
the Flexner study. For its part the Carnegie Foundation had
taken considerable interest in the development and role of
professions, viewing them as potentially, "stabilizing
influences in their communit(ies)" (Berliner, 1975: 587).

The Flexner Report, carried out under the auspices of
the Carnegie Foundation, was widely perceived as a neutral
evaluation of medical education (unlike the partisan AMA
study conducted in 1906). However, as Berliner observes,
not unlike the previous AMA study, the basis for the evalua-
tion of medical education was a school emphasizing scientific
medical research, in this case, Johns Hopkins. Thus, the
Flexner study post-dated and paralleled a study conducted by
organized elements in allopathic medicine who had already
begun to undertake the task of reforming the occupation.

Upon completion of the study, many medical schools were

forced to close their doors, including the bulk of those

50

training women and minorities. In contrast, allopathic
medical schools received over $154 million dollars from
foundations ($66 million from Rockefeller alone) to facili-
tate medical education reform toward scientific medicine and
medical research (Berliner, 1975: 589).

The reason for the intense interest in medical education
by representatives of the industrial capitalists was, accord-
ing to Berliner, the convergence of paradigms. Industrial
capitalists in particular were faced at the time with the
thorny problem of facilitating further capital accumulation
while maintaining social order, that is, they sought to
legitimize and entrench the existing social relationships
with regard to the mode of production. During a period of
intense social unrest, scientism emerged as a vehicle for
creating reforms which were ultimately conservative: they
conserved the existing system inhibiting radical transforma-
tions in fundamental social relations (cf. Kolko, 1967).
Berliner (1975: 574) explains,

The response of the capitalists as a class
manifested itself in the transformation
of social problems into technical problems.
Problems whose actual basis was social and
hence whose solution was political were
transformed into problems of science whose
solution was technological.
In this context, scientific medicine, which construed illness
and disease as resulting from specific etiology (cf. Dubos,

1959) was preferred by capitalists to holistic approaches.

Allopathic medicine focused attention on individual pathology

51

and construed the body as machine-like (a metaphor likely to
be attractive to industrial capitalists). It is thus
individuated medical care and diverted attention from both
social and environmental causes of illness and collective
orientations to medical care and health promotion.2 Thus,
Berliner implies, allopathic medicine was sponsored in no
small part as a vehicle of social control.

Because of this convergence of ideology, scientific
medicine, as undertaken by the university-educated elite of
allopathic medicine, was intensely promoted by industrial
capitalists, Berliner argues.

However critical the initial convergence of ideology
between the professionalizing occupation and its sponsoring
elite, the protected status of the profession enables it to

deve10p along its own course. At the same time that its

 

2Thismode of individuation of medical care derives in part
from a medical acceptance of Spencerian ideology creating
what Sedgwick (1974) calls "medical individualism." This

is a model of care-giving based on a contract model deriving
from a fee-for-service orientation and privatizing care-
giving. Medical individualism tended to restrict access

to "first quality care" to those able to pay, that is, able
to enter into the contract. It was later to create a system
of sponsorship of hospital patients by physicians. Several
authors have critiqued the manner in which a two or three-
tiered system of care-provision has emerged, in whch those
unable to pay are either turned away or transformed into
teaching or research material thereby receiving lower
quality care or experimental treatments often linked with
active staff evaluations of social worth and efforts at
social control (Jones, 1981: Scully, 1980: Ehrenreich and
Ehrenreich, 1978; Lorber, 1975: Reissman, 1974; Shaw, 1974:
Zola, 1972).

52

potential for the productioncflfideology is enhanced, it is
freer to diverge from that of the sponsoring elite, Freidson
suggests. For example, we have already seen that federal
efforts at cost-containment in health care are inhibited by
increasingly active (and expensive) medical intervention into
conditions (such as childbirth) which are, in some other nations
with better overall health outcomes, thought not to require
medical intervention.

Nonetheless, Freidson (1970a: 73) observes that having
elite and state-sanctioned autonomous professional status

"...if a

does not constitute a timeless guarantee, rather,
profession's work comes to have little relationship to the
knowledge and values of its society, it may have difficulty
surviving."

EXpanding on Freidson's analysis, Larson (1977) observes
that the great wave of professionalization in the Western
world emerged along with the rise of industrial capitalism
while its roots extended into the larger transformation from
the feudal mode of production to capitalism--typically
referred to as the process of "modernization." In a period
of profound social transformation, previously unavailable
occupational opportunities emerged and professionalization
represented a collective enterprise by participants to locate,
and control, and eventually, monopolize markets for their
standardized services. Larson refers to this new form of

organization around the cash nexus as a "collective mobility

project."

53

Previously established professional collectivities were
tied to and ideologically liked with older and declining
elites. But, new professionalizing occupations were emerg-
ing, led by organizers and reformers "organically" tied
(thus ideologically linked) with the rising class, the
bourgeoisie. Where traditional professions had served elites
or functioned in elite-controlled spheres, new professionaliz-
ing occupations sought to locate new and broader markets.
Where traditional professions emphasized exclusivity and
status markings, the emerging professions burned the candle
at both ends, sometimes invoking status markings but more
typically stressing training, education, and systems of
credentialing as guarantees of competence.

Occupations successful at the collective mobility pro-
ject eventually enjoyed higher incomes, higher status and
often, freedom from lay intervention. According to Larson
(1979: xvii), "professionalization is...an attempt to trans-
late one order of scarce resources--special knowledge and
skillls--into another-~social and economic rewards." This
translation is a lengthy process.

In order to begin to establish market control, associa-
tions of producers of services had to define a cognitive
base. Once this base wasauzleast approximately delineated,
the occupation could begin to use it to make claims of
superiority and to create monOpolies over access to it, that

is over teaching and training (necessitating a break from

54

apprenticeship training systems where standardization could
not be guaranteed).

It was in control of the educational process that the
basis for monopolization of a market was laid, since it was
in the educational process that the "production of the
producers" of services took place. This control was critical,
Larson suggests, because the actual commodity being produced
was not the task performance itself buttfiuaprofessional person
performing the services. Thus it was in education that the
negotiation of cognitive exclusivity could be realized and
claims to superior knowledge, skills and task performance
(as well as professiontF assertions of high ethical standards)
could be translated into a reliable and standardized product:
the producer. According to Larson, the Flexner Report and
the reforms associated with it represented and echoed the
broader nation-wide process of "...rationalization of produc-
tion which had arisentxameet the anarchy of competition and
the excesses of laissez-faire," (1977: 163). At the same
time, these successful reforms marked the culmination of the
process of professional unification (determining who was in
and who was out). The‘dgjfggto restriction of medical
education (and thus professional practice) to white men of
the middle and upper classes probably improved the profession's
prospects for success. As Hughes observes (1964: 44),

The movement to 'professionalize' an
occupation is thus collective mobility of

some among the peOple in an occupation.
One aim of the movement is to rid the

55

occupation of people who are not mobile
enough to go along with the changes.

However, once this process was completed, the struggle for
position within the professions emerging system of internal

stratification began in earnest.

Internal Stratification in Medicine

In the wake of the Flexner Report and subsequent reform
of allopathic medical education, the sucess of the AMA in
controlling the profession appeared to be assured. After
all, its desired outcome--the scientifically trained
generalist physician--was rapidly becoming a reality. AMA
control of state licensing boards provided a check on both
would-be competitors and its own graduates. But even as
these reforms were being instituted, they were becoming out—
dated, the movement in allopathic medicine was toward
specialization, as Stevens (1976: 116) observes,

As the basic licensing process was 'solved,‘
the scramble for specialization was on.

The AMA had focused on the university as the
center of medical training; it was doubtful
whether it would be able to achieve the

same domination of medical training at the
graduate level which it had achieved so
spectacularly in its undergraduate program.
To do this would be to involve the extension
of its influence over all aspects of medical
practice, including the hospitals and the
increasingly independent specialist groups.

The hospitals themselves had grown dramatically from
1800 to 1920, paralleling the rise of allopathic medicine
and helping to shape it. Though hospitals in one form or

another had existed for centuries, they had historically

56

been tied to religious charity, death houses, or state
supported poor houses. While they may have provided vehicles
for medical and surgical training, they did not provide paying
patients; in fact, patients who could pay shunned hospitals
until around the turn of the century when they began to be
drawn into them. We shall examine later how nursing is tied
to this trend, for now it is useful to note that this trend
was both the outgrowth of and further impetus for the rapid
development of surgery.

With more widespread understanding of the principles of
asepsis and greater attention to the practices of antisepsis,
surgery became more viable and surgical specialization, includ-
ing subspecializa'tion such as gynecological surgery, was
creating what we would now call a growth industry. Feeling
the pressure of the developing trends in the structure of
medical organizationand practice, the university-trained
generalist's education was increasingly being augmented by
internship (hospital apprenticeships). Where previously
these internships were few and guaranteed special privileges
to those who completed them, by WWI they had become increas-
ingly a component of standard medical education.

The AMA Council on Medical Education (composed largely
of medical professors) had become interested in internship
programs and thus in the hospitals in which the interships
took place. The AMA considered undertaking the task of

examining and reforming internshipauuihospitals but was

57

discouraged from this venture when Carnegie funding for

the project was not forthcoming. Meanwhile, The American
Collegeof Surgeons, formed in 1913 as the second specialist
organization in the U.S., decided to undertake the project
itself. By 1916, the College had received a Carnegie grant
for this purpose and, after being formally joined in the pro-
ject by the American Hospital Association, it set about to
reform and standardize hospitals.

Thus, the AMA was never able to gain full control of
graduate medical education and training, specifically intern-
ships and residencies. The outcome might have been different
had they been able to assert leadership in hospital reform.
As it was, a specialist organization, the College of Surgeons,
was able to wrest control of this (expensive) leadership
role. Here, as elsewhere, the AMA, which functioned as the
spokesperson of the generalists, took second place to
specialists.

Though generalists continually attempted to resist sub-
ordination to specialist overlfluanext fifty years, speciali-
zation continued to be more lucrative and prestigious. When
finally, general medical education and internship came to
be construed as the basis for specialist residency programs,
the die was cast and generalism continued to decline into
its current virtual oblivion. (However, the power of the AMA
has not declined similarly, for example, Brown [1973] argues
that it currently functions as something like a holding com—

pany for specialist interests.) A recent attempt to create

58

specialization in general practice via residencies in "family
practice" has had some success in attracting students, but

many of the other problems of generalist vs. specialist remain.

The State and the Relationship With a Lay Clientele

 

Medicine needed to differentiate itself from the lay
public, unify and differentiate itself from competitors, and
standardize the production of professional producers. At the
same time it had to locate a market. Larson suggests that
for medicine this situation was particularly problematic
because of the unique characteristics of the potential market.
In this aspect, as in others, state intervention was critical,
and establishment of a monopoly was necessary for the success
of the professionalization project. In healing, the market
is potentially wide-open and encourages competition. In
this context allopaths were faced with the task of‘constructhu;
a market for their services.

The 'premodern' situation culd not be over-

come by medicine so long as consumers, when

they changed providers, also changed medical

commodities: in such a situation we cannot

speak of'opg_market for medicine, but of

many (Larson, 1977: 20).
Thus, realization and control of a market for the commodity
required the elimination of competing commodities, that is,
other producers of services. This necessitated assistance
from the state since the location and control of the market

could be realized without state intervention facilitating a

monopoly (via accreditation of educational facilities and

59

licensing of their graduates).
The universal need for medical services
represents a tremendous asset for a category
of professional producers only after they have
succeeded in establishing a monopolistic hold
on their market. Until then, the universality
of the need operates in reverse, breeding
competition (Larson, 1977: 21).

Both Freidson and Larson point out the important role
played by the state in granting the medical profession
legitimate autonomy and thus a market monopoly. Nonetheless,
they also emphasize that this crucial turn of events does not
in itself guarantee success for the profession. Medicine is
a "consulting profession" (Freidson, 1970a: 17) and, as such,
requires active use by a lay clientele. Though the profession
and the state may, in partnership, eliminate competitors,
they cannot coerce the lay public to consume medical services.

Freidson indicates that while ...the survival of medical
practice depends on the choice of laymen to consult it.
Choice to consult cannot be forced; it must be attracted"
(1970a: 21). Larson develOps this point, emphasizing the
role of ideological production and internal unification
within the profession facilitated by reformers and leaders
in the professionalization project.

The actual effectiveness of (legally

enforced monopolies of practice) depends

on the parallel constitution of a 'monopoly

of credibility' with the larger public

(1977: 17).
Where these authors point to ideological persuasion as the

profession's ultimate vehicle for the creation of a con-

sulting clientele, Illich (1976) emphasizes its coercive

60

strategies for extension of its monOpoly. He accuses medicine
of creating a "radical monopoly." In this extreme monopoly
not only is access to competing products severely inhibited,
but even the choice not to consult is discouraged as self—
care is undermined.

(R)adical monopolies disable peeple from

doing or making things on their own...they

impose a society-wide substitution of

commodities for use-values by reshaping the

milieu and by 'appropriating' those of its

general characteristics which have enabled

people so far to cope on their own.... The

malignant spread of medicine...turns mutual

care and self-medication into misdemeanors

and felonies (1976: 42).
In contrast, Freidson (1970a: 17) explicitly counters Illich's
charges by asserting that medicine has never had,

...anything like a complete monopoly over

healing services, either formal or informal.

It is still virtually impossible to prevent

a patient from treating himself (sic) or

from seeking help from friends and relatives.
In regard to childbirth and the home birth movement, this
debate will be most relevant.

In summary, persuasion of elite sponsors and creation
and control of state vehicles for development and maintenance
of monopoly were critical in a110pathic medicine's process
of professionalization. At the same time, the professionaliz-
ing occupation needed to locate a market for its services
among the lay public and convince a clientele to consult it.
These are the larger ways in which professionalization has

historically occured for medicine. But examined at the

micro level of analysis, professional status is both realized

61

and recreated in face-to-face interactions with other workers.
The work place becomes the arena in which occupational turf

is claimed and defended.

Professional Turf

 

On the level of day-to-day work performance, how do
participants in an occupation create and recreate (or main—
tain) professional status? Kronus (1976) suggests that another
way of construing the professionalization process is to look
at the delineation and defense of "turf." The "turf" is a
socially created social space which typically consists of
particular task activities, whose performance an occupation
has monopolized. Freidson suggests that for allopathic
medicine the crux of these task activities is the ability to
diagnose illness, to cut and to prescribe medication. As
previous dicussion of the literature indicates, these task
activites will be construed by the profession as necessary
and central to the facilitation of particular outcomes, for
example, effecting a cure. Further, the associated producers
will assert special expertise in the knowledge about and
performance of these tasks.

Once task activities have been delineated and monopolized,

' must

their socially created parameters, "task boundaries,‘
be carefully maintained. Pressure from competitors fre-

quently takes the form of incursion on task boundaries: Kronus
suggests that incursion must be successfully resisted in order

for the profession to maintain its turf and thus the basis

62

of its claims for professional status.

Professions, like other elements of social life, are
dynamic and it would be inaccurate to suggest that the turf
of an occupation does not change. Friedson was careful to
describe only the most fundamental tasks as the crux of
medicine. I have already suggested, as have other authors
(Reiser, 1981; Stevens, 1976; Hughes, 1964), that the nature
of medical practice has changed fairly dramatically since the
Flexner report of 1910. The rise of scientific medicine and
specialization coupled with increasing reliance on sophisti-
cated technology has created a kind of medical system and
medical practice quite unlike that of the generalist-centered
primary care provision of seventy years ago. Nonetheless,
as Kuhn (1964) and Larson suggest, the profession's prospects
have been tied to the success of its paradigm.in explaining
and predicting phenomena. This paradigm has come to form the
base of the occupation's created status and, barring a major
(and disruptive) paradigmatic shift, the "turf" of allopathic
medical practice will continue to derive from this base. Thus,
medicine's paradigm, cognitive base, or social construction
of reality, give it some room to move in terms of turf; at
the same time, a paradigm imposes very real limitations and
demarcations.

At least one observer suggests that by so actively
embracing technology and by delegating tasks to subordinates,
physicians are finding themselves transformed beyond recogni-

tion becoming more like technicians or managers than primary

63

care-givers (Maxman, 1973). The parameters and thus limita-
tions of the medical paradigm.are also closely examined by
Rothman (1978) who compared medicine's construction of‘
pregnancy, and childbirth with that of lay/empirical midwives.

Thus, the turf may change somewhat but ultimately both
incursion by competitors and presentation of alternative
pardigms must be actively resisted.

Finally, some authors (Bucher and Strauss, 1961) have
suggested that the process of professionalization may be
fruitfully understood as a social movement. Others, (for
example, Larson, Hughes), have emphasized the collective
aspect of the undertaking and the necessity for individuals
among the associated practitioners to accept the primacy of
collective goals and strategies in their pursuit of the
"collective mobility project."

A social movement orientation to professionalization
highlights, among collective strategies, assertions of
"special contribution" (including special knowledge and skills,
with the added sense of mission). The participants not only
endeavor to persuade relevant elites, they simultaneously
create and project an image: while that is a strategy, it
is also an aspect of the larger process of deve10pment of
ideology. Strategies and ideology are expected to be linked,
contradictions tend to produce conflict or at least dissent
within the ranks.

Thus, the process of professionalization can be seen as

64

something more than simply a rational collective creation of
better paying work which confers higher social status. Parti-
cipants are likely to believe in the work they are doing,
participate in the recreation of the ideology and take on all
or parts of the ideology as their own world-view with a sense
of personal mission. This shared world-view is one manifesta-
tion of the boundaries oftfluaprofessionalizing occupation, in
addition to those other markings previously discussed, for
example, credentials, license, etc. As with other movements,
segmentation, conflict and schismogenesis are possible, though
perhaps less likely since the collective undertaking promises
material rewards.

Strategically, professions and professionalizing occupa-
tions negotiate and maintain their turf through alliances;
clues to both ideology and strategy may be suggested by
"colleagueship" the process by which particular others come
to be construed as colleagues. Finally, mechanisms for
recruitment into the profession/professionalizing occupation
as well as those aimed at resisting the defection of members

may be fruitfully examined.

The Development of the Medical Division of Labor

 

A central characteristic solidifying the pre-eminence
of the medical profession is its location hiand relationship
to the medical division of labor. As Freidson notes, the
medical division of labor is, overwhelmingly, organized

around the medical profession and its turf. In fact, Freidson

65

(1970a: xvii) suggests that a profession is distinguished

from other occupations by the fact that it is, ...an occupa-
tion which has assumed a dominant position in a division of
labor so that it gains control over the determination of the
substance of its own work." Describing medicine's claimed
mandate to determine the nature of the social reality with
which it deals, Hughes (1964: 78) explains,

(The mandate) include(s) a successful claim

to supervise and determine the conditions

of work many kinds of peOple; in this case,

nurses, technicians, and many others involved

in maintaining the modern medical establishment.

The medical division of labor is noteworthy, according

to Freidson, in that it is ordered not by historical accident
or pluralistic competition for turf, but by the medical
profession itself. Questioning the notion that the perform-
anCecflfparticular task activities is crucial in the placement
of medicine in the medical division of labor, he points out
that many tasks once regularly performed by physicians have
now been delegated to other workers. Instead, he emphasizes
that it is social relationships which define the medical
professionals and paramedical workers:

What the physician does is a part of a

larger technical division of labor and some-

times not a very distinct or generic part.

It is the physician's control of the

division of labor that Is distinct (Freidson,

1970a: 48).

Paramedical occupations, in contrast, are more noteworthy

for their, "relative lack of autonomy, responsibility, author-

ity and prestige" (1970a: 49). Nonetheless, they are closely

66

associated with practitioners in a lucrative, powerful and
prestigious profession and that propinquity colors their own
work and ideology. Further, Freidson observes that some other
occupations, performing functionally comparable tasks may be
characterized as "quacks" rather than paramedical personnel,
because they are outside the control of the dominant profession.

Thus, the current medical division of labor emerged
after the ascendance of allOpathic medicine around which,
and largely by which, it was organized. The previously exist-
ing unorganized division of labor in healing was super-
seded and largely replaced by medical/technical workers sub-
ordinate to allopaths who function primarly in hospital-
based work structures. Not all competitors were eliminated,
some, like pharmacists, continued to remain independent, if
restricted, while others, such as nurses continued the age-
old function of care-giving but under strict medical control.
Subsequently, many new, largely technical occupations would
emerge. As early as the second decade of the 20th century,
the diagnostic laboratory, which became more widely used
after WWI, created a new realm of work for chemists and
pathologists and, subsequently, growing ranks of lab tech-
nicians (Reiser, 1981: 143).

With the early impetus toward Specialization in medi-
cine hospitals began to emerge as the central site of medical
practice. With the provision of federal funding for exten-
sive national hospital construction—~the Hill-Burton legis-

lation of l948--the hospital's central role in care provision

67

was solidified and it further penetrated rural areas. Along
with the rise of the hospital system, an extensive division
of labor in medical care began to emerge. More and more
tasks previously performed by physicians were being delegated
to assistants of various sorts, in addition, new tasks were
being developed and delegated, for example, respiratory
therapy. As medical practice became more technically and
mechanically oriented a whole new realm of paramedical
occupations opened up: the technicians.

Why is the control of the division of labor so important
to organized medicine? Brown (1973) argues that the allied
health occupations have the potential to conflict with
physicians for turf. In fact, many technically specialized
subordinates have greater expertise in their particular area
of work than does the supervising physician. Recognizing
this potential competition, organized medicine has sought to
control these other occupations and has largely been success-
ful.

The medical industry is essentially labor-intensive and
skilled workers labor in various relatively small-scale
organizations. Thus control of the market cannot be achieved
through control of capital.

The means of production are the applied
skills, knowledge and labor of people rather
than of machines. Therefore, efforts to
create, change, monopolize, or benefit from

a relation to the means of production require

direct and conscious intervention in the
occupational structure (Brown, 1973: 436).

68

As the industry expanded, it created an increased demand for
skilled workers. This demand could have been met in one of
two ways. First, more physicians could be produced. (In
fact, ever since the AMA gained control of medical education
and licensing it has sought to limit the production of physi-
ciansixlorder to decrease competition and raise practitioners'
incomes.) Second, new health/medical workers could be created
receiving considerably lower incomes and performing work which
is physician-structured and controlled. The latter is the
dominant approach.

While it may appear that expansion and bureaucratiza-
tion of the hospital structure dooms physicians to proletar-
ianization and subordination to managers and administrators,
Brown cautions against this conclusion.

As physicians lost direct control over
production organizations, they gained
control over producers through the AHA
(American Hospital Association), JCAH
(Joint Commission on Accreditation of
Hospitals), CME (Council on Medical Ed-
ucation), and medicare organizations
(1973: 437).

As Larson noted, a critical juncture in the process of
professionalization is the occupation's acquisition of the
control of its education. Agreeing, Brown points out that
organized medicine has sought to short-circuit the profes-
sional aspirations of its subordinates by maximizing physi-
cian control of their education. For example, the federally

sanctioned CME (Committee on Medical Education of the AMA)

includes among its functions the accreditation of schools

69

and certification of graduates in medicine and several sub-
ordinate occupations. It can use this position to inhibit
the development of occupations by failing to accredit their
educational programs. Other health occupations may be simi-
larly undercut by other arms of organized medicine.

The JCAH can and has threatened to withdraw
its accreditation from hospitals which offer
training in unacceptable occupations. The AAMC
(American Association of Medical Colleges)
and individual medical colleges control access
to the necessary clinical training facilities
in teaching hospitals and university medical
centers, and can agree to refuse to allow
training for developing occupations. The
development of nurse-midwifery has been slowed
by the reluctance of hospitals and medical
schools to approve training programs. Obste-
tricians have been most active in blocking the
gegeéopment of this occupation (Brown, 1973:
3').

In other comparable strategies, physicians have either
opposed the licensing of subordinates, in order to stymie
their professionalization attempts, or have sought to control
licensure. Physicians often predominate on licensing boards
of subordinates. With these concerns in mind, let us take

a look at the development of nursing.

Nursing as a Professionalizing Occupation

 

The occupation of nursing is the prototypical example
of the fact that professional status is not achieved merely
by emulating the characteristics of other professions (for
example, developing a body of knowledge, developing a code

of ethics, raising educational standards). The piece that

70

was missing from the outset in nursing was the requisite social
power to determine its own fate. Though leaders in nursing
attempted in a rational way to achieve professional status,
their success was at best partial. In large part, this was
because they were ultimately unable to extricate themselves
from the control of the medical profession and hospital
administrators (themselves physicians, historically). Cer-
tainly a critical factor in the inhibited development of
autonomy in nursing was the fact that nursing was an over-
whelmingly female occupation in a male—dominated medical
hierarchy which was itself part of a male-dominated society.
As the following discussion suggests, because of its inherent
subordination, the development of nursing might be more

"3 The more nursing

accurately construed as "underdevelopment.
was drawn into the medical mainstream and hospital care and
the greater were the numbers of nurses and kinds and uses of
the nurse, the more firmly was their subordination entrenched
and the more fundamentally was the occupation as a whole
exploited for the benefit of these who dominated them.

As was the case with hospitals, early nursing functions
were associated with religious charity. While as early as
the 1100's an order of the Beguines provided care to lepers,

the first nursing order was begun in 1633 under the auspices

of the Catholic Church (Pelley, 1964:22). By the 1700's,

 

3This is a term originally used to describe uneven and exploi-
tative economic development of dependent third world nations
by capitalist coutries (cf. Cockcroft, et al., 1972).

71

nursing in England and Germany had come to be linked with
prison reform and growing social consciousness. Fitzpatrick
(1977) observes that Florence Nightengale, influenced by this
trend, set about to upgrade, secularize and standardize
nursing in England in the 1800's. Nightengale also worked
with some success to differentiate nursing education and
nursing practice, separating her own training school from the
hospital. At the same time, she worked to clarify the diff-
erence between trained nurses and untrained care-givers(some-
times working at cross purposes with midwives) (cf. Donnison,
1977). She also developed a code of rules for nursing which
bore a greater resemblance to the "cult of true womanhood"
(Welter, 1966), and military discipline than it did to a
professionalizing occupation's code of ethics. Nonetheless,
Nightengale's contribution to nursing was pivotal and far-
sighted. For example, she introduced the concept of "health
nursing" which anticipated nursing's later developments in
primary-care-giving and health promotion (Fitzpatrick, 1977).
Rational and far-sighted though it was, Nightengale's
model of education for nurses did not take hold in the U.S.
Although an organized feminist movement had begun in the mid-
1800's and the Civil War had created a demand for hundreds
of women trained as nurses (many by women physicians), only
a few comparably organized schools were begun in the 1870's
and 1890's. These were created largely by upperclass women

reformers. While the number of nursing schools grew

72

dramatically in the latter part of the 19th century, most
were associated with hospitals and drew not elite women, but
working and middle class women who needed wage work (Ashley,
1977; Cannings and Lazonick, 1975).

By the late 1800's, the U.S. population had become
predominantly urban and as community-oriented mutual care-
giving further broke down, a demand for both private-duty
nursing and hospital nursing grew, as did physician's use
of hospitals. As allopathic medicine claimed for itself the
function of curing illness, it increasingly was prepared to
delegate bedside caring to others, those others were nurses
(Ehrenreich and English, 1973).

Nursing was, from the outset, construed as subordinate
to the medical profession; its tasks were delegated to it
by physicians who continually characterized the work as
simple-minded if not superfluous. The Goldmark Report of
1923 (the nursing version of the Flexner Report) acknowledged,

We have the extreme view expressed by many
physicians that for bedside care the present
nurse is 'over-trained;' that her charges are
so exorbitant as to be prohibitive to all but
the very rich; that the nurse is merely the
doctor's 'extended hands;' hence, that any
biddable girl can quickly be trained to
obtain the necessary deftness and skill to
carry out his orders (Goldmark, 1923: 162,
quoted in Cannings and Lazonick, 1975: 198).
The medical view was not only an outgrowth of arrogance but
a largely successful strategy to undermine organized nursing's

claims to special knowledge and skills which differentiated

it from the lay public. In a manner akin to the capitalists'

73

discovery that the degradation and segmentalization of work
makes workers more vulnerable to replacement (cf. Braverman,
1974), physician efforts to carefully circumscribe nursing's
role enabled medicine to successfully depress efforts at pro-
fessionalization by effectively utilizing the growing reserve
army of unemployed women. Medicine was essentially closed
to women (Walsh, 1977), while nursing was a rapidly expanding
woman's occupation. Discrimination against women in employ-
ment throughout the economy truncates women's opportunities
for wage work. This creates greater vulnerability to exploi-
tation by placing women workers in a "female job ghetto,"
(cf. Howe, 1977; Blaxall and Reagan, 1976) and intensifying
competition between women for jobs. As Brown (1975: 174)
notes,

Few occupations are open to women whereas

many are open to men. Out of 80 major

occupational categories listed in the 1970

United States Census, seven occupations con-

tain 43 percent of all women workers. One

of these occupations is nursing. Non—white

women are concentrated in service and labor

occupations.

Historically, nurses worked long hours for extremely

low wages or no pay at all, ostensibly receiving training.
In fact, the development and expansion of the nursing labor
force facilitated and encouraged the growth and expansion
of hospitals (and helped fill the coffers of medical schools)
in part because cheap, subordinate nursing labor power made

such undertakings by physicians profitable (Ashley, 1977).

An 1894 statement by a nursing educator summed up the

74

situation, "Practically, then, the hospital secures nursing
for $12 a month on its payroll, which at its market value
would bring at least $15 a week..." (Deck, 1894, quoted in
Cannings and Lazonick, 1975: 193). The vast majority of
hospital laborers were, until the 1930's, nursing students
who typically worked more than a forty-hour work week. This
meant that nurses were unable to determine the content of
their education most of which was "learning by doing." The
hospital nursing supervisor was answerable to the hospital
director whose interest typically contradicted that of the
nursing leadership.

Meanwhile, organized medicine had, as previously noted,
become increasingly interested in hospitals in the 1910's
and 1920's. Ashley (1977: 86-7) points out that this expanded
interest included an overt focus on nursing. While the
Goldmark Report of 1923 was the product of a Rockefeller-
funded study of nursing education, the committee which under-
took the project was composed not exclusively of nurses but
of elite male physicians with ties to prestigious medical
schools, RNs and some other women. Its suggested reforms
were moderate, particularly in contrast to those of the
Flexner Report; it recommended, for example, the licensing
of registered nurses to distinguish them from the growing
ranks of untrained "practical nurses," (Cannings and Lazonick,
1975: 197).

During the 1920's and 1930's, numerous AMA committees

75

undertook studies of nursing. In 1927, the AMA's position
on nursing was that:

All surveys, studies and recommendations

shall emanate from the American Medical

Association and not from any newly consti-

tuted independent organization. The problem

of nursing education and service is a vital

one to the public and to every physician.

It is a problem in which.we should exert

and evidence opinions and recommendations

and accomplish their institution. It is a

service we owe to the public, to hospitals,

to training schools and to fellow members.

The American Medical Association should, yea

must, undertake its solution and formulate the

result and principles when they are announced.

We become negligent and shirk our responsi-

bilities and forfeit guiding direction if

we delegate the task to others (JAMA, May 21,

1927, quoted in Ashley, 1977: 87).
Thus organized medicine sought to supersede nursing in con-
fronting and resolving the problems of nursing education
many of which it had helped to create. Concomitantly,
leaders in nursing education, in an effort to upgrade their
educational facilities decided to cooperate with the American
Hospital Association. While the nursing educators hoped to
create affiliations with colleges, or failing that, high
high schools in an effort to provide solid scientific train-
ing, Ashley concludes that their efforts were largely un-
successful and had the unanticipauzed effect of strengthen-
ing AHA control of nurses' training. Finally, in the 1940's
the National League for Nursing changed course and set its
own standards for accrediting nursing schools. Nonetheless,
"...collegiate education for nursing did not take hold until

the late 1940's and early 1950's, and hospital schools remained

76

the chief route of entry for most nurses" (Fitzpatrick, 1977:
824). When, after WWII, junior colleges emerged and pro-
duced two-year RNs, three levels of nurses emerged--2-year
programs, 3-year hospital programs and baccalaureate degree
programs--all of which were called RNs and took the same
licensing exams. Frequently, they did the same work in

hospitals.

Nursing Practice

 

It has been suggested that professional socialization
of baccalaureate nurses does not actually prepare them for
the routine and subordinate work they are likely to be engaged
in. It may be, as the title of Kramer's (1975) book suggests,

Reality Shock--Why Nurses Leave Nursing, a depressing

 

realization. For while nursing education has improved dra-
matically and prepared nurses for more knowledgeable and
autonomous work, the circumstances in which they work stifle
their independence. In fact, the dropout rate among graduate
nurses is so high that it cannot begin to be explainedby
factors such as competing familial responsibilities. It is
well above rates for comparable predominantly female occupa-
tions, such as primary education. The following chart
illustrates the distribution of activity among graduate

nurses based on 1970 data (Sadler, et al., 1972: 60).

77

Figure 3.1

Distribution of Activity Among Graduate Nurses

   

   
 

 

24% (325,000) 24% (325.000)
Don't Maintain Maintain license
license but Don't Practice

    
      

 

 

15°lo (200,000) 37°lo (500.000)
Practice full-Time Nurses
\ Part-Time (Includes
\ Prartitioners,

[dumlom and
Administrators)

It is certainly plausible that many innovative and
independence-oriented nurses are driven out of traditional
nursing practice by the repetitive and mundane nature of
much of the work. Many others, perhaps out of economic
necessity, are compelled to submit to performance of routine
tasks. Hofling, et al., (1960) conducted a study in which
hospital ward nurses were given erroneous orders for medica-
tion over the phone by a researcher impersonating a physician.
While phone orders are typically discouraged by hospitals
and several factors visibly indicated the "physician" had
ordered an excessively large dosage, researchers were sur-

prised at the nurses' overall uncritical willingness to

78

carry out orders. Bullough (1975) has argued that nurses

have been socialized into subordinate behaviors (for example,
passive-aggressive behaviors or coyness) which makes it diffi-
cult for them to accept opportunities for increased inde-
pendence if and when they become available. However, rather
than "blaming the victim," Brown (1975) points out that such
behaviors are components of broader gender behaviors and,

with Henley (1977) and Kanter (1977), emphasizes that they

are more symptoms than causes of social, legal and economic
power differentials of social actors. Where promotion

out of this routine execution of orders has been formally
available to some nurses, it has historically taken the
form of administrative, rather than care-giving work.

While Brown (1975) has observed that compared to other
women's occupations, nursing wages and working conditions
(for example, steady employment) are not particularly bad,
Cannings and Lazonick (1975: 189) suggest that, "When educa-
tional credentials, skills, and responsibility are taken
into consideration, nursing workers in general are poorly
paid relative to other occupational groups in the U.S.
economy."

Leaders in the nursing professionalization movement
might well have not foreseen the intense subordination of

nurses in hospitals. Even in the Goldmark Report of 1923,

79

the concern with hospitals was a concern about nursing ed-
ucation, not employment. In 1920, only about 10 percent

of nurses worked in hospitals. Most RNs engaged in private-
duty nursing in which they were not immediately subordinated
to physicians. During the "Progressive Era" public health
nursing developed rapidly as reformers became concerned
with sanitation in urban areas and diseases among the lower
classes. Here too, nurses were relatively autonomous in
their daily work. But during the Great Depression, private-
duty nursing contracted sharply as the market for it shrank;
families were simply unable to afford it. The glut on the
nursing labor market drove down nursing wages sharply,
ultimately making many hospitals willing to close their
nursing schools and hire graduate nurses. Then, during the
1930's, hospital-based medical care grew dramatically, an

outgrowth of, ...the development of capital-intensive
medical techniques . . . (b)ut perhaps moreimportant. . . the
development of hospital insurance," (Cannings and Lazonick,
1975: 199). Thus, as external opportunities for nursing
employment contracted, institutional nursing employment
expanded. The result was that nursing as a whole was brought
more firmly under medical control.

Once in the hospital, the internal stratification of
nursing became more pronounced and overt. Organized nursing

had not been able to resist the earlier medical and hospital

development of the lower-paid and more tractable licensed

80

practical nurse. However, the RNs were able to gain some
control over the licensing of LPNs and to subordinate them

in the hospital division of labor. Further subordinated
were the growing ranks of nurses' aides, positions fre-
quently occupied by women of color. So, by 1950, the process
of internal stratification of nursing had come to be institu-
tionalized and drawn into the highly articulated division

of labor in medical care (Cannings and Lazonick, 1975: 201).

The Expanded Role of the Nurse

 

Embarking on a new direction in the quest for pro-
fessional status, nursing.has developed clinical specialists,
for example, nurse anesthetists. While they present competi-
tion to anesthesiologists, they have successfully resisted
medical efforts to eliminate them. One reason this and other
nursing specialties represent competition to physicians is
that the nurses work for considerably lower wages; they have
proved attractive to Health Maintenance Organizations, among
other medical delivery systems (Neuhoff, 1977; cf. Ellwood,
et al., 1971). In response, physicians have developed as
substitutes, technicians who have lower skills and are under
the control of both organized medicine and individual physi-
cians in practice (Brown, 1975: 178).

In the late 1960's, programs fortraining the newly
created pediatric nurse-practitioner were developed with
the blessings of the leadership of pediatrics. They re-

ceived a mixed response from practicing pediatricians (Baron,

81

1971; Bell and Misbach, 1971). But physicians were increas-
ingly being alerted to the benefits of hiring nurse-
practitioners, including both extending their own practices,
providing care not previously practicable and, through proper
management, realizing a good return on the investment (Oken
and Golden, 1975: 352).

By 1974 there were over 100 programs providing training
for "role extension" for nursing (Oken and Golden, 352).
Despite its apparent success on the educational front, the
concept of nurse practitioner or nurse-clinician has received
active debate in nursing journals. For example, Murphy
(1970) emphasizes the difference between role-extension--
the addition of new tasks to nursing routine, or horizontal'
extension of duties--and role expansion—~broadening the
sc0pe and autonomy of nursing, or vertical expansion of
nursing function and practice. Many support the concept
of the "role extension" or the "expanded role of the nurse"
as presenting a viable opportunity for nurses to achieve
professional status and in so doing, demonstrate the inde-
pendence of which nurses are capable (MacPhail, 1976;
Mauksch, 1975).

Some nurses argue that what is really needed is not
new expanded roles for a few nurses but recognition of
"...the unnumerable independent decision-making functions...
nurses (already perform):

Nurses may take histories, observe symptoms,

even suggest diagnoses and treatments, but
they are careful to only 'suggest' since

82

the physician is the one who is legally
responsible for making the diagnosis and
ordering treatment. This is why it's kept
very quiet when nurses write prescriptions
over the physician's signature on the pre-
scription blank. Physicians may write
innumerable p.r.n. (to be given as needed)
orders to cover any expected contingencies,
but little consideration is given to the fact
that it is the nurse who decides when the med—
ication or treatment is needed. Nurses'
opportunities to operate as independent prac—
titioners have been limited by the fact that
nurses cannot provide nursing care required
by a non-institutionalized person and

bill for third-party payment. The physician,
though, can hire the nurse, pay her a salary
and bill for her services given to the patients
(Yeaworth, 1976: 8).

Thus, nurses need to seek greater recognition of their
actual work and further independence as a group, this
position argues. While it is typically suggested that this
be achieved through further efforts at professionalization,
more and more voices charge that professionalism, (the
ideology of professions, or acting as though one had pro-
fessional status, including a service ideal), has gotten
nursing nowhere fast (The Boston Nurses' Group, 1978).
Increasingly, nurses are organizing into unions (Sexton,
1982), however, this still seems the minority position among
nurses.

Still others (Rogers, 1975) have pointed out that the
"expanded role of the nurse" was largely the outcome of medi-
cal interests for meeting "manpower" needs without producing
competitors for physician salaries. By accepting physician-

structured training (cf. DHEW, 1976: 3556), Rogers argues

83

nurses are giving up or at least undercutting their own
claims to unique nursing contributions and are becoming
junior doctors. Meanwhile, Brown (1975) points out, should
nurse-practitioners consider competition with physicians,
medical schools have developed acnunter-part practitioner,
the physicians-assistant, designed to undercut them (cf.
Schneller, 1976).

Nonetheless, nurse-practitioners appear to be more
satisfied with their work and receive considerably higher
incomes than other care-giving nurses. They successfully
perform primary care-giving functions, including managing
cases, frequently improving outcomes. Patient acceptance
has been generally quite high, especially when accompanied
by physician support. Acceptance by pediatricians, inter-
nists and family practitioners has been good. Again and
again, nurse-practitioners anticipate and value an expanded
scope of autonomous practice as well as collaborative re-
lationships with physicians (Dunn and Chard, 1980).

Medicine has helped to spawn new health practitioners
who, to a greater or lesser extent, have come to value the
autonomy associated with professional status. Nurse-
practitioners are organized into national associations and
are actively pursuing their own interests. The development
of their occupations, as well as their effects on nursing's
continuing efforts to professionalize, will be intriguing.

One of these nursing specialities, or expanded roles,

is nurse-midwifery to which we turn next.

Chapter IV

The Development and Rediscovery of Nurse-Midwifery

Introduction

 

The nurse-midwife was a product of Progressive Era
reformers' efforts to improve maternal and infant health
among the lower classes. Due to their public health work,
nurse-midwives were not drawn into hospital practice during
the 1930's as were the bulk of other nurses, who then
experienced intense subordination to physicians, routiniza-
tion of work and fragmentation and stratification of the
occupation. In fact, while nurse-midwives were always few
and marginal in medical care, they were considerably more
autonomous than their fellow nurses in hospital practice.
After considering the history and development of nurse-

midwifery in the U.S., we shall return to this observation.

‘The Early Development of Nurse-Midwifery in the U.S.

 

As early as 1911, the concept of a nurse with special
training in midwifery was being suggested in America (Litoff,
1978: 122). However, the idea found little substantial support
until the formation of the Maternity Center Association in
New York City in 1918. The Association, originally comprised
of nurses, mothers and obstetricians, was an outgrowth of
the rising concern with public health. The (lay) midwives

had largely been eliminated and fee-for-service medical

84

85

practice developed at the same time that the U.S. was

rapidly industrializing and large numbers of immigrant
workers were entering the country. The result was that large
numbers of people were underserved or unserved.

The Maternity Center Association set out to improve
maternity care, particularly ante-partal care, in the city;
it developed a three-part plan to achieve this goal. By the
end of 1920's, the Association came to regard its first two
goals as effectively met through the establishment of matern-
ity centers throughout the city and the more widespread pro-
vision of prenatal and rudimentary childbirth education to
pregnant women and their families. It then turned toward
its third goal, the improvement of antepartal nursing.

After having initially been thwarted in its effort by
the Public Health Department, the Association developed a
school for teaching midwifery skills to nurses. The
Association for the Promotion and Standardization of Midwifery,
Incorporated, an outgrowth of the Maternity Center Association,
opened the first nursedmidwifery school in the U.S. in New
York City in 1932. The school's stated objective was to
"...prepare nurse-midwives to assume responsibility for the
supervision, care and instruction of women during pregnancy,
labor and puerperium, under the guidance of a competent
obstetrician," (Maternity Center Association (MCA), 1955:

18).

86

The school, located in Harlem, was associated with a
maternity clinic which both served the largely Puerto Rican
population and allowed the nurse-midwifery students to obtain
clinical experience. Emphasizing its public health orienta-
tion, the school required of its students a background in
public health nursing which was then supplemented in the
nurse-midwifery education. Clearly, the precedent of utiliz-
ing nurses specially trained in midwifery for "marginal"
pOpulations, with the aim of improving public health, was
set in the first nurse-midwifery school.

The nurse-midwifery service was primarily a home—
birth service in which nurse-midwives provided the bulk of
the care for women whose pregnancies and births were proceed-
ing normally, active care and back-up by obstetricians were
readily available to the nurse-midwives. In light of this
fact, it is particulary interesting to see that the data
they generated are so good. In the first four years of its
existence, the safety of the service compared very favorably
with the surrounding area of the city (which generally repre—
sented a lower risk population). The MCA maternal mortality
rate was 1 per 1000 live births, compared to 10.4 per 1000
live births in the surrounding area. Similarly, the rate of
neonatal deaths (21/1000 live births) was less than half
that of the rest of the district (Litoff, 1978). Data for
the twenty year period 1932-1952 showed a maternal mortality

rate of 0.9 per 1000 live births (MCA, 1956: 32).

87

While the Maternity Center Association's midwives
served an inner city population, the public health role of
nurse-midwifery had earlier and independently been under-
taken in the service of a rural population in Kentucky.
In the 1920's, Mary Breckenridge, a nurse from Kentucky,
began an effort to improve maternity care for the rural
poor in the mountains of her home state. After completing
nurse-midwifery training in England, she returned and helped
form the Kentucky Committee for Mothers and Babies. Together
they embarked on the development of a nurse-midwifery service
in Leslie County, Kentucky. So isolated and underserved was
the area that nurse-midwives traveled by horseback and per-
formed extensive public health nursing work. For example,
an early project, undertaken at the request of the physician
in charge of the state health commission, was the inoculation
of residents to clear up diptheria and typhoid, which had
been endemic to the region (Browne, 1968: 76).

The influence of British midwifery training and practice
was strongly felt in both early nurse-midwifery programs,
The early nurse-midwives in Kentucky, in what came to be known
as the Frontier Nursing Service, were either British or were
Americans trained in England. Although American—trained
midwives became involved after the Maternity Center in
New York City began graduating its first classes, foreign-
trained midwives still predominated. So significant was

the involvement of nurse-midwives from Britain that their

88

return to England in 1939, at the outbreak of World War II,
necessitated the establishment of the Service's own school
of nurse-midwifery in the same year (Litoff, 1978: 127).
In the Maternity Center Association's deve10pment of

nurse-midwifery training, the nurse-midwife was construed
as a blend of public health nursing, obstetrical nursing,
midwifery training and close cooperation and consultation
with obstetricians. This particular configuration was,
"...designed to unite the best of medicine and nursing in
the service of mother and family," (MCA, 1956: 22). While
early physician supporters of nurse-midwifery characterized
the occupation as physician extenders or obstetric technicians
(Watson, 1931), the influence of British training and models
of midwifery practice provided a counter-weight. The
perspective of British midwifery contrasted with the
developing interventive orientation of American obstetricians
(Anisef and Basson, 1979). And, as the first nurse-midwife
on the staff of the MCA school was trained in London, the
influence of this alternative view was felt from the outset.

As in England, the concept that child-

bearing is a normal process was the domi-

nant philosophy....The coursestressed the

normal process of the maternity cycle,

while giving due weight to the recognition,

evaluation and the care of deviations from
the norm (MCA, 1956: 23).

89

Early Physician Involvement in the Development of Nurse-Midwifery

 

While much of nurse-midwives' training was drawn on the
British midwifery model, control of the nascent occupation
was in the hands of American obstetricians. The impetus for
the development of nurse-midwifery came, in part, from the
leadership of organized obstetrics. In addition, nurse-
midwifery's continued existence has been contingent upon
obstetrician support or at least the absence of organized
opposition from the medical specialty which dominated its
market. The previous analysis of medical involvement in nurs-
ing and other subordinate occupations, indicates that medi-
cine demonstrates an active interwast in the development
of any occupation which represents potential competition.

From the outset, physicians have been actively involved
in shaping not only nurse-midwifery education and practice,
but also the occupation's ideology, including claims to a
special contribution to care-giving. Benjamin Watson, an
early supporter of nurse-midwifery was a professor of
obstetrics and gynecology at Columbia University's College
of Physicians and Surgeons. He sought to delineate the para-
meters of the occupation and clarify its relationship to
obstetrics.

I believe that the maternal mortality in

this and every other country would be very
materially reduced if the practice of
obstetrics were in the hands of thoroughly
trained midwives working in conjunction with

and under the supervision of properly trained
doctors....I believe that such a system would

90

work out not only to the benefit of the
patient but to the economic advantage of
the doctor. To the latter would belong
the whole responsibility of prenatal care
and the determining of the ability of the
patient to go through a normal labor.

...by a trained nurse-midwife, I mean
a nurse who has a full general hospital and
who subsequent to that has had a least a
year's training in the delivery room, wards,
clinic and outdoor practice of a maternity
hospital. With such a training, she ought
to be able to act as obstetric technician to
a doctor. The doctor with a busy practice
has an office nurse and technician who does
his x-ray work, his blood counts and his
chemistry. . .a nurse can become just as expert
and reliable in conducting normal delivery
as can a technician in doing a blood count
or blood chemistry. ...there is a great
opportunity to graft upon our present system
of practice all the best features of the best
type of midwife practice abroad.... I should
like to see every obstetrical hospital with
a staff of trained midwives so that when a
doctor sends in his patients...he has the
assurance that a normal delivery can be
conducted in his absence (Watson, 1931,
quoted in MCA, 1956: 13).

While several elements of his statement indicate a con-
cern about nurse-midwife's subordination to the obstetrician,
he nonetheless seemed willing to grant nurse-midwives an
element of autonomy in practice and agreed that thorough
training was required. Further, this argument for nurse-

midwifery appeared in the New York State Medical Journal,

 

and it is possible that he sought to address his readership
in terms meaningful to them. Despite the overt concern with
the interest of obstetricians in his article, he was roundly
criticized by many of his colleagues in subsequent issues
(Strachan, 1968: 72). It is likely that the obstetrician's

leadership's support for nurse-midwifery was a self—interested

91

as that of the average practitioner, but it was less
immediately subject to market forces and thus able to take

a longer view. Therefore, Watson sought to instruct fellow
practitioners in the potential benefits ultimately available
to them in return for their support of nurse-midwifery.
However, here as elsewhere, the process of agreeing on
collective interests and subordinating individual interests
to them was problematic.

The need to avoid antagonizing obstetricians while
engaging their self-interested support was expressed by
Dr. Lobenstine, a primary supporter of nurse-midwifery for
whom the first New York clinic was named. He asserted that,
"...(if) midwifery is to succeed in this country a means of
bringing all midwives under medical supervision must be
devised," (Kosmack, 1943, quoted in MCA, 1956: 14).

The extent to which obstetricians were involved in the
formation of the first school of nurse-midwifery and the clinic
associated with that school may be suggested by their repre-
sentation on the boards of directors, the membership of which
overlapped almost totally. Six of the eight members of
the clinic's board were obstetricians. The executive commit-
tee of the organization, which was engaged in developing the
nurse-midwifery school was comprised of three obstetricians
and one nurse who was the organization's general director.
One of the obstetricians who sat on both boards was the

editor of the American Journal of Obstetrics and Gynecology

92

as well as chair of the medical board of the Association

of Obstetricians and Gynecologists (MCA, 1956).

Nurse-midwives and the Professionalization Project

 

For its part, nurse-midwifery was initially less
concerned withtiuaissue of control of education and training
(Larson's, "production of producers") than it was with
establishing the education. Having begun to delineate (or
have others delineate for them), a cognitive base--drawn in
large part from British midwifery and public health nursing-—
participants in the occupation set out to establish additional
education programs for nurse-midwives.

Graduates from both the Maternity Center Association
and the Frontier Nursing Service were instrumental in creat-
ing additional nurse-midwifery services and schools. This
was important for a number of reasons. First, it both
demonstrated some key dimensions of the potential contribu-
tions of nurse-midwifery practice and helped to expand the
available number of nurse-midwives. Outside nurse-midwifery-
initiated programs, nurse-midwives tended to be drawn into
public health nursing supervision (including efforts to
train and/or restrict "granny midwives"), education of
maternity nurses or practice in overseas nursing services.
While such work met significant needs and broadened the
influence of nurse-midwifery in nursing, it diluted nurse-
midwifery and severly limited actual practice of the occupa-

tion in the U.S.

93

In the 1940's, two new services and schools were begun
by nurse-midwives. From 1941 and 1946, the Tuskegee Program,
which.was aimed at training Black nurses in midwifery, grad-
uated 25 nurse-midwives and provided high quality maternity
services to rural Alabama. The Catholic Maternity Institute
of Santa Fe, New Mexico, began its nurse-midwifery service
in 1944 and in the following year developed a school in
conjunction with the Catholic University of America. Operat-
ing until 1968, the school graduated over 90 nurse-midwives.
The Columbia University Program admitted its first class in
1955, and John Hopkins began a nurse-midwifery training
program in 1956. In 1958, the Maternity Center Association
linked its educational program with Kings County Hospital
and the State University of New York Downstate Medical
Center. While the fortunes of the nurse-midwifery schools
were mixed, by 1962 a known total of 750 graduates had been
produced by six schools (American College of Nurse-Midwives,
1965).

The 1950's and 1960's marked a watershed in nurse-
midwifery. Previously, the growth of educational programs
was slow and uneven, then,

...in the middle 1950's the demand for
maternity personnel having nurse-midwifery
education began to rise. This heightened
demand resulted in an increase in the number
of nurse-midwifery schools. More educational
programs have been initiated in the past

twe ve years than had been available in the
previous 23 years. Most of these programs

are on a post-baccalaureate level and more
universities would initiate programs of

94

graduate education with specialization

in nurse—midwifery if qualified faculty

were available to staff them (Runnerstrom,

1968: 90).
While in 1964, data indicated that of the fewer than 1,000
nurse-midwives in the U.S., less than 40 were engaged in
active practice or teaching (Thomas, 1965, cited in Ander-
son, 1968), nurse-midwifery education had entered the main-
stream of nursing and medical educational facilities, pro-
duction was stepped—up and more graduate nurse-midwives
were going into nurse-midwifery practice. In addition, where
earlier, l-year certification programs had been the rule,
more schools were conferring master's degrees, some taking
it upon themselves to train nurse-midwifery educators .
(Barnes, 1968: 43). Nurse-midwifery had been "discovered"
as one nurse-midwifery educator noted, "Suddenly, in the
last three years or so there is tremendous interest in this
particular discipline. Before that, nobody was interested.
Now, everybody wants to have a school for midwifery" (Keane,
1968: 101).

What I have been describing is a kind of "take-off"
point in the education and development of nurse-midwifery.
What is there to explain the change in the fortunes of the
occupation? Is this the result of an active and unified
professional organization?

In fact, a professional organization for nurse-midwives

was relatively slow in developing. Nurse-midwifery's

efforts to create a professional organization succeeded when,

95

in 1945, a special section on nurse-midwifery was established
within the National OrganiZation for Public Health Nursing
(NOPHN).- However, after NOPHN was disbanded in 1952, nurse-
midwives were again without a formal organization with
which to pursue their goals. After two years of being unable
to find an appropriate niche in either the American Nurses'
Association or the National League for Nursing, they decided
to create their own organization. This also enabled them
to create an maintain ties with other midwifery organizations
abroad, many of which were not affiliated with nursing. By
1955, the American College of Nurse-Midwifery was begun.
Later, in 1969, a merger with the American Association of
Nurse-Midwives, based in Kentucky, formed the American College
of Nurse-Midwives (Litoff, 1978: 127-8).

In 1962, the College conducted a study of its membership
to acquire information about their education and practice.
In the mid-1960's, almost wholly on volunteer time, members
of the College began to develop standards of practice and
set up criteria for the evaluation of educational programs.
But by 1968, the ACNM still had fewer than 400 members
(Kean, 1968: 100).

So, the impetus for the rapidly expanding development
of nurse-midwifery in the 1950's and 1960's cannot be
explained by a powerful professional organization. What then

were the reasons for the emerging trends?

96

The medical profession and the federal government began
to carefully examine the availability of labor power in
medical care during this time period. Many analysts projected
physician shortages (Peckham, 1968; Jacobsen, 1968), and
consequently interest in so-called allied manpower was growing.
In addition, concern with population control was emerging
as an interest of federal government, some elites and others,
and foundation monies were becoming available for these
projects. (Interestingly, this concern coincided with the
growth of the American Civil Rights movement and liberation
movements in the Third World.) Labor power concerns were
increased with the passage of federal third-party payment
for the poor and the elderly, the Medicaid and Medicare
legislation. As planners began to embark on the development
of new "allied health workers," including the "expanded role

of the nurse, they rediscovered nurse-midwifery.

During the 1970's programs for nurse-practitioners
burgeoned. By 1976, nurse-midwives constituted only a small
percentage of all nurse-clinicians (the terms are often used
interchangeably, indicating in part their varied origins
and the difficulty of unifying the concept). Nonetheless,
in a 1976 study of nurse-practitioners education (Sultz,
et al., 1976), (which included nurse-midwives) findings showed
that nurse-midwives had the lowest certificate-to-Masters-

student ratio (that is, they were upgrading their education

more successfully). In addition, the faculty-to-student

97

ratio was higher in Master's programs than in certificate
programs. And certificate programs relied more on physicians
and less on nurses as teaching staff than did Master's pro-
grams. Further, nurse-midwifery programs compared very
favorably with other nurse-clinician training programs in
that they had more teaching personnel overall and those
teachers were more likely to be nurse-midwives. Finally,
the nurse-midwifery programs tended to have longer didactic
components in both Master's and certificate programs, than
other nurse-practitioner programs. They also were much less
dependent upon preceptorships (apprenticeship training).
This information indicates that nurse-midwives had been much
more successful in upgrading and standardizing their educa-
tion. They seem to have gained significant control of their
education (thus, the production of producers) and this has
helped them considerably to make claims to a reliable
practitioner (product) capable of giving quality care in a
specific area of expertise. That is, it enabled them to
begin to assert a unique or special contribution to care-

giving.

Delineation of the Occupation and Claims to Special

 

Contribution to Careegiving

 

As early as 1966, the American College of Nurse-Midwives
developed a definition of the nurse-midwife.
The nurse—midwife is a registered nurse who

by virtue or added knowledge and skill gained
through an organized program of study and

98

clinical experience recognized by the ACNM

has extended the limits of her practice into

the area of management of care of mothers

and babies throughout the maternity cycle

so long as progress meets criteria accepted

as normal (ACNM, 1966, quoted in Olsen,

1964: 463).
The criteria of "normal" turn out to be central to the
definition and practice and are not as objective as they may
seem in this statement (Rothman, 1982), but we shall turn
to this t0pic later.

Nurse-midwives were faced with the task of differen-
tiating themselves from nurses engaged in related work, for
example, maternity nurses, a task necessitated in part by
their new-formed expansion but perhaps more importantly by
their more subtle shift into hospital practice where daily
interaction with maternity nurses and others was rapidly
becoming a reality. What distinguishes nurse-midwives
from.others according to this definition, is the ”management
of care" that is, they are attempting to lay claim to an
area of care-giving in which they are at least somewhat
autonomous.

A neat distillation of the nurse-midwifery ideology
is presented by Brennan and Heilman (1977) who enumerate
the central characteristics of nurse-midwifery's claims to
special contributions. They emphasize that nursedmidwives
are women and as such can more easily have empathy and

rapport with women. They are not doctors and are neither

pathology- nor technology-oriented. Though they are able

99

to recognize pathology, they are tained to manage normal
labors and births. Several authors stress that nurse-
midwives are nurses, and thus bring a nurturing and family
orientation to their care-giving, that is, they do not leave
the social person in the waiting room while they examine

the body (Runnerstrom, 1968). As Kean (1968: 98) suggests,
many nurses enter nurse—midwifery out of a conViction that
"...through midwifery they will be able to assist in provid-
ing a service that is really family-centered, rather than
pelvis-centered or perineum-centered."

The nurse-midwives assert that, because of their special
orientation to care-giving, they are non-interventionist and
inclined to be flexible whenever possible--that is, they
are client-centered. They sometimes cast themselves as
patient advocates. They encourage prepared childbirth and
the presence of fathers (or other significant others) at
labor and birth. (The MCA was an early and outspoken pro-
ponent of prepared childbirth). Nurse-midwives provide
labor support in addition to attending the delivery. Since
they also are trained to provide prenatal, post-partal and
interpartal care, nurse-midwives can provide a kind of
continuity of care which is increasingly uncommon in the
face of the trend toward further fragmentation of health
care delivery. Accessibility is another asset of nurse-
midwives, who pride themselves on having time to spend with

clients to talk; in fact, nurse-midwives view patient education

100

as one of their purposes (MCA, 1956: 47). Additionally,
nurse-midwives provide lower cost care since their incomes

are dramatically lower than physicians'. Finally, nurse-
midwives all seem to echo the sentiments that they should

and do function as an integral part of the health care "team."

The Journal of Nurse Midwifery, the official publication

 

of the ACNM, includes in every issue the following information
which formally defines both the nurse-midwife and nurse-
midwifery practice, (see Appendix B for ACNM documents):

WHAT IS A CERTIFIED NURSE-MIDWIFE?

A certified nurse-midwife (CNM) is an
individual educated in the 2 disciplines
of nursing and midwifery, who possesses
evidence of certification according to the
requirements of the American College of
Nurse-Midwives.

WHAT IS NURSE-MIDWIFERY PRACTICE? Nurse-
midwifery is the independent management of
care of essentially normal newborns and
women, antepartally, intrapartally and/or
gynecologically, occuring within a health
care system.which provides for medical con-
sultation, collaborative management, or
referral and is in accord with the Functions,
Standards, and Qualifications for Nurse—Mid-
wifery Practice as defined by the American
College of Nurse-Midwives.

The Nurse-midwife provides care for the
normal mother during pregnancy and stays with
her during labor and delivery. She evaluates
and provides immediate care for the normal
newborn. She helps the mother to care for
herself and for her infant; to adjust the
home situation to the new child, and to lay
a healthful foundation for future pregnancies
through family planning and gynecologic ser-
vices. The nurse-midwife is prepared to teach,
interpret, and provide support as an integral
part of her services (Journal of Nurse-Midwifery,
25(1), 1980).

101

These statements, based on formally agreed-upon guidelines
adopted by the College in 1975, indicate the extended scope
and more careful delineation of the occupation. In addition,
after 1971, graduates of accredited nurse-midwifery educa-
tional programs were able to sit for the national ACNM exam,
upon successful completion of which they became certified
nurse-midwives and therafter took the initials CNM. We will
hereafter refer to nurse-midwives, as they themselves do,

asCmm.

The Concept of the Team Approach in Maternity Care

Of even greater importance to the development of nurse-
midwifery than the guidelines of its own organization, was
the Joint Statement of Maternity Care (Appendix C, p. 298 ).
This statement was written and endorsed by the American
College of Obstetricians and Gynecologists (ACOG), the Nurses
Association of the American College of Obstetricians and
Gynecologists (NAACOG), and the American College of Nurse-
Midwives (ACNM), and it represented several years of negotia-
tion and collaboration.

With this statement, nursedmidwives were officially
brought into the medical division of labor in a specified
manner via the formal recognition of the team concept. With
an agreed upon goal of the improvement of maternity care,
the statement made several recommendations, largely specifying

team members' contributions. The first two are as follows:

102

1. The health team organized to provide
maternity care will be directed by a
qualified obstetrician-gynecologist.
2. In such medically-directed teams, qualified
nurse-midwives may assume responsibility
for the complete care and management of
uncomplicated maternity patients.
In addition, nurses and other health care workers were expected
to contribute to the team according to their education and
capabilities.

The team concept was not new, having been discussed in
the medical and nursing literature for several years. For
nurse-midwives it was perhaps the way to come to terms, as
autonomously as possible, with Lobenstine's prediction that
nurse-midwifery's success would require some structure of
medical supervision. At the same time, it was a vehicle to
acknowledge the contribution of maternity nurses in an
effort to minimize boundary disputes in that area.

However, the team concept also represented some real
drawbacks for nurse-midwives. Obstetrician-led teams meant
that an expert in obstetric pathology and surgery would be
superviSing an expert (the NM) in normal physiology. Also,
the notion of obstetrician-directed teams was a far cry from
the successful founding practices of nurse-midwifery in the
U.S., the Frontier Nursing Service and the Maternity Center
Association. Begun in 1932, the Maternity Center Association
developed its division of labor in health care in the post—

depression years. During World War II, the demands on the

medical staff encouraged restricted use of the physicians'

103

time. After physicians had conducted initial exams, patients
whose pregnancies progressed normally were seen by nurse-
midwives who also attended their births, if no complications
appeared. This structure enabled obstetricians to focus on
their specialty: pathology (MCA, 1956). Meanwhile, the
duties of the nurse-midwives in the Frontier Nursing Service
were indicated by the nature of their training,

Our students are taught to give total care

to the normal childbearing woman and her new-

born baby; to recognize the abnormal for which

the physician is called; and to institute

emergency measures should it be necessary

before the arrival of the physician (Browne,

1968: 78).
Furthermore, both services generated data on outcomes which
were far superior to national averages, even on poor and
thus, higher-risk populations. It also contrasts with
conceptions of the role of nurse-midwives articulated by
some nursing educators. For example, Coates (1968: 64-5)

"...share mutual respons-

indicates that the nurse-midWives,
ibility for the care of patients and their families...with
medical personnel" (cf. Barnes, 1968: 44).

Apart from the formal statement issued by ACOG, NAACOG
and ACNM, the team concept in health care has been variously
contrued. Some physicians have taken it upon themselves to
define nurse-midwifery's contribution to the team,

As for the role which (nurse-midwives) can
play on the obstetric team, the transcendant
contribution which they have to make is a

unique, personalized form of attention through-
out pregnancy, labor and the puerperium (birth).

104

By training, temperament, and outlook,
they are singularly fitted for this
important mission. This is their main
raison d'etre, (Eastman, 1953: 8-9).

 

While the team concept has been adopted formally by ACOG,
some physicians are wary of the vagueness of the term and
the possibility of broad or negotiable parameters. Some
even regard it as a potential vehicle for the erosion of
their professional power and pre-eminence. They seek to
further clarify and circumscribe the meaning of the term,
for they recognize that it could function as a Trojan Horse
for some aggressive professionalizing occupation.

The concept of a collegial relationship

between the nurse and the physician is

gaining wider acceptance, especially in

nursing. Fundamentally this is sound....

However, the role of the physician as leader

of the team.is being challenged.... I am

a staunch supporter of nurse-midwives, but

as members of physician-led teams, (Thiede,
1978: 923).

In contrast, other physicians (in this case pediatricians)
endeavor to critically examine both the potential and the
sources of problems of health care teams. They recommend a
model of collaboration in which the members' varied expertises
and abilities are equally valued and attention is given to
group processes, decision-making and communication.

To function effectively, a group needs many
acts of leadership: rather than one leader,
it needs many leaders.... (D)epending on

the situation and the problem to be solved,

different members can and should assume
leadership (Wise, et al., 1974: 541).

105

This phenomenon of physician willingness to negotiate team
functioning is uncommon but nonetheless occurs; we shall
subsequently see that while it is extremely rare among
obstetricians, it is more common among family practitioners.
Organized obstetrics thus creates for itself a potential prob-
lem albeit minimal, physician-headed teams create the possi-
bility of the appearance of physicians who defect from the
narrow definition of the team and seek to c00perate toward
care-giving in a more egalitarian model.

The team concept is not only prescriptive, defining
nurse-midwifery's functions and scope of practice, it is also
proscriptive, outlining the boundaries of practice which
must not be crossed. However, most subordinates are fairly
sensitive to the limitations to their actions imposed by
superordinates, even when they are not formally codified.

As early as 1955, nursedmidwives recognized obstetricians'
fears that nurse-midwives would compete with them and the
Maternity Center Association tried to quell them.
It cannot be emphasized too strongly that
the nurse-midwife should not function as a
lone worker, attempting to supply all the
elements which enter into complete maternity
service. Her strength and her skills are best
realized as part of an obstetric team,
supplementing, not supplanting, the other
members (MCA, 1956: 115).

With the development of the team concept, independent

practice for nurse-midwives came to be overtly proscribed.

This position was started by an obstetrician involved in the

Johns HOpkins nurse-midwifery graduate program (Barnes, 1968: 43).

106

The nurse-midwife...will function in a
medical center where adequate physician
consultation is available and where she

is a member of the team.... She will

most certainly not go into private practice
herself, nor will she move towards a return
to domiciliary care (e.g., home birth).

A decade later, another obstetrician again spoke of this
fear of nurse—midwives entering into independent practice
and becoming involved in home births, among other proscribed

activities (Thiede, 1978: 923).

(T)here are nurse—midwives actively promoting
home deliveries, free-standing childbirth
centers, independent practice for nurse-
midwives and even menstrual extraction and
abortions by nurse-midwives. To be fair,

in all the situations I know about, there
have been physicians involved in these activi-
ties to one degree of another. While these
views and activities are not necessarily
shared by a majority of nurse-midwives, it
seems unwise to establish programs that might
enhance the concept of autonomy. In short,

I think it is important to have the physician,
along with the nurse-midwives, involved in
seeing patients on a regular basis.

Restating the potential contribution to obstetrician-centered
care, Maeck (1978: 926) emphasized the team approach.

Today, (the nurse-midwife) is a very competent,
competitive professional.... Midwifery is

a valuable and natural counterpart of obste-
tric care, and is not, and should not be a sub-
stitute for the obstetrician: it should comple-
ment the obstetrician. It must not become an
independent provider of obstetric care. I
believe the obstetric and nurse-midwifery
leadership should continue to emphasize and

to reaffirm a joint statement made several
years ago which indicates that nurse-midwifery
is practice only in association with the
obstetrician and under the direct supervision
of professional medical care.

107

These physicians have been actively involved in the
leadership of organized obstetrics, and they are associated
with University Medical Schools and teaching hospitals which
incorporate nurse-midwifery practices.

Hellman (1978: 925-6) reminded his colleagues at the
eighty-eighth annual meeting of the American College of Ob-
stetricians and Gynecologists that their lack of foresight
had allowed them to miss a critical opportunity to gain con-
trol of nurse-midwifery, the result of which was a greater
threat of competition.

In the early 1960's...a committee of the
College (ACOG) was formed to discuss and to
recommend the relationship of nurse-midwifery
to the practice of obstetrics and gynecology.
This was the time of considerable agrument
about nurse-midwifery.... (The committee's)
first recommendation to the College was made
because we feared many of the things that have
happened. We feared a fragmentation of nursing,
so that there would be nurse-assistants, nurse-
associates, and what-not, with varying degrees
of training and responsibility. I do not

think we foresaw the rebirth of home deliveries.
(The then president of the ACOG, two other
Ob-Gyns and Hellman) at that time ran the
only-university—affiliated school of nurse-
midwifery that existed in the United States,

and it was our recommendation...that the
College assume accreditation of the schools

of nurse-midwifery in the United States...

but I think the recommendation, although it

was turned down, would have made a significant
difference in the organization of our specialty.
I am sorry, but I believe that the refusal of
that recommendation was a mistake.

For its part, the ACNM has formally acknowledged that

nurse-midwifery ...practice is continually evolving...(and)

(b)ecause of this the nursedmidwife may frequently be in a

108

position of having to evaluate a new function for possible
inclusion in her practice" (ACNM, 1979). Such inclusion may
represent expansion of function, or extension of function,
running the risk or making the nurse-midwife an extension

of the physician; this situation suggests that which con-
cerned nurses considering the expanding role of the nurse.
Toward enabling nurse-midwifery to accept the potential
inclusion of new functions while retaining its identity and
philosophy of care-giving, the ACNM developed initial guide-
lines for this process. Further, in its 1976 statement on
home birth, the ACNM noted that "...the hospital or maternity

home is the preferred site for childbirth...(but that) (w)here

 

home births are indicated, the obstetric team.must develop
guidelines which will ensure the safety of mother and infant

(emphasis mine)." Finally, the ACNM chooses to refer to

nurse-midwifery as ...an interdependent health discipline....
(ACNM, 1972).

This potential competition has, however, been more than
a contest of words. In its larger move to reassert hospital
birth and obstetric hegemony, organized obstetrics, in
tactics that suggest an effort to assert what Illich calls
a "radical monopoly," has sought to eliminate or severely
restrict nurse-midwifery practice where it has appeared
threatening.

As early as 1966, a nurse-midwifery demonstration pro-

ject in Madera County, California, which promptly and

dramatically improved health outcomes for the patient

109

population, was shut down. Its continued existence necessi-
tated a change in the state law enabling nurse-midwives to
practice and the Council of California Medical Association
blocked the change by refusing to support it. To the sur-
prise of no one, the negative health outcomes reappeared
(Levy, et al., 1971).

In several cases, obstetricians have sought (often
successfully) to stifle nurse-midwifery practice, especially
independent and/or home birth practice, by withdrawing
hospital privileges and or bringing pressure on back—up
physicians (NAPSAC NEWS, 6(1 and 2)l98l). For their part,
CNMS have in several cases reSponded with suits claiming
restraint of trade, and on December 18, 1980 the Subcommittee
on Oversight and Investigations of the U.S. House Committee
on Interstate and Foreign Commerce convened a hearing to
examine the issue of physicians' efforts to restrain trade
by blocking nurse—midwifery practice. Dr. Pearse, the
executive director of ACOG, was questioned extensively by
committee members on the specific meaning of physician-
direction of the team (as stated in the 1971 Joint Statement),
(The Federal Monitor, 1981, cited in NAPSAC NEWS, 6(1)l98l:
10, passim). By mid-1981, the American Medical Association,
earlier enamoured with the concept of allied health workers
sought to reverse its position. At the annual meeting of
the AMA, delegates "...took steps to stifle competition to

doctors.... (They) voted to seek elimination of federal

110

funds for training of physician assistants, nurse practi-
tioners, and other midlevel practitioners. Some delegates
specifically mentioned nurse midwives...for whom they would
like to see federal aid for training eliminated" (Van, 1981,
quoted in NAPSAC NEWS, 6(1)198l: 8).

What changes had occurred in nurse-midwifery practice

to so alarm and arouse organized medicine?

The Location of a Market and the Collective Mobility Project

 

Nurse-midwives came out of marginal but relatively
autonomous work structures. Functioning as adjuncts to the
‘medical division of labor which was based on fee-for-service,
nurse-midwives as public health nurses worked in structures
funded through the state, private contributions, or churches.

As important change in the practice of nurse-midwifery
took place during the late 1950's and early 1960's. Both
the major nurse-midwifery practices, the Maternity Center
Association and the Frontier Nursing Service, altered their
home-birth service programs toward hospital or clinic birth
services. The MCA undertook an affilitation with hospital
practice in 1958 after its hospital referral rate rose to
18 percent. The MCA, concerned by these figures, examined
them carefully and concluded the referrals were medically
indicated: they were encouraged in their affilitation by
the head of the Department of Obstetrics and Gynecology at
Kings County Hospital. In Kentucky, the FNS attributed the

change in its practice during the 1960's to the availability

111

of third-party payment for hospital birth. With the
provision of state funding for hospital birth, the home birth
service, even though considerably less expensive, represented
an out-of-pocket expense to consumers (Browne, 1968: 77).

In the 1960's, nurse-midwives began to be drawn into
hospital practice, along with other newly created medical
workers, to meet projected "physician shortages." Their
changing direction was reflected in a study conducted by the
ACNM in 1962 (ACNM, 1965). Of the total number of respondents
(213), three quarters were living in the United States--mean-
ing fewer were leaving for foreign nursing services. Only
one third of the respondents were trained in public health
nursing indicating a shift away from the role of nurse-
midwives as essentially specialized public health nurses
whose function was primarily of exclusively to serve the
"underserved."

While by 1976 the numbers of CNMS in the United States
had increased dramatically, they retained a pattern of
geographic concentration. This was particularly true for
those NMs engaged in clinical practice. Of a study popula-
tion of 1,200:

Nearly 252 of the study participants in
clinical practice work in the central
Atlantic states around New York and
especially in New York City itself. The
second largest number of clinical nurse-
midwives are located in the six south-
eastern states (Alabama, Florida, Georgia,

Mississippi, North Carolina, South Carolina,
comprising 13%) (Rooks, 1978: 14).

112

The nature of the work structures in which nurse-
midwives were involved in clinical practice also indicated
concentrations. Fully 45 percent worked in hospitals, the
majority of which were located in cities with over 500,000
people. Less than 13 percent were in private practice with
a physician (M.D.), and while their numbers were more evenly
distributed among communities of different sizes, over half
were located in those with populations under 50,000. Nurse-
midwives in independent private practice were rare, comprising
only 2.4 percent of the study population, and they were most
likely to be found in cities of half a million or more people
(Rooks, 1978: 18). Even though nurse-midwives were beginning
to move into the mainstream of medical care-giving in 1976
they delivered only slightly over one percent of all the
babies born in the United States. In fact, nurse-midwives
were in short supply, a concern expressed by both nurse-
midwives and sponsoring obstetricians since the early 1950's.
Some areas had minimal nurse-midwife representation, for
example, of the nurse-midwife study participants located in
the five northeastern states (Maine, Massachusetts, New
Hampshire, Rhode Island, and Vermont) only seven managed
deliveries with any regularity and these averaged 33 births
a year, accounting for less than one percent of all births
managed by nurse-midwife study participants. Thus, both
the distribution and role of nurse-midwives was still quite
restricted by 1976.

Meanwhile, the collective mobility project was succeeding.

113

Even as early as the 1950's, nurse-midwives were reporting
greater satisfaction with their work (MCA, 1956: 47).

Only a decade ago it was difficult to

recruit nurses for the obstetric departments

of hospitals: obstetric nursing had become

so mechanized, so dissociated from human

relationships, that the nurse spent her days

in routine procedures bringing little

personal or professional gratification.

The nurse-midwife, on the other hand, finds

obstetrics a highly satisfying work.
These Nurse—midwives attributed to their increased scope of
autonomy and responsibility and greater personal involvement
with patients. It was a sentiment echoed by nurse—midwives'
writing in the late 1970's (Brennan and Heilman, 1977). In
addition, salaries and incomes for nurse-midwives represented
a substantial improvement over that of staff nurses (Judge,
1973: 104). Data from the 1976 ACNM study not only corroborated
these findings, they also suggested that CNMs were making al-
most as much money through direct patient care as they were
through administration and supervision, thus providing a way
out of the old dilemma facing nurses interested in patient
care. Interestingly, data indicated that the mean salary
of CNMs whose income was based on patient fees ($21,600) was
over $5,000 higher than CMS on fixed annual income ($16,111)
(Rooks, 1978: 27).

In terms of the larger professionalization project, the

transformations of the 1960's and 1970's suggest mixed

interpretations. On the one hand, nurse-midwifery showed

many signs of concrete improvement. Education was being

114

upgraded and CNMS were largely in control of it. Practi-
tioners experienced higher salaries and increased satisfac-
tion. Legislation facilitating nurse-midwifery practice was
passed state-by-state during this period. By the end of
1977, enabling legislation had passed in every state except
Michigan, Missouri and Wisconsin. Even in those states,
CNMS were able to function in specific settings. By 1977,
nurse-midwives worked in at least 42 states and Washington,
D.C. (Rooks, 1978: 42).

On the other hand, nurse-midwives were still few in number
and restricted both geographically and in terms of sc0pe of
practice. Obstetricians were working hard to harness nurse-
midwifery firmly in the "team." And by the late 1970's,
organized medicine began to take an active, obstructionist
stance toward CNMS.

The major reason for medicine's concern is the fact
that CNMs finally began to locate a market for their services
which had previously been monopolized by obstetricians.
Furthermore, neither the projected baby-boom nor the physician-
shortage materialized and some were even predicting an
obstetrician surplus (NAPSAC NEWS, 6(l)l981).

While the ideology of scientism had been dominant when
allopaths were consolidating their power, competing ideologies
emphasizing "natural," "humanistic" social relationships
and "appropriate technology" were emerging and being taken

up by large segments of the middle class. Movements concerned

115

with health, particularly the women's movement, were raising
the expectations of consumers and recipients of medical
care. More and more women were openly challenging and
criticizing obstetricians. Birth reform and childbirth
education brought the message of "natural childbirth" to
prospective parents across the country. The lay-referral
network took on new meaning as informed consumers began to

"shop for care-givers, comparing information with one
another. By the mid-1970's, informed consumers had discovered
CNMS and were spreading the word through friendship networks.
The later 1970's would provide mass access to this information
through "women's magazines."

The clientele the CNNs were drawing were increasingly
white, middle-class, educated and often professionals (Stein-
man, 1975). These people were often willing to travel con-
siderable distances to have access to the nurse-midwifery
services. Informed consumers liked nurse-midwives precisely
because nurse-midwives delivered the kind of care they
professed to in their claims of special contribution. The
NMs had finally located a new clientele, much larger and more
socially and economically powerful than the underserved
populations which had previously been their exclusive
province. Furthermore, this new clientele was a least some-
what activist and they were willing to demand and patronize
nurse-midwifery services. The philOSOphy of practice of

nurse-midwives typically allied them with birth reformers

116

and their client-centered orientation attracted consumers

with raised expectations.
There are still few of us, but we're in
strategic positions in hospitals and in
the community, and we have managed to
influence maternity care to a remarkable
degree just by being totally flexible
ourselves, letting our patients have it
their way whenever we can, persuading our
tradition-bound hospitals to bend their
rigid rules, and turning out beautiful,
healthy babies for mothers who tell the
world about their happy experiences
(Brennan and Heilman, 1977: 52).

While the status of a profession in often claimed to be
tied to its function in society (cf. David and Moore, 1945),
in fact the status of the practitioner is frequently tied
to the status of the clientele (Friedson, 1970a: Shaw, 1974).
Thus, the higher status of the newly located clientele of
nurse-midwifery will probably be linked to the rising status
and visibility of nurse-midwives.

In her examination of the deve10pment of the pharma-
ceutical profession in England and the United States, Kronus
concludes that the relationship with a clientele proved
critical and that a supporting clientele proved a key resource
in the professionalization project. On more than one occasion,
when apothecaries or druggists were attempting to gain state
sanction for their expanded task domain,

When the occupation was able to demonstrate
that it controlled a sizeable portion of the
market-—as indicated by the size, wealth and

loyalty of its clientele--its task boundary
efforts succeeded (Kronus, 1976: 35).

117

Certainly, nurse-midwives' claims that organized medicine's
obstructionism represents restraint of trade are strenghtened
by a supporting, or demanding and influential clientele.

The ability of an occupation to achieve professional
status is, according to Larson, based on several major
components. In her analysis of engineering, she examines
elements which effectively inhibited professionalization.
Several characteristics are unique to engineering, for example
the power and knowledgeability of its clientele. However,
the heteronomy of engineering is not unique. Larson observes
that during a critical phase of development, engineers were
salaried empolyees working in large-scale economic organiza-
tions. Their capacity to determine the quality of their
product was frequently dependent upon economic considera-
tions decided by their employers. Engineers' access to their
market was not independent.

No matter how vigorously or successfully

the engineering profession might have
organized to secure its market and face

its employers, it could not have controlled
its professional market because the market was
inherently subordinate.... (T)he attempts

to standardize the "production of producers"
independently of industry's prodefinitions
simply reveal again the inescapable stricture
of subordination of the professional marked....
(T)he autonomy in defining the content of work--
or control over new cognitive areas-~does not
by itself compensate for the structural sub-

ordination of the professional market (Larson,
1977: 29-30).

 

In terms of nurse-midwifery, the fact that the vast

majority of nurse-midwives work as salaried employees of

118

hospitals or physicians in group or individual private
practice assures structural heteronomy. The organized
efforts of obstetricians to control access to hospital
privileges and withhold them from NMs in independent practice
indicate physician efforts to maintain the inherent sub-
ordination of the market. Physician strategies of withhold—
ing or eliminating physician back-up and third-party payment
for independent CNMs serves a similar purpose. Insofar as
obstetricians (experts in obstetric pathology and surgery)
are able to define what constitutes "normalcy" in obstetrics,
they are able to define the potential market for nurse-mid-
wifery services. Where nurse-midwives function under physi-
cian-determined protocols (as suggested in the Joint State-
ment amended in 1975), subordination is structurally assured.
The inherent subordination of the nurse-midwifery's market

is a direct outgrowth of the hegemony of organized obste-
trics and a change in the nature of that market requires
fundamental changes in the relationship between nurse-midwifery
and obstetricians. Nurse-midwifery is not in a position to
struggle to alter that relationship fundamentally at this
point. However, other elements outside nurse-midwifery,

for example an organized clientele, may take up the cause.
Meanwhile, some obstetricians have further strategic uses in
mind for nurse-midwives. At a 1975 regional meeting of
ACOG, Long (1975: 39), suggested that nurse-midwives could

be employed to meet consumer demands without significantly

119

altering the practice of obstetrics and gynecology. Note

how he construed patient discontent as an outgrowth of

(mis) perceptions.

(T)he insistence of women upon control of
their bodies (emerged) as a social phenomenon
of this decade. All of us in gynecology and
obstetrics are quite aware of the discontent
among women all over the country--not so
much with the quality of gynecologic and
obstetric care as with the manner in which
the care is supplied.... The idea, whose
time is now, seems to me to be establishing a
system in which our patients can have their
say in how their care is rendered, as well

as maintaining excellence in quality of care.

At a 1977 national meeting of ACOG, Thiede (1977: 923) was

more explicit about the kind of obstetrical care-giving he

wanted to see and the role of nurse-midwifery in facilitating

it.

Couples anticipating childbirth have a
responsibility to seek a labor-and-delivery
setting that will ensure the greatest pro-
tection for the fetus. The medical profession
has the responsibility to modify its approach
to obstetric care to make it more acceptable
and responsive to the perceived needs of the
patients. Nurse-midwives have the responsi-
bility to help prevent the creeping polarization
of patients and physicians by working for this
compromise, (emphasis mine).

 

Chapter V

The Early Development of Nurse-Midwifery in Vermont

Having considered national trends in birthing practices
as well as interprofessional relationships in the obstetri-
cal division of labor, we now turn to the early development
of nurse-midwifery in Vermont. To begin, we need to con-
sider major characteristics of the state and particularly
the major settings around which the case study is organized.

Vermont is a small state both in population and geo-
graphic area. The state's population grew gradually over
the period of study, from.an estimated 446,500 in 1970 to
493,300 in 1979 (State of Vermont, Department of Health,
1981). Comprising an area of 9,609 square miles, Vermont
ranks 42nd in size among the 48 contiguous states, and 47th
in population. It is predominantly a rural state: two-thirds
of its population lives in towns and villages of under 2500
people. I have confined my study to northern and central
Vermont; this area includes the two major urban areas of
the state, Burlington and the surrounding area on Lake
Champlain and the Barre-Montpelier area in the northern
center of the state. While Burlington is the most densely
populated city, Montpelier is the state capitol.

The state is mountainous and geographic divisions,

coupled with narrow, winding roads encourage localism. An

120

121

exception is a major four—lane highway, which connects
Burlington and Montpelier and continues south connecting
with another major highway, which runs most of the length
of the Vermont-New Hampshire border. (Both highways were
completed in the late 1970's.) East-west travel in most
of the state is difficult. Traveling in and through
Vermont, I had the feeling that the major highways served
more to connect Vermont with the New York City and Boston
areas, or to allow passage through to Montreal, than to
facilitate travel within the state.

One of the state's major sources of revenue is tourism.
In addition there are nine colleges, several of them private.
Both the beautiful scenery and the excellent skiing draw
visitors into the state. It is no wonder Robert Frost wrote
so lovingly about the natural world and meaningful human
interaction, his native Ripton is located in the heart of
the Green Mountains and is the epitome of a quaint, remote
New England village surrounded by natural beauty. However,
while its geography attracts tourists and its winters attract
skiiers, they discourage year round residence. Nonetheless,
some who come as visitors devise ways of remaining in the
state. Nearly all of the people I interviewed were not
natives.» Native Vermonters and those who choosetleive in
the state are perhaps best noted for their hardiness, inde-
pendence and resourcefulness. A bit of Vermont's history

may help to illustrate this point.

122

During the early 1800's the territory which became
Vermont was disputed and claimed by both New Hampshire and
New York long after much of the land was settled. One ser-
vice provided by the "Green Mountain Boys" led by Ethan
Allen, was protection of home-steaders' lands from rival
claims. After the Revolutionary War, Vermonters sought to
make theirs the fourteenth state in the union. Since the
territory was still disputed their request was rejected.
These plucky folks were, however, undeterred.

Snubbed by Congress, Vermont announced
itself an independent republic, establish-
ing a postal service and issuing copper
coins from the Harmon mint.... Meanwhile,
Congress began to grow alarmed as informa-
tion leaked out that the Allens were
negotiating with the British in Canada
(Dodge, 1977: 33).
Vermont subsequently became the 14th state, but not until
certain of its conditions were met.

To some extent, the independence, self-sufficiecy and
pluck of early Vermonters still characterize residents today.
In interview, one subject offered the following, "In Vermont,
people are taken on their own individual merits, not their
background (including degrees, titles, etc.)." And while
discussing diversity and deviance in the state (for example,
home birth) another subject explained that one must under-
stand that, "...there's a philosophy of 'mind your own
business' in Vermont."

Vermont is not an affluent state. The median annual

family income in 1969 was $8,929 and the per capital income

123

was $2,776. By 1979 the median annual family income was
$17,206 and the per capita income was $6,179. Both of

these figures were below national median annual incomes.

A list of the top ten industries and the numbers of people
employed in them will help to explain the situation. The
top three employers are local government (18,500 workers),
health services (14,750), and state government (13,700).
These are followed by electrical machinery manufacturing
(12,250), eating and drinking establishments (10,650), con-
tract construction (10,650), non-electrical machinery manu-
facturing (7,300), educational services (6,650), hotels,
motels, etc. (6,550), and retail food stores (6,150). The
two largest private sector employers are International Busi-
ness Machines and General Electric, both located in the
Burlington area (information from the Vermont State Planning
Department).

With health services constituting the second largest
employer in the state, it might seem likely that Vermont
residents' medical care needs were adequately met. Whether
or not that is true, the distribution of medical services
in Vermont is not even. Examining primarily 1969 data,
Wennberg and Gittlesohn (1973) found considerable variation
among hospital service areas of the state in terms of ratios
of hospital beds and personnel to pOpulation, utilization
rates and expenditures. For example, they found a range

of 34 to 59 in numbers of hospital beds per 10,000 persons,

124

while the number of hospital personnel per 10,000 persons
varied from 68 to 138. Calculating physician activity per
10,000 persons they found a range of .l to 1.1 (full time
equivalent) among physicians practicing obstetrics. Similar
ranges were obtained for general surgeons and pediatricians,
differences between low-service and high-service areas were
even more pronounced in the distribution of general practi-
tioners and Internists.

They emphasized that this considerable variation seemed
only to be exacerbated by state and regional planners who
tended to construe use as the outcome of patient need. Thus,
hospitals with the highest ratio of beds per population were
granted the largest percentage increases by planners. In
addition, PSRO's (Professional Standards Review Organization)
chose to ignore data indicating, for example, significant
correlations between the numbers of surgeons in practice in
areas of the state and the amount of surgical procedures
being undertaken there. These problems are hardly unique
to Vermont, inequitable distribution of medical services is
a national problem and the relationship between numbers and
kinds of physicians and the frequency of various treatments
of procedures has been noted elsewhere (Bunker, 1970).
Summarizing their findings Wennberg and Gittlesohn (1973:321)
concluded that.9physicians concentrate(d) their efforts in
more populous service areas and in those with higher per
capital incomes." This pattern is also typical of the

United States as a whole.

125

More specifically related to the issue of the obstetri-
cal division of labor, the Vermont birth rate, which closely
paralleled the national white birth rate, declined from
25 per 1000 population in 1947 to a low of 14.3 in 1976.

By 1979 it had risen to 15.2. In both Vermont, and the
nation as a whole, the predicted baby-boom of the 1970's
failed to materialize. In 1979, the average age for all
Vermont women giving birth was 25.5 years, a figure which
had remained fairly constant through the 1970's. Of birth-
ing women, 81 percent had high school educations and 18

percent had completed four or more years of college.

The Settings

 

I have chose four settings for an examination of nurse
and lay/independent midwifery in Vermont. These areas I
have located around hospitals since they are either sites of
practice for nurse-midwives, sites of practice for physicians
creating in-hospital birthing alternatives and/or backing
up lay/independent midwives or referral centers for home
birth attendants. In each of these settings I am concerned
with specific work relationships, birthing practices and
reforms in those practices. This case study is undertaken
in an effort to see how nurse-midwives and lay/independent
midwives attempt to negotiate for turf in the obstetrical

division of labor and reforms in birthing practices.

126

UH/RMC University Hospital/Regional Medical Center

UH/RMC is located in an urban county which contains over
20 percent of the state's population. It is also the economic
and educational center of the state. The hospital (actually
two separate units organizationally joine d in the late
1960's) is associated with university medical and nursing
schools and functions as a teaching hospital. It serves the
'area population and also functions as the referral and high
risk medical center for the region. Forty percent of all the
obstetrician-gynecologists in the state work in this area
(this number includes subspecialists in ob/gyn, for example,
gynecological oncologists). UH/RMC has the largest number
of obstetrical beds in the state (32), and in 1979 was the
site of approximately 27 percent of all births to Vermont
residents and nearly 30 percent of all births which took
place in the state (including those to out-of-state residents).
These numbers vary little over the period of study, 1970-
1980. The obstetrical service included 17 attending ob/gyns
in 1979, fourteen of whom.were in a group practice associated
with the medical school. In addition, obstetrical residents
worked as house staff in the hospital and helped to super-
vise interns from the medical school. A full nursing staff
was complemented by nursing students from the nursing school
who also participated in care-giving as part of their training.

UH/RMC constitutes the major and initial site of nurse-

midwifery practice in the state and will receive the majority

127

of my attention.

SCCH/South Central Community Hospital

 

SCCH is a small community hOSpital centrally located
in the state in a town of slightly over 2,000 persons.
Throughout the period of study there were no obstetricians
associated with the hospital, instead the population was
served by several general practitioners and family practi-
tioners who limited their practice to obstetrics. In 1979
it had 5 obstetrical beds and over the period of study
accounted for approximately 2.5 percent of hospital births
in the state. This area was the site of considerable home

birth activity and important in-hospital birthing alternatives.

NERH/North East Regional Hospital

 

NERH is a relatively recently built hospital (completed
in the 1970's) serving two towns with a joint population of
10,000 as well as the surrounding sparsely populated region.
The pe0ple were served by a few general practitionersuntil
an obstetrician began a practice there in 1978. He sub-
sequently hired a nurse-midwife. In 1979 the hospital had
12 obstetrical beds, and over the period of study it accounted
for approximately 5 percent of the hospital births in the

State.

NCCH/North Central Community Hospital

 

NCCH serves two adjacent towns with a combined popula-

tion of over 18,000 as well as the surrounding moderately

128

populated area. The population is served by four obstetri-
cians in a group practice, a few general practitioners and,
late in the study period, a family practitioner. The hospital
had 20 obstetrical beds in 1979 or 11 percent of the obste-
trical beds in the state. Over the period of study, NCCH
accounted for an average of approximately 12 percent of
hospital births in the state. Although NCCH is a large
hospital by Vermont standards, it is only a minor site in
this study. Only one nursedmidwife worked in the area during
the study period and she was forced into an exclusive home
birth practice after her hospital privileges were suspended
at NCCH. The nurse-midwife's practice will be examined but

the hospital will not figure importantly in the study.

Origins of Nurse-Midwifery Practice in Vermont

Nurse-midwives first entered the state in order to
practice in 1968. Their presence was the result of initiatives
taken by the head of the Department of Obstetrics and Gyne-
cology at UH/RMC. He was a native of the state and had come
to the conclusion that involving nurse-midwives in obstetri-
cal practice would improve the quality of care to pregnant
and birthing women in Vermont. As early as 1971, he spelled
out in the medical literature his vision of a new kind of
working relationship in the delivery of obstetrical care,
one in which the nurse-midwife figured importantly (Maeck,
1971).

In his view, the then much discussed "crisis in health

129

care" was mistakenly laid at the doorstep of the "doctor
shortage." As we have already noted, considerable discussion
both among leaders of organized medicine and representatives
of the federal government in the 1960's centered on questions
of adequate labor power in medical care. The federal govern-
ment focused its attention primarily on the creation of new
medical schools in order to increase the supply of physicians
but Maeck found this direction misplaced. Meanwhile, he
became interested in allied health.workers as his conviction
grew that the highly trained obstetrical and gynecological
specialists were using their time inefficiently and some-
times ineffectively in practice.

He agreed that the health care system was ineffective
and inefficient: that many people received inadequate care
while others received no care at all. There was inadequate
access to quality prenatal care and many women genuinely at
risk were not receiVingadequate obstetric care. The situa-
tion existed, he felt, because obstetricians' work had
broadened in scope and, instead of countering this trend by
attempting to limit the scOpe of practice to the ob/gyn's
special expertise, they had continued to attempt to be "all
things to all people." Because of this, the limitations
which did develop were in terms of the numbers of people
who could obtain their services. The problem of obstetri-
cal/gynecological health care delivery could then appear to
be one of inadequate numbers of practitioners when in fact,

he felt, it was more realistically viewed as ineffective and

130

inefficient use of physician's time and expertise. In inter-
view, he expanded upon this point.

I thought that most obstetricians practiced

pretty routine obstetrics and it's pretty

mundane (work) and we don't do mundane and

routine things very well. (Ob/gyns) don't

do much teaching of the patients. They just

record certain data, spend three minutes with

a prenatal patient and are off to the next

one. Furthermore, I felt that we needed more

professional care to pregnant women and that

it was a terrible waste of highly-trained,

highly-skilled surgeons/obstetricians (for

example, physicians standing around waiting

for essentially normal labors to progress).

All of which could be better done by...mid-

wives in attendance.

Maeck (1971) argued that if a new division of labor
in obstetrical care were developed, goals such as improved
prenatal and post-natal counseling for all women, improved
family planning, provision of services effectively and at
reansonable cost and reduction of infant morbidity--especially
among the disadvantaged, could be realistically undertaken.
His goal was to include nures-midwives in the care of all
pregnant, birthing and interpartal women. He decided that
the way to accomplish this was to train residents in obste-
trics and gynecology to work with nurse-midwives in the
delivery of obstetrical care to women. That is, he con-
cluded that allowing nurse-midwives to perform some tasks
previously monopolized by obstetricians would improve both
patient care and obstetricians' work performance.
In 1967, with this conviction, he set about convincing

his colleagues that the project of bringing in nurse-midwives

131

was worth trying. He subsequently traveled to England to
secure the commitment of two English nurse-midwives to work
with him at UH/RMC. The first nurse-midwife began work in
Vermont in 1968 and remained for three years. While she
engaged in some clinical practice, the bulk of her work con-
sisted of familiarizing the staff and patients with the
potential contributions of nurse-midwifery. In addition, the
possibility of establishing a school of nurse-midwifery at
UH/RMC was considered, but was subsequently dropped for a
variety of reasons, including prohibitive expense.
Interestingly, English nurse-midwifery, so important
in the initial development of nurse-midwifery in the United
States in the 1920's and 1930's appears again in the
beginnings of nurse-midwifery in Vermont in the 1960's. This
is not particulary surprising. Nurse-midwives in England had
located a niche in the medical division of labor (Bayes, 1968)
and had the support of British physicians, some of whom
voiced strong support for nurse-midwifery to their American
counterparts (Tompkins, 1977). Furthermore, as we have al-
ready observed, nurse-midwives in the U.S. were in short
supply. Nonetheless, Maeck's willingness to travel to England
to locate nurse-midwives to practice in Vermont and help
to win the support of skeptical medical personnel clearly
indicates his commitment to his vision of a new division of
labor in obstetrical care. It should also indicate his

leadership in this area.

132

In 1970, the second English—trained nurse—midwife
arrived. At this point, a growing acceptance of nurse-mid—
wives by both physicians and patients enabled her to begin
some clinical work in labor and delivery. When, in 1971,
the first English nurse-midwife departed, an American-
trained NM was hired and attention was focused on further
development of clinical practice as well as on the instruc-
tion of medical and nursing students.

As we have seen, the American College of Nurse Midwives
has worked to define the special contribution of nurse-
‘midwifery in practice and guarantee it through standardiza-
tion in education and licensure requirements. However, it
has often been the obstetrician/gynecologists who have been
more capable of both making their views of NM's special
contribution heard and translating them into the actual
division of labor and the delivery of care. Here in Vermont,
we find an obstetrician whose view of nurse-midwifery is
central to the creation of a new niche in the state's medi-
cal division of labor. In this case, however, he appears
to be more closely attuned to the nurse-midwives' own claims.

In my belief, (the CNM) has an extremely
important role to play in newly developing
systems of maternal and child health care.
Because of her training, she is qualified to
manage the uncomplicated pregnancy and labor
and to recognize the abnormal. Her motivation
and background bring to this professional care
an important aspect of psychologic and educa-
tional support which is often neglected by the
busy obstetrician.... Her qualifications
permit her to share responsibility and much

of the routine obstetric care with the obste-
trician who could then afford to devote more

133

of his effort to the patient at risk.

Such a real professional partnership should

deliver optimal obstetric care to a much

larger number of patients at no extra

cost (Maeck, 1971: 317).
In Larson's (1977) terms, Maeck was attempting to rationalize
the production and delivery of professional services by
reorganizing the division of labor. His goal of returning
the obstetrician/gynecologists' turf to complicated and
abnormal aspects of obstetrical and gynecological care con-
trasts sharply with the trend in obstetrics and gynecology
to monopolize the primary care of women (cf. Burkons and
Willson, 1975).

That such a project was conceived and undertaken at a
University hospital served primarily by ob/gyns employed
in a group practice and engaged in teaching and research is
understandable. Countervailing market forces are not keenly
felt by practitioners in such contexts. Experiments in
the development and employment of ancillary workers could
serve to improve obstetrical care thus enhancing the prestige
and power of obstetrician/gynecologists. It is worth noting,
for example, that neither Maeck nor other leaders of ACOG
were calling for expansion of production of general practi-
tioners to meet the needs of birthing women. General
practitioners would probably prove to be much more difficult
potential competitors to contain.
.Partnership was the major component of Maeck's vision

of a new obstetrical division of labor. He described the

emerging work relationship at UH/RMC in some detail.

134

A.model of total maternal care based on
(partnership) is being developed at our
Medical Center. The midwife (CNM) and ob-
stetrician are both involved in the care of
each patient throughout pregnancy, labor and
delivery and the puerperium. The midwife is
responsible primarily for patient education
by conducting mothercraft classes, demonstra-
tions and regularly scheduled interviews at
routine prenatal visits. After the initial
interview and evaluation by the obstetrician,
the midwife may well alternate with him at
follow-up examinations during which she must
make value judgements as to the course of the
pregnancy. In our experience, potential
problems have been detected which might other-
wise have been overlooked. Because the mid-
wife establishes rapport with the patient early
in pregnancy, she has an unparalleled oppor-
tunity to discuss future family planning and
related problems.... In our experience, the
obstetrician has had limited opportunity to
instruct the patient about nutrition, personal
hygeine and general activities. These aspects
of obstetric care have never been accomplished
so effectively as when the midwife functions
as a member of the team.

...The program also includes the midwife
in the conduct of the labor and delivery of
the uncomplicated pregnancy. She acts in
association with a member of the obstetric
staff who serves as a consultant and is
available for operative procedures or the
management of complex problems demanding
his particular skills. It is my firm belief
that this type of team approach can and does
render superior obstetric care with optimum
patient rapport and satisfaction (Maeck,

1971: 317).

Maeck was seeking a CNM to help design and participate
in research on nurse-midwifery practice in the state. In
1973, he was joined by a CNMvfluntook a leave of absence from
her teaching position in a masters nurse-midwifery program.
While by that time nurse-midwives had worked in the state

for nearly five years, they had practiced solely through

135

.UH/RMC and under its auspices. The nurse-midwifery educator
and Maeck designed a research project aimed at extending
nurse-midwifery practice beyond UH/RMC. 'As Maeck explained
in interview,

I felt that we didn't need Nurse-midwives

here because we have more residents than

we know what to do with, more students,

more obstetricians than we know what to do

with...but, I felt that out in the rural

areas that isn't true. We could develop

a model here which might be replicated in

our rural Vermont as well as nationally.

And I think it has had some impact.

The unequal distribution of generalists and specialists
in the state has already been noted. In an effort to counter-
balance this trend, the research project aimed to place a
CNM in a small town south of UH/RMC. The project's goal was
stated in a mimeo issued from the Department of Obstetrics
and Gynecology at UH/RMC (January, 1979). "The purpose of
the project was to improve and expand obstetrical care in
rural communities with the (UH/RMC) obstetricians as con-
sultants."

The nurse-midwife was to work under the auspices of a
general practitioner in the town within carefully constructed
protocols. The G.P. was supportive of the project and after
six months of preparation the project appeared to be realiz-
able. However, when it reached the point of getting hospital
privileges for the CNM at the local hoSpital, the project
was snagged. The hospital's legal advisor recommended against

granting privileges since the state had no clear laws regard-

ing nurse-midwifery practice and the hospital might have to

136

assume liability. The project was effectively stopped, and
the originators decided to put their energy into changing
the law. This prOposed project was interesting for several
reasons. First, it demonstrated a concern on the part of

at least some obstetricians at UH/RMC with the general
nature of the delivery of obstetrical care throughout the
largely rural state. Secondly, it coupled the traditional
use of nurse-midwives as specialists with a publix: health
orientation serving the "underserved" with a new kind of team
concept in which nurse-midwives and obstetricians alternated
prenatal patient visits. Finally, it sought to employ non-
medical workers in an undertaking aimed at extending the
influence of the University hospital, a trend some have
criticized (Ehrenreich and Ehrenreich, 1971).

Efforts to develop enabling legislation became the new
focus of the CNM and interested ob/gyns. The state nurses
association was interested in and supportive of the proposed
legislative changes. Furthermore, UH/RMC was interested in
bringing in other nurse-practitioners. So the decision
was made to develop broad-based state legislation to create
a legal framework for nurses practicing in "expanded roles."
National nursing organizations were unable to provide guidance
since they had themselves only begun to set up legal guide-
lines for expanded roles in nursing practice. Furthermore,
states which had legislation facilitating nurse-practitioner

and nurse-midwifery practice varied considerably in the

137

nature of the legal framework created.

Interested actors in Vermont concluded that their best
chance for fruitful change was an expansion of the existing
Nurse Practice Act rather than the creation of a totally
new law. An interview subject involved in this undertaking
explained that it would have the effect of avoiding a CNM
separation from nursing and at the same time keeping other
disciplines out of the realms of practice being delineated
in the legislation.

The CNM and representatives of both obstetric and
gynecology at UH/RMC and the State Nurses' Association spoke
before the board of nursing practice in support of the
legislation. In 1974, the revision was granted. It stated
that nurses with appropriate training were allowed to practice
in expanded roles under the auspices of licensed physicians
and working under protocols and guidelines for practice. It
did not specify that CNMs had to work under the auspices of
obstetrician/gynecologists or the particular settings in
which CNMs could work.

While proponents of the expanded role of the nurse
sought to broaden the Nursing Practice Acts, the state
was encouraging licensure under the Physician's Assistant
Act. The several actors involved resisted this more. The
P.A. act required considerably less training than nurses in
expanded roles had obtained. Secondly, as one CNM pointed

out, "CNMs are not assistants to physicians." To emphasize

138

this point, the CNMS drafted a document stating their opposi—
tion to the state's suggestion.

After seeing the completion of the legislative project,
if not the research project, the CNM educator was prepared
to return to her post. However, by early 1974, the other two
nurse—midwives at UH/RMC had left and the future of nurse-
midwifery in the state was unclear. But the Department of
Obstetrics and Gynecology reaffirmed its commitment to nurse-
midwifery and the CNM was persuaded to stay on.

That was a critical decision'for she subsequently brought
her considerable skills and energy to the development of
nurse-midwifery at UH/RMC. Several interview subjects suggested
that she was politically sophisticated and thus able to pro-
vide valuable leadership and direction in this critical phase
of development. Her previous experience in nurse—midwifery
education at a major graduate school probably helped con-
siderably.

As the only CNM at UH/RMC her work was varied. She taught
in the medical school, and did some teaching to obstetrical
residents and fourth year nursing students. In addition she
did clinical work, mostly prenatal care in the office, al-
though she did take labor and delivery call for a physician
who had not yet relented to the inclusion of husbands/fathers
in the labor and delivery room. However, one CNM at a large
teaching hospital was not enough. Shortly after she decided

to stay, she and Maeck began to seek funding to expand the

139

nurse-midwifery practice at UH/RMC.

By 1976, funding from the Private Foundation was obtained.
The head of the foundation, located in Vermont, had been a
practicing nurse and midwife in China for 30 years and was a
gynecologic patient at UH/RMC. She agreed to provide initial
funding for the development of a nurse-midwifery practice
over a five-year period (1977-1981). The money provided for
the salary of the CNM already on staff and enabled the depart-
ment to hire two more CNMS over the following two years.

Meanwhile, an instructor at the nursing school associated
with UH/RMC had acquired a certificate in nurse-midwifery and
a new instructor with a masters degree in nurse-midwifery was
hired. While these two CNMS were engaged primarily in teaching
rather than clinical practice, they did create increased CNM
representation at UH/RMC and engaged in a function widely
performed by nurse-midwives.

A second CNM was hired in early 1977 and another in mid-
year. In 1978 the acquisition of federal Maternal and Infant
Care (MIC) monies made it possible for the department to hire
another CNM. While the bulk of her work involved the delivery
of prenatal and postnatal care in an outreach clinic, a
portion of her time was devoted to the UH/RMC CNM service.

With four CNMS in practice the senior CNM arranged for
the nurse-midwives to divide their time among the twelve
physicians in group practice so that all patients were seen
prenatally by a CNN. This model was consistent with Maeck's

vision of partnership in obstetric care. And it is a fairly

,140

"teams"

unique structure among the various manifestations of
throughout the U.S.

Little by little, nurse-midwives were able to be on call
for the labors and births of patients who requested their
presence. However, the physicians "didn't want us to adver-
tise" that is, actively compete for patients as more than
one CNM put it. So the idea had to occur to the prenatal
patient. As we shall see later, the idea did occur to several
women and it began to filter through the lay-referral net-
work.

However, as the nurse-midwife involvement in obstetric
care increased so did the obstetrician-gynecologists' control
of the program. For example, the senior nurse-midwife was
never formally given a budget for the program, instead money
was doled out through the department of obstetrics and

gynecology. As one respondent explained, "

...physicians were
keen on maintaining some kind of control of the whole thing
(the CNM program)-" In mid 1978, an obstetrician was appointed
Medical Director of the nurse-midwifery service.

By 1979, nurse-midwives were working in or around each
of the four study sites in the state. At UH/RMC, four CNMS
were on staff engaged in clinical practice and two were
instructors in the nursing school. In the NCCH area a CNM had
set up an independent practice. Both the new obstetrician-

gynecologist at NERH and the family practitioner at SCCH had

hired a CNM. The manner in which their work relationships

141

were negotiated as well as the nature of the work they

performed will be taken up in chapters seven and eight.

Chapter VI

Out-Of-Hospital Birth Reform: The Home Birth Movement

Introduction

 

While nurse-midwives were being drawn into the medical
division of labor in Vermont and elsewhere, alternative
phiIOSOphies of childbirth were emerging and being disseminated
throughout the United States by a growing birth reform move-
ment. The diffusion of these ideas and practices into Ver-
mont occurred primarily through immigration into the state.
Both "hippies" and more mainstream, middle-class couples
brough with them raised expectations about childbirth ex-
periences and new orientations to birth, including an inter-
est in home birth. Some of these philosophies were to find
fertile soil among the independent-minded Vermont natives.

The home birth movement, by advocating and practicing
alternatives in childbirth, altered the birthing environment
in the state. An examination of the movement will indicate
the ideological and practical changes it created as well as
the strategies by which these changes were brought about.

In addition, it highlights the importance and complexity
of a profession's relationship with its clientele.

The home birth movement is an increasingly active compo-
nent of the birth reform.movement, and it is its most radi-

cal element. The larger birth reform movement is quite

142

143

diverse and components of it diffen: considerably in both
their short-term goals and strategies. However, both in-
hospital and out-of—hospital birth reformers share the larger
goals of better birth outcomes and better birth experiences.
It is plausible that these different strategies and loci

of change constitute a division of labor in the movement.
Whether their paths diverge dramatically or ultimately

converge, their overall goals were initially the same.

The Birth Reform Movement and the Revolt of the Client

 

The birth reform movement has had a significant impact
upon orientations to childbirth among both the lay public
and providers of obstetric services. However, some care-
providers, such as nurse-midwives and some nurses, actively
embrace birth reform while obstetricians and more traditional
nurses have been more cool toward the idea. This may be
explained in part by the fact that the movement changes the
context in which nurse-midwives negotiate for both turf in
the division of labor and a market for their services. The
movement may work to their benefit while challenging obste-
tricians' autonomy and the functions of nurses accustomed
to traditional hospital practices. While the professionaliz-
ing occupation of nurse-midwifery navigates a cautious course
and is ever-attentive to the turf claimed by physicians, the
birth reform movement has been somewhat less constrained

and more able to seek changes using a variety of tactics.

144

These include persuasion of both physicians and nurses to
incorporate desired changes into their routine practices
and education and activation of the lay clientele. A brief
examination of the ideology and strategies of this larger
movement will aid in understanding and locating the home
birth movement.

The incipient birth reform movement arose as a reaction
and/or adaptation to what were regarded as problematic
obstetrical practices. Interestingly, it came from among
physicians themselves. In 1944, Grantly Dick Read, an English
physician, published Childbirth Without Fear. The title

 

neatly summed up his goal. After many years of practicing
obstetrics, he became convinced that the bulk of the pain
suffered by women in labor was the result of culturally-
induced fear of childbirth, enhanced by ignorance of the
normal process of birth. Rather than attempting to suppress
the pain with anesthetics, as was the common practice, Read
felt that with proper education and preparation provided by
physicians, birthing women would be able to experience "the
personal triumph of motherhood."

Subsequently, in the 1950's, a French physician,
Ferdiannd Lamaze, developed another philOSOphy aimed at
inhibiting the pain of childbirth. Drawing on the experi-
ments of Ivan Pavlov, whose work indicated that the experi-
ence of pain could be inhibited through conditioning, Lamaze

applied the principles (called psychoprophylaxis) to human

145

experience.
(I)n the psychoprOphylaxis method, the lab-
oring woman responds to uterine contractions
with specific breathing techniques which she
has learned and practiced: this focuses her
concentration in a way that does not permit
the sensation of pain to register....
Lamaze preparation for childbirth is a precise
and rigorous system. Beginning in the
seventh month of pregnancy the woman (and her
coach, typically her husband, are) trained....
(Parfitt, 1977: 47).

Interestingly, while Read's work initially had a limited
impact in the United States, the program suggested by Lamaze
was quickly picked up and disseminated. In 1960, Elizabeth
Bing and Marjorie Karmel co-founded the American Society
for Psychoprophylaxis in Obstetrics (ASPO) in New York
City. Perhaps the scientism.and the specific program of the
Lamaze method provided a more attractive basis on which to
pursue birth reform. ASPO has chosen the strategies of
cooperation with obstetricians (who are included in its
board of directors) and professionalization in order to
institute its desired reforms. For example, it requires
standardized and rigorous training for its instructors whom
it certifies. And, having acquired some legitimacy among
obstetricians and hospitals, some childbirth educators are
able to make at least a part-time career out of what was
previously an avocation.

Other organizations which prepare birthing women and

their partners are more eclectic in their approaches and tend

to draw upon both Read and Lamaze while adding new components.

146

These include the International Childbirth Education Associa-
tion (ICEA) which was also begun in the early 1960's, and

the Bradley method of the American Academy of Husband-Coached
Childbirth, popularized in the mid-1960's. While these
organizations have also provided training programs for in-
structors and promoted standardization, they appear less
committed to the twin strategies of professionalization and
cooperation with obstetricians.

Whether or not such training programs enable women to
experience what they have called "natural childbirth" is
questionable. As Margaret Mead observed,

It should be pointed out that natural child-
birth, the very inappropriate name for forms of
delivery in which women undergo extensive
training so that they can cooperate consciously
with the delivery of the child, is a male in-
vention, meant to counteract practices of
complete anesthesia, which were also male
inventions. Contemporary fomms of natural
childbirth are an attempt to restore to women
what women among many peoples once had (Mead,
quoted in Parfitt, 1977: 37).
Echoing her sentiments, Rothman (1982) suggests that child-
birth education has largely been coopted by medical interests.
It has become a vehicle to socialize patients into hospital-
oriented births by training them in self-control which
enables them to better cooperate with physician and staff
demands. It suggests to patients that they are in control

and freely making choices while in fact they are adjusting

to the hospital organization of labor and childbirth (e.g.,

147

"don't push now, we're going to the delivery rooml").

Still, even at its most conservative, the birth reform
movement has encouraged the patient to shun the passive role
and it has raised both the patients' and the providers'
expectations about the acceptable level of quality of the

prenatal care and birth experience. In so doing, childbirth

 

education has largely accepted the medical segmentalization
of childbirth and its conception of the separation of the
body and the mind/psyche. While management of labor and
birth is left to the physician, childbirth educators attend
to the patient's experience. Nonetheless, increased lay
involvement in childbirth practices has produced a movement
which medicine finds difficult to contain.

The growth of the birth reform movement, and the home
birth movement in particular, is indicative of a growing
rift between obstetricians and at least some portion of their
clientele. Since medicine is a consulting profession, its
continued success rests upon the willingness of its clientele
to seek its service and regard its authority as legitimate
(Freidson, 1970a). However, among the laity, growing con-
cern with and criticism of hospital and physician practices
have given rise to movements aimed at reforming medical
care or offering alternatives to it. Haug and Sussman (1969)
refer to this phenomenon as "the revolt of the client."

These lay challenges to the profession's authority and

its claims to both trustworthinessenuithe reliability of

148

producers of professional services have taken several forms.
Informally, clients activate and alter the function of the
lay-referral network by exchanging information about care-
givers in order to "shop" for the right practitioner. They
also have more ready access to knowledge about health and
medical care via both the mass-media and patient-education
organizations such as childbirth education. Armed with this
information and knowledge, many clients seek to manage their
interactions with professionals (Lopata, 1976: 443). In so
doing, they attempt to alter the asymmetrical relationship
by, "us(ing) the expert as consultant, not as authority
figure," (Haug and Sussman, 1969: 158).

The client revolt thus poses a fundamental challenge
to the medical profession which counts as one of its bene-
fits, freedom from lay control and intervention, particular-
ly in the delivery of its services. What was previously
construed as a question of individual patient compliance
has increasingly become a question of collective challenge.
The profession's ability to "exercise power over subordin—
ates, the clients...." is eroded as more patients seek to
participate in decision-making (Haug, 1975: 207).

While Haug (1975) views this trend as heralding a
societal move toward deprofessionalization, Lopata (1976)
anticipates instead greater variation within the clientele
(some in revolt, others more inclined to compliance) result-

ing in greater variation in client-expert relations. In

149

either case, the collective revolt of even a portion of the
clientele may have a far-reaching impact on the medical
profession and the division of labor, particularly if that
portion of the clientele is educated, articulate and vocal.
The revolt of the clientele presents a fundamental challenge
to both the profession's claims and its status.

Within the birth reform.movement, the early 1970's was
a period in which some elements became radicalized, and the
strategy of cooperation with the medical profession was
superceded by overt challenges to its autonomy. In 1972,
Doris Haire, who was then president of the ICEA, wrote an
essay which was widely cited in birth reform literature.
In it she charged that obstetrical practices has "warped"
childbirth and had failed to significantly improve infant
mortality and morbidity rates. This essay set the tone of
the argument which was continued by Suzanne Arms (1975) who
scathingly critiqued what she called the "new, improved,
quick-and-easy, all-American hospital birth." She challenged
virtually every component of hospital obstetrical delivery,
particularly the phenomenon she described as "birth's
machine age." The impact of the work was enhanced by the
fact thatieras accompanied by a photo-essay and a plethora
of quotes from the women-in-the-stirrups.

In addition, Arms examined alternatives to the
hospitalized and medicalized obstetrical services, includ-

ing American nurse-midwives and lay midwives as well as

150

maternity practices in Denmark and the United Kingdom,

both of which included professional midwives. This work

is still widely read and is regularly stocked in the health
sections of many bookstores I have visited in several states.
Many women with whom I have spoken both in this study and
more casually have pointed to Arms' book as making a turning
point in their views about childbirth.

Thus, where previously the profession had enjoyed freedom
from fundamental and antagonistic lay intervention, it now
faced an activated clientele which demanded accountability
and change. The medical profession itself is not of one
mind on the issue of birth reform. As Bucher and Strauss
(1961) observe, professions include segments which may move
in different directions. Some physicians have been won-over
by birth reformers' critiques and proposals for change. 'This
is especially true of physicians who are more client-centered.
But other physicians oppose the movement, as Lopata (1976:
443) explains,

(T)raditiona1 experts see these moves as

an erosion of professional authority. In
fact, they are shocked at the behavior not
only of the client, but also of the younger
members of their own profession.

Among the clientele, the more radical critiques of
hospital birth and physician practices had a varied impact

on the movement's strategy. While for some the effect was

a renewed commitment to further in-hospital birth reform,

151

for others it was an impetus to consider home birth.

The Home Birth Movement

Reviewing the diffusion of the ideology and practice
of birth reform during the 1960's and early 1970's, Hazell
(1976: 8) noted that home birth continued to be regarded
as deviant.

Newman (1965) defined the population
interested in natural childbirth, home
birth and breast-feeding as a part of
the 'Back-to-Nature-Ethos' also noting
that they were concerned with ecology
and the survival of mankind (sic) as a
whole. In the years since Newman's
work, it has been my observation that
natural childbirth, breast-feeding and
ecological concern have become adopted
much more in the wider cultural ethos,
while home birth remains by and large
culturallypunacceptable.

I would argue that Hazell's assessment is still accurate
today. In large part this is because home birth involves
a more complete cessation of faith in the medical profession
and its claims. In addition, it requires the willingness
to assume personal responsibility for an area of life which
the profession has claimed as its legitimate responsiblity.
Particularly in the face of professional charges of
negligence, home birth parents must assume a posture of
greater willingness to take risks along with their assump-
tion of responsibility. However, this situation assumes

that clients have access to professional medical care which

152

they choose not to utilize.1

During the 1970's, several home birth organizations
were formed. The hospital-oriented childbirth preparation
organizations had been unwilling to align themselves with
home birth advocates for fear of losing physician cooperation.
Thus, peOple planning home births found themselves with
many needs and few resources. In response to those needs,
organizations designed to aid those planning home births
were created. In the early 1970's, the Association of
Childbirth at Home, International (ACHI, formerly ACAH) and
Home Oriented Birth Experience (HOME) were begun independent-

ly, to educate home birth parents. As in other movements,

 

1While the Home Birth Movement is overwhelmingly white and
middle-class that does not mean that only white and middle
class Americans are having home births. Rather, it is these
people who have recently "discovered" home birth and who
vocally champion it. As the history of both lay and nurse-
midwifery indicates, minorities and the poor have engaged

in the practice of home-birth both before and after allopaths
achieved dominance. Lee and Glasser (1974) found that Black
and Mexican-American midwives in the Houston area served a
population 80 percent of which was Black or Mexican-American.
In 1974, at the time it was closed down over the active
protests of supporters and clients, the Chicago Maternity
Center's patient population was 40 percent Latina, 45
percent Black and 15 percent white (Parfitt, 1977: 168).
These populations have fewer resources, are less vocal, and
are probably not as used to having their concerns taken
seriously as are white, middle-class Americans.

The fact that physicians have rarely sought to attend this
potential clientele is illuminating and suggests fundamental
questions about the profession's commitment to responsibility
for childbirth. Apparently, it feels greater responsibility
for the births of white and middle class patients while it
considers alternative care-providers acceptable for less
attractive clients. The home birth movement has only begun
to develop this critique of professional interests.

153

small newslettnars were begun and information was dissemi-
nated. In addition, ACHI trained childbirth educators to
aid prospective parents in preparing themselves for home
births. While prospective home birth parents clearly
represented a need for home birth oriented childbirth
preparation, childbirth education also represented a vehicle
by which advocates could legally support its practice. In
addition, it provided an avenue through which those planning
home births might gain access to a lay-midwife and meet one
another. A childbirth education class for home birth parents,
which I attended in Michigan for several weeks, was marked
by a strong sense of camaraderie and mutual support.

In the mid-1970's, the National Association of Parents
and Professionals for Safe Alternatives in Childbirth
(NAPSAC) was formed. It held its first national conference
in 1976 and attracted over 500 participants. While it chose
not to support home birth exclusively, NAPSAC became a strong
advocate for the practice and it facilitated the interaction
of many smaller groups championing home birth. During this
period, associations of providers of care to hOme birth
parents were also formed, including the American College of
Home Obstetrics (ACHO, these physicians were generalists,
not obstetricians), and the American Midwives Association
(AMA).

In 1976, Ina Mae Gaskin, a midwife at The Farm (an

intentional community in Tennessee in which midwife-attended

154

births predominated), published her book, Spiritual Midwifery.

 

In it she also announced the Farm's newsletter, The

Practicing Midwife. Both the book and the newsletter con-

 

tained not only her counterculture philosophy of birth but
also considerable technical information typically unavailable
to lay-midwives and people planning home births. On the
whole, these strategies of disseminating information were
efforts to end the profession's monopolization of knowledge

about pregnancy, labor and childbirth.

Characteristics of Movement Participants

While movement participants share a desire for home
birth, both their commitment to the movement and their other
interests may diverge markedly. Speaking to a conference
organized by ACHI, Suzanne Arms (1980: 3) acknowledged their
considerable differences.

I think there is a basic fallacy in
thinking today when we come to confer-
ences, particularly when there are a lot
of peOple from divergent backgrounds and
the going line is something like, 'Well,
we all want the same thing, don't we?‘
This is a fallacy; we don't all want the
same thing. Many of us want many differ-
ent things. Some people are willing to
accept far more risks in their lives than
others. Some people are willing to tolerate
far more potential problems and take far
more courageous steps than others. Some
people are very product oriented, others
are process oriented.

My own experience attending a 1981 NAPSAC conference bears

out Arms' claim. While the participants were all white and

155

predominantly middle-class, some were clearly professionals
(there were many advanced degrees) while others dressed and
presented themselves more as members of the counterculture
suggesting downward social mobility. Another indication of
the diversity of the movement is the fact that, until the
recent past, NAPSAC has avoided the topic of abortion,
recognizing that its membership would split over the issue.
Levin and Idler (1981: 84) spell out the differences more
explicitly.
Although the enthusiasm for the home birth
experience is common to all members of the
movement, their interests differ considé
erably, as do their perspectives on the problem
of hospital obstetrics. Feminists see child-
birth practices preempted from women by a
male-dominated medical profession: counter-
culture members see the human body as a pri-
soner of technology; midwives see the pro-
fessional issues in the takeover of normal
childbirth by medical obstetrics.
In addition, other perspectives can be described; conserva-
tives see the traditional family as harmed by professional
intervention (Teasley, 1981), while others, including health
care workers, stress the negative health outcomes of hospi-
tal birth. Certainly most of these positions are not
mutually exclusive, but this multiplicity of interests
indicates the potential fragility of the movement. In addi-
tion, as Arms (1980) noted, there is considerable variation
in participants' willingness to take risks and their commit-

ment to broader social change. This spectrum of interests

among home birth supporters suggests that physician efforts

156

to reassert hospital birth may be met with greater accept-
ance from some elements than from others.

Other differences also exist. In Hazell's (1976) study
of over 300 home births in the San Francisco Bay area from
1969 through 1974, she found only 10 percent of the popula-
tion were involved in the "hip" subculture. Fully 90 per-
cent of the home birth parents she studied were middle-class
whites who fit the dominant expectations about appropriate
life-style. They lived in single-family dwellings, owned one
or two cars, and the husband was employed. The majority of
the subjects had attended college but few had graduated.
Examining.a population in the same area, Mehl (1976), found
class and cultural differences among home birth parents in
choice of attendant. Participants in the counter-culture
were more likely to engage midwives while professionals were
more likely to opt for physicians.

Whatever the differences among participants in the home
birth movement, the movement as a whole is in agreement on
the larger goal of freedom from professional control of
childbirth. It seeks to rearrange both the occupational
turf and the power relations inthe provision of care to
pregnant and birthing women and their families. This anti-
professional-hegemony movement challenges the medical monopoly
on care-giving and for many participants this takes the form

of deprofessionalization and support for lay midwifery.

157

The Home Birth Movement in Vermont

 

The home birth movement has been active in Vermont
since the early 1970's and both the numbers of home births
and home birth activism grew throughout the period of study.
The movement has been successful in creating awareness of
its chosen birthing Option and engaging the medical pro-
fession in public debate. Whatever else, it has brought the
issue to the fore. In addition, the home birth movement has
facilitated the development of "new" birth practitioners,
the lay midwives. (See Table 6-1)

The home birth movement and the rise of midwifery in
Vermont are continually ascribed to a grass-roots demand for
a new kind of childbirth. The people desiring such birthing
alternatives are often characteristized by those inter-
viewed as seeking self-sufficiency through alternative life-
styles involving a back-to-nature orientation. These people
are typically described as having originated from outside the
state. One lay midwife said of her clientele,."(they) are
interested in an alternative life-style. They want to build
their own homes....They've gone to college, most of them...
they're also somewhat free spirits." A midwife working in
a different section of the state echoed this characterization,
adding, "(Their involvement in home birth is) part of their
larger move away from medicine (and toward) taking more
responsibility for themselves, not blindly trusting the

opinions of 'experts.'" While the theme of self-sufficiency

158

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159

and independence is hardly new to Vermont, this particular
manifestation of it seems to have been brought into the
state from outside, having grown out of other social move-
ments. As one physician explained his involvement in

home birth,

In 1974 the hippie movement was still fairly
strong in Vermont, even though it was dying
out elsewhere. I guess that's because a lot
of hippies had moved to Vermont. They picked
up on the fact that I was (not the ordinary
physician) and I had a lot of requests for
unusual things: herb medicines and so

forth. A request which was continuing,
though not in great numbers, was birth

at home.

However central the counter-culture movement of the
1960's was to the inception of the home birth movement in
Vermont, it was not only the causal factor nor the sole
source of home birth clientele. The larger birth reform and
childbirth education movements continued to raise expectations
of birthing parents. In the face of hospital recalcitrance
and disinclination to meet their demands, some birthing
parents were radicalized. In interview, a home birth couple
indicated that part of the impetus for their home birth came
from a growing frustration with the standard hospital birth.

I think that around 1976 (in the UH/RMC area)
there was a middle-class upheaval. The

more educated person was saying, 'Look, we
don't want to be pushed around in the hospital.
We do want to have (the birth naturally)....
Especially with second babies, like us, we've
tried it, we've been through it.

Many people I spoke with distinguished the home birth

population from the "native Vermonter,‘ who they often

160

characterized as "traditional." As one home birth parent
pointed out, parents who have home births are typically more-
educated and older than Vermont natives. Data from.the
Vermont Health Department bear out these assertions. For
example, in 1977, forty percent of the 117 women recorded as
giving birth at home were college-educated and ninety-five
percent were high-school graduates. In contraSt, of the
women giving birth in hospitals, only seventeen percent
were college-educated and eighty-one percent completed high
school. In addition, fully sixty-five percent of the women
who chose birth at home were between the ages of twenty-five
and thirty-four. This compares to only forty-eight percent
for women giving birth in hospitals (Burlington Free Press,
November 24, 1978). (See Table 6.2).

In addition, other differences between home birth
parents and the surrounding pOpulation also exist. A nurse-
midwife observed that at the opposite end of the spectrum from
the home-birth clientele was a component of Vermont popula-

1!

tion which is a ...rigidly traditional lower socioeconomic
group: their main source of information is Mom (who probably
experienced a traditional hospital birth). Some people are
still angry they didn't get a Spinal." An independent mid-

wife noted that many native Vermonters are, "

...people who
have been brought up all their lives on a farm, they are very
conservative and they totally believe in the system. Going

to the hospital is part of being involved in the system.

161

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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162

In contrast, other interview subjects point to similar-
ities between rural native Vermonters and alternative-
oriented newcomers. A.nurse-midwife working in a reformed
hospital explained.

(The peOple here are) a lot of loggers,

farmers, salt-of—the-earth type folks.

There are also homesteader types....

It seems like there is an incredible

number of pe0p1e from (an east coast city).

We like the life up here and we're trans-

fers. Really. it's a very good population to

work with. The old-timers who have been

here are not into the high-technology birth

experience: they've never been exposed to

it. Half of them work with cows all the

time and can't see what the big deal is

anyhow. (We) transplants and homesteaders,

of course, are not into the high-technology

scene anyway--that's one of the reasons

we're here.
Another interview subject, a birth attendant, observed that,
as a countervailing force to the authority of expertise,
"...in New England, peOple are taken on their own merits."

Whatever points of similarity or difference exist be-
tween the home birth advocates and the rest of the Vermont
population, this larger population plays a critical role in
determining the fate of the small minority of movement
participants. Whether it is legislators considering lay-
midwifery legislation or jurors deciding whether to convict
a lay-midwife of practicing medicine without a license, the
home birth movement must attempt to persuade the larger pop-
ulation to shield it from medical efforts to curtail or
eliminate it.

The central ideological factors which distinguish

163

home birth practitioners from the broader population are:

a skepticism about the authority of experts, the desire to

be more in control of their lives and, perhaps most impor—
tantly, the willingness to undertake preparations for a birth
that is an autonomous, intimate, family experience. A home
birth parent, writing in a local paper stated the position
clearly,

...we recognized that for us home birth
provided the details and atmosphere that

had become important to our concept of family—
centered birth. We found little support

from the medical staff and our only alternative
was Birthwork, a group of women experienced

in home births and associated with the People's
Free Clinic. We knew our decision was not
without risk but we found the women knowledge-
able, competent and supportive. Although they
try to attend all births, they insist that
parents accept total responsibility for home
delivery. For us this meant an in-depth
knowledge of what to do when, as well as
learning danger signals. It was important

to them that we know when the risk becomes

too great and the hospital became anecessary
friend. This meant that the months before the
births were spent reading, studying, learning
and rehearsing, but it also gave us a sense

of total involvement: a commitment that
brought us infinitely close to each other

as well as to our child (Osher, 1976).

The Ideology of the Home Birth Movement in Vermont

During the late 1970's in particular, newspapers paid
considerable attention to the questioncflfbirth reform, home
birth and lay/independent midwifery. At least one newspaper
supported home birth and birth reform in an editorial (Th3

Times Argus, December 12, 1977). (Some in-hospital care-

 

164

providers explained in interview that they were rankled by
what they saw as lopsided reporting).

Statements of the home birth movement's ideology appeared
in newspapers in various forms, including interviews with
lay/independent midwives and home birth parents and letters
to the editor (of which there were many). In addition, news—
papers provided accounts of collective meetings of home birth
supporters, including those surrounding trials and public
legislative hearings at which lay-midwifery legislation was
being considered. Other statements of ideology are drawn
from interviews.

The movement for home birth and lay midwifery is ex-
plicitly striving for independence from medical control.

In addition, it is seeking to rearrange both the occupational
turf and the expert-client relationship in the care of
pregnant and birthing women. This is a grass-roots movement
whose goal is primarily the creation and maintenance of
viable options in birthing in order to meet the needs of its
advocates. It thus seeks to enable people to make meaning-
ful choices in childbirth.

Medicalized and hospitalized childbirth has become
normative and physicians have claimed the care of birthing
women as their domain. Thus, in order to make their desired
birthing options available, this lay movement is forced to
challenge the medical profession's authority and its claims

to both a monopoly on expertise and commitment to a service

165

ideal. The very existence and visibility of the home birth
movement highlights the fact that birthing practices are
socially organized and thus subject to change: it undermines
the medical monopoly on defining this reality. Perhaps

the central issue on which the ideology of the home birth
movement is constructed is personal autonomy and concomitant
responsibility. Home birth parents typically refer to their
birthing experience as a crucial point at which they took
control of their lives and assumed responsibility for making
hard choices, recognizing the risks they faced in the under-
taking. However, it is important to note that they do not
celebrate the risk-taking in and of itself: they do not

see themselves as reckless. Additionally, many are quick to
point out, as some national pro-choice birthing organizations
have done (NAPSAC, 1977: 1979), that it is naive to think
that peOple do not face significant risks within the hospi-
tal, some of which are unique to the hospital.

Thus, rather than advocating a new norm in childbirth
(e.g., midwife-attended home birth for all but high-risk
women), the movement embarked on the strategy of advocating
freedom of choice in childbirth. However, even though some
of its spokespeople suggest that as many as ninety percent
of all births could safely take place at home with properly
trained attendants and adequate medical back-up, most will
specify that nowhere near that percentage of birthing women

is currently adequately prepared for such an undertaking.

166

In this regard, phrases sometimes used are "prepared,"
"responsible," or "informed" homebirth. Each of these
terms emerges in part out of debates with the medical
establishment. "Prepa red homebirth is used to distinguish
planned home births from births which occur at home but are
accidental, unanticipated and undesired. This distinction
is made necessary in part because organized obstetrics,

in its efforts to delegitimize home birth, has analyzed

as "home birth" outcomes data which included accidental
births, miscarriages and unplanned home births (NAPSAC News,
1981:6(1): 10).

"Responsible” or "informed" homebirth are terms used
to counter physician criticism asserting that home birth
parents are ignorant and cavalier about their choices. For
example, the physician in charge of the neonatal intensive
care unit at UH/RMC publicly charged that people who chose
home births were "crazies who go off to caves and log cabins
to deliver the newborn who has no say in the process:" he
went on to say that home births were a "selfish fad" (Calta,
1977). From the point of view of the dominant medical
profession, the laity's choice not to consult it represents
irresponsibility. Physicians make such charges (which they
may sincerely believe) as a way of restating their claim to
authority and a monopoly on appropriate expertise. In con-
trast, lay people's use of the terms "prepared," "responsible"

and "informed," suggest that those who practice home birth

167

have access to expertise, are reasonable and ethical and
both desire and deserve legitimacy.

Central components of the concept "responsible home-
birth" include self—selection by participants augmented by
screening by midwives.

A home birth mother, writing in support of home birth
in a localpaper, emphasized the importance of both midwife
screening and self-selection in responsible home birth.

No person will be attended at a home birth
who hasn't been screened as thoroughly as
possible for complications. Because of the
risks involved in home births, the women
are usually far better informed and prepared
than those destined for the hospital. We,
who are for home births or alternative
birthing feel ourselves not irresponsible
but more responsible for our actions
instead of putting ourselves in others'
hands totally. If we had assumed any
potential danger we would have used the
available medical facilities (Brown, 1977).

Other supporters of home birth pointed out in interview that
screening and self-selection included consideration of
psychological factors as well as geographic location and
weather conditions. As one subject noted,
PeOple who (successfully) do home births have
to be super together....(Some likely home
birth candidates choose to give birth
in the hospital) because they're together
enought to realize that two miles up a dirt
road in January...(it) is the better part of
valor to come in.
Finally, a lay-independent midwife explained, "We're not
against hospitals and would recommend, whenever there's

a question, that the birth be in the hospital. We're not

168

trying to take on a role we're not capable of" (Reilly,

1977: 3A).

The Critiqge of Hospital Birth

 

Most home birth advocates present their position as one
supportive of the option of home birth. As I have suggested,
this enables them to take the more defensible strategy of
advocating freedom of choice rather than championing a new
birthing norm. However, throughout their statements, runs
the thread of a critique of physicians, hospital birthing
practices and professional power.

Some general criticisms seem to apply to most hospital
births in the area of the state under study, while others
point to particular hospitals or medical practices. I
located several related components of the critique. First,
physicians are criticized for placing professional interests
ahead of the provision of health care. Many physicians,
especially obstetricians, appear to be disinclined to know-
ingly provide prenatal care for women planning home births.
The home birth friendship networks and lay midwives typically
provide referralstx>the few sympathetic medical personnel
who do knowingly provide prenatal care to prospective home
birth parents. However, some people planning home births
don't have access to these sorting devices of the "lay-
referral network" or they must utilize the available medi-

cal prenatal care in the area, despite warnings against it.

169

These people often relate stories of physician harassment.

Home birth supporters frequently criticized physicians
for their unwillingness to provide back-up medical care for
home births, for example, few physicians were willing to
discuss cases with midwives over the phone. In addition,
certain hospitals were notorious among the home birth
clientele for harassment and brow—beating of midwives and
birthing parents who came into the hospital when complica-
tions had arisen at home. In interview, a midwife explained
that one hospital in particular (NCCH), was so opposed to
midwifery and home birth that she could not accompany her
clients into the hospital, assuring ar1 abrupt break in
the continuity of care.

One of the home birth movements central critiques of
typical hospital birth turns on the hospital and physician
usurpation of birthing parents' decision-making and ability
to have their needs met. They charge that, even when physi-
cians are practicing responsibly, they are colleague-centered
and committed to particular methods of practice. Closely
related to this is the assertion that hospital birthing is
not "family-centered," that people become "patients" and
are treated insensitively, receiving standardized hospital
care rather than personal care. Particularly at UH/RMC, the
charge is frequently made that physicians practice "cook-
book obstetrics," as one interview subject characterized it.

This was a reference to the standards of practice agreed

170

upon by the 14 obstetricians comprising the ob/gyn group
practice. A related concern is the lack of continuity of
care: often patients in group practice see different care-
givers throughout pregnancy and have to take as the
primary caregiver whoever is on call at the time of birth.

Other home birth advocates challenge physician's control
of the event of birth. One woman, writing in a local paper
asked "Whose children are they?" She suggested to readers,
"It is not necessary to submit yourself both physically and
mentally to a standardized medical procedure.... It is
most important to know your rights as a patient upon enter-
ing the hospital" (Cram, 1976). Many home birth advocates
balked at the arrogance of some physicians opposed to them,
as one critic wrote,

When the arrogant 'experts' can st00p to
bring infant souls into this world with the
same humility, spiritual sense and loving
touch that I have observed in the people
who attend local home births, then, and only
then, will I consider having anyone but

our local independent midwives help birth

a child of mine anywhere but in my own

home (Hawes, 1977).

Finally, a comparison of the costs of home and hospital
births indicated that midwife fees ranged from approximately
$200 to $450 (for a two-person team) while normal hospital
births averaged $1500 (complicated births were considerably
more expensive). Some critics implied that physicians were

charging higher fees than were necessary. As one home

birth supported said, "midwives fees are more in line with

171

(the income of) the people they serve." In all these
critiques, SCCH is excepted since its orientation to birth,
as well as its fees are relatively unique. Its role in birth

reform will be discussed in detail below.

Lay Midwifery

 

While home birth parents stress their own responsibility
for birth, in Vermont they also typically support and pro-
mote lay midwifery. Thus, out of this eminently anarchistic
movement arose a number of birth attendants and midwives,
incipient leaders and certainly the foci of the movement.
While many of the home births were planned and carried out
by the family involved, the vast majority included prenatal
consultations and birth attendance by lay midwives. Several
respondents pointed out that the Vermont Health Department
records indicating father as birth attendant include a sub-
stantial number of midwife-attended births. Sometimes
parents do this to protect the midwives. (See'Table: 6.3)

The birth attendants (a term for beginning midwives) and
midwives perceive themselves as having arisen to fill a need
in the community. Each of them stressed to me that they do
not seek out home birth clients: rather, they are sought out.
Apparently, the information that they are willing to attend
home births spreads rapidly by word-of-mouth through friend-
ship networks and via some parent-oriented structures such
as day-care centers. Not surprisingly, many midwives cast

their choice as a kind of calling. Certainly they emerge

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173

as the key risk-takers in terms of the movement as a whole
and they generally indicate a very strong commitment to both
their home-birth clientele and to the viability of home
birth as a birthing option.

For many of the midwives, attending the home birth of
a friend as an observer/support person marked a turning point
for them. They typically referred to this experience as
transformative. For others, planning and having their own
birth at home was crucial in their decision to become a
midwife. Most of the midwives had had a least one home
birth. Finally, some women came to an inclination to mid-
wifery through a larger concerwx for health care, often
women's health care in particular. Here the influence of
the feminist movement is more clearly felt and mentioned by
these respondents. Of course the stories are varied and
intertwined, but it is worth noting that there are several
related routes into midwifery.

Once the self-selected birth attendants embark on the
calling of midwifery, their path is far from clear. For
example, one respondent recalled confiding to a friend her
desire to be a midwife, but admitted knowing neither what
it actually was nor how to go about becoming one. There
were virtually no structured avenues to midwifery training
and socialization, so, like the New Age/counter—culture
people form which many of them came, the midwives gathered

information where they could and made the rest up as they

174

went along. As one lay midwife explained, "...1ay midwives
got responsibility and then scrambled (to learn adequate
skills)." After the virtual obliteration of midwifery by
the rising medical profession early in this century, there
is little known tradition on which to build the work of
midwifery. Thus, midwives find themselves re-inventing what
is probably the oldest form of health care. However, in
Vermont, there were some variations on this theme. Midwives
were aided in acquiring training by a physician who broke
ranks with the medical establishment. In addition, a mid-
wife intfluasouthern portion of the state, (to which I never
gained entree') was trained and worked for some time as a
nurse-practitioner in Canada. She referred to herself as

a domiciliary midwife and, having attended approximately

500 births by 1977, could hardly be called an amateur (Calta,
1977b: 8).

Most beginners seem to have referred to themselves as
birth attendants, emphasizing the centrality of the parents'
responsibility for the birth. Given their level of skill,
they were simply unable to take responsibility for the birth;
they came to assist the parents in carrying out a home birth.
The point at which the birth attendants began to call them-
selves midwives was problematic for them. One birth atten-
dant explained that people typically called her asking for
a midwife, she responded with the caveat, "...well, I have

assisted at a number of births but I am not a professional

175

midwife.... Becoming a midwife does seem to suggest a

higher level of skill and thus, perhaps, a somewhat altered
relationship with the birthing parents. A.woman wo did con-
sider herself a midwife described the point at which she
made the transformation,

Other people started calling me a midwife

long before I was calling myself a midwife.

(Meanwhile) the more births I attended the

more comfortable I felt. I was doing an

enormous amount of self-studying and going

to conferences. Then one day it sort of fell

into place. They'd say 'Are you a midwife?‘

and I'd say, 'Yes.‘ Instead of saying, 'Well,

no...‘ and go into a long explanation of

what a midwife was...it got to be a hassle.

And before I knew it, I knew in my heart that

I was competent at attending births. I did

know what I was doing...it was a couple of

years before I felt comfortable. About

forty births.

Most birth attendants charge little or no money for
their services while midwives, often working in pairs, may
charge up to $450 for prenatal and postnatal care and atten-
dance throughout 1abor and birth.

The process of becoming a midwife is not clearly marked,
and neither is the label used to indicate having completed
that training. The medical establishment, and often the

' emphasizing

public, refer to the midwives, as "lay midwives,‘
that they are not professionals. However, the midwives them-
selves don't uSe this term. As one explained to a reporter,
"We prefer the term 'independent' to '1ay' because '1ay'

means unskilled, and we're not" (Reilly, 1977). This label

is taken at least in part to distinguish these midwives

176

from nurse-midwives who, almost without exception, work in
the hospital in the health care team, and thus structurally
under the supervision and control of the obstetrician.
Thus it is linked to both their claims to turf and special
expertise. Writing in response to a nurse—midwives' state-
ments about midwifery legislation, an independent midwife
stated,
The nurse-midwives...write...that they are
qualified to practice independent management
of labor 'within a health care system which
provides for medical consultation, collabora-
tive management or referral.‘ Independent
domiciliary midwives have the same responsi-
bilities, only our practice is in the home which
the medical profession has defined to be out-
side the system. We must challenge the health
care system to provide consultation and
collaborative management for homebirth
couples (Nolfi, 1979).

Independent midwives also point out that physicians
and the vast majority of nurse-midwives currently graduating
are trained for hospital births, not home births. They argue
that midwifery skills are largely different from medical
skills, though they do overlap. This position wouldhelp
to explain physician's fears about home birth. Since physi-
cians are trained for treatment of the abnormal in a high
technology setting, home births leave them stripped of
skills and resources. Independent midwives, in contrast,
are trained to pay closer attention to prenatal care,

screening and preparation of birthing parents. They travel

light and treat birth as a natural event.

177

They also sometimes refer to themselves as "empirical
midwives" indicating that while they may have extensive
training, it is not a formal, theoretical/(medical)
education. Consistent with their philosophy of freedom of
choice and inclination to question authority, these "inde-
pendent midwives" emphasize that they are answerable only
to their clientele and one another.

The position of midwife in this movement is complex.
She differentiates herself from her clientele as a skilled,
independent practitioner, but at the same time she is, as
least ideologically, firmly client-centered. The midwives
characterize their role as that of helper: providing infor-
mation on birthing options and responsible birth (in any
setting), and making viable the option of prepared/respons-
ible home birth and thus facilitating careful choice in
childbirth.

Even the issue of screening out people who are "at
risk" becomes difficult. Since most independent midwives
view individual decision-making as virtually sacrosanct,
most are loathe to deny care to women who might otherwise
be categorically characterized as "at risk." One midwife
pointed out that independent midwives, nurse-midwives and
physicians could agree on risk factors, but they would
probably not agree on how to deal with them, that is, how
to practice. The assumption here is that nursing and medi-

cal personnel, would be more inclined to "go by the book"

178

and treat people categorically. This treatment would

occur in part because it is within the model and structure
of medical practice that the data and prescribed practice
for risk factors were developed. The midwives explain that
every pregnancy and labor is different and they resist
categorical treatment.

Constructing a hypothetical situation of a woman
apparently "at risk" (multigravida, over 35) but determined
to have a home birth, a midwife explained,

I, as an independent midwife, am committed

to that woman out of my own ethics. I can

explain to her why I think that she is "at

risk" but I cannot refuse to give her care.

I think a lot of midwives feel that really

strongly. Because it's her decision. You

share your knowledge but you don't make

decisions for people. If you start making

decisions for people, you're professional:

you're turning people away, you're medical.

Because the medical profession has turned

away home birth people, all the time: that's

partly why lay midwives started....
However, some evidence suggests that midwives may take a
more active role in screening and management of labor and
delivery than this statement indicates. At least some mid-
wives do actively screen and are unwilling to take on clients
who smoke, for example. Also, an obstetrician described
having been contacted by a midwife who requested aid in con-
vincing birthing parents that a complication requiring
hospital care had arisen.

Several of the midwives noted that their role was

sometimes problematic. For example, a few birthing parents,

179

who the midwives had helped to inform and train through
prenatal classes, gave up responsibility during the birth.
This effectively forced the midwife to assume a physician-
like decision-making role. The more skilled midwives are
able to do it, but greatly dislike it.

Even if everything goes as planned, midwifing is des-
cribed as exhilirating but also demanding physically,
mentally and emotionally. What midwives are doing is facil-
itating an often lengthy intense, intimate, emotional and
physical experience for the birthing family. Upon completion,
the midwives return home to their own lives, exhausted. One
midwife discussed the irony of the romanticization of the
midwife,

There's a mystique about being a midwife,
there's an awe about it. It really is an
incredible thing to be doing and I love
it.... At the same time it s an enormous
amount of work. It can be so draining.
You're on call all the tbme. You can go
crazy. People just don't kHOW'What a

heavy deal it is to be somewhat responsible
for someone's life and death.

Training and Organization of Midwives

The viability of home birth as a birthing option may
be indicated by the success or failure of the midwives. They
become the foci of the movement because the struggle to
assure the viability of the movement often means struggles
to locate, sustain and support home-based birth attendants.

As long as medical personnel are essentially absent from the

180

practice of home birth, these attendants will be lay/
independent midwives. Also, it is typically the midwives
who bear the brunt of harassment from the medical community
and state medical examiners. Thus, as the primary risk-
takers, they become symbolic leaders and often function as
spokespeople for the movement.

The first organized activities of home birth attendants/
midwives in the sections of Vermont studied, began around
1973. There appear to be two primary sites of origin with
growing connections between them as well as dispersion of
activity over time. The first site is the UH/RMC area, in
an urban country. The second site surrounds the SCCH and
is a rural area.

The Free People's Clinic, apparently begun in 1972 in
the UH/RMC area, attracted progressive physicians and
paramedic staff. A.number of staff were women, many of
whom were interested on women's health care. Included in
the early staff was one of the independent midwives with
whom I spoke. She had previously received training as a
"barefoot doctor" from an area physician who had set out
to train health care workers from.among the communards,
she had gone as a representative of her commune.

From.among the staff involved in the clinic, a group
of six women interested in birthing emerged in late 1972
or early 1973. They embarked on a group study of pregnancy

and birth. During the next few years, several of the women

181

had home births. The staff at the clinic had been doing
prenatal care and their clientele included women planning
home births. Apparently they did not begin actively attend-
ing home births themselves until 1974; at this time they
were joijned by a physician also interested in home birth.
Two years later, after attending many home births with
the women, the physician left the group. At this point,
internal conflicts emerged within the group. Some members
felt that their training was not yet adequate to enable
them to safely attend home births without a physician.
Other disagreements centered around feminist issues and
group process. By 1977, four of the members had left the
group, three of whom apparently did not continue their
involvement in birthing care. The two members remaining
reformed the group naming it Birthwork. Subsequently
another physician, a family practitioner, attended several
home births with these midwives and helped to train them.
The newly formed group began teaching a series of even-
ing classes several times a year on choices in childbirth.
The classes covered topics including prenatal care, normal
pregnancy, labor and birth as well as some complkmtions
and common hospital procedures. The classes were primarily
geared toward training clients for midwife-attended home
births; while some additional group members seem to have been
added, the core members continued to be the midwives who

were still attending home births as of 1980.

182

It was at the second site of midwifery activism, the
SCCH area, that organized midwifery in the state received
its major stimulus. Here the involvement of a family prac-
tice physician was central: his willingness to provide
textbook training, and subsequently, apprenticeships at both
hospital and home births provided the midwives-in-training
with crucial resources. In 1974, this physician left the
group practice in which he was involved in the SCCH area.
He had become frustrated with his first practice, feeling
rushed and unable to practice as he wanted to. He decided
to "retire" from.medicine, but planned to complete the care
of his last birthing patients. At this point, he began
to be drawn into the practice of home birth at the
initiation of some of his patients and interested home
birth parents in the area. He was reticent until he attended
the home birth of a friend, as an observer. Describing
the experience as transformative, he embarked upon serious
consideration and study of home birth. Shortly thereafter,
he began teaching classes on basic obstetrics and prenatal
care to birthing parents and birth attendants. Beginning with
informal sessions at his home, he was by mid-winter 1975
teaching a more formal course to a group of about fifteen
women. By this time he was actively attending home births
himself and learning first-hand about its special consid-
erations. Describing the class, he explained,

We worked on basics. They needed training.
They'd only been to four or five births

183

and they didn't know a lot. They'd

read books, they were dying for exper-

ience. And they were doing births out

there in the back-woods. God, I made it

very clear that this was a big respons-

ibility, and that you had to carry certain

equipment. So we went into it pretty well...

as it turned out, about three of them be-

came midwives, (and continue to practice).

During the year and one half that he attended home

births, he took on a few apprentices. One apprentice-
partner who worked with him for several months was a co-
founder of the first and only state-wide organization of
lay midwives: the Independent Midwives of Vermont, begun
in 1976. The impetus for the organization came in large
part from the collective interaction made possible by the
training sessions which the birth attendants had regularly
attended. The organization was formed for "mutual support
and education (as well as) the formulation of political

strategy, the co-founder eXplained.

Physician willingness to train and support midwives did
not give rise to the movement for home birth and lay mid-
wifery in Vermont. However, physician involvement was im-
portant and sometimes pivotal. Obstetricians seem never
to have been involved in overt attendance or support of
out-of-hospital births. The physician involvement I
discovered came almost exclusively from general practitioners
and family practitioners, some physicians in residency pro-

grams were also involved at points.

This division among physicians is not surprising since

184

historically general practitioners have been cut out of the
practice of birth attendance in hospitals by obstetricians.
In Stevens' (1976) discussion of the process of specializa-
tion in the American medical profession, she observed that
training for general practice came to be construed as pre-
liminary to specialist training. This characterization was
then employed by organized specialists as a rationale for
their usurpation of work previously performed by generalists.
This process continued into the 1950's nationally, and, in
more rural areas initially less attractive to specialists,
perhaps into the 1970's. In at least one area of Vermont,
obstetric specialists were still quite new at the time of
this study.

In larger competition between generalists and special-
ists, generalists have attempted to counteract their lower
status, income and declining numbers by creating residency
programs (thus "specialization") in family practice. How-
ever, the specialist usurpation continues relatively un-
abated. The family practitioner with whom I spoke related a
case at a nearby hospital in which a generalist, in practice
successfully for over twenty-five years, was being severely
restricted in his ability to practice by recently arrived
obstetric specialists. The obstetricians had decided, for
example, that all twin births or breech presentations re-
quired their attendance.

The ongoing competition for obstetric patients has

185

clearly had the effect of undercutting unity among physi-
cians as obstetricians continue to attempt to marginalize
general and family practitioners. Nationally, the leader-
ship of the American College of Obstetricians and Gynecolo-
gists has attempted to woo and placate generalists by sug-
gesting a future more equitable division of labor in the
care of pregnant and birthing women (Pearse, 1980). The
ACOG leadership no doubt senses that disaffection by gen-
eralists may spoil organized obstetricians' desire to
reassert full monopoly. Or worse, that some generalists/
family practitioners would engage, as this one did, in
sponsorship of client revolts and new care-providers which

further challenge specialist hegemony.

Strategies of the Home Birth Movement

 

Several of the people that I interviewed pointed to
the years of 1976-77 as marking a watershed or peak in the
Vermont home birth movement. This period does not con-
stitute a peak in the actual numbers of home births in the
state, those continued to rise at least through 1978.
However, it may be the point at which home birth advocates
became most vocal and visible. A collection of news clip-
pings on home birth from the UH/RMC and NCCH areas spanning
the years 1976-1980 was made available to me by an independent
midwife. A perusal of it would certainly suggest that 1976

marked the turning point at which home birth parents and

186

lay midwives "went public." Also, many women receiving pre-
natal care began "coming out" to their physicians about their
planned home births. Meanwhile, in the area surrounding
SCCH, the family practitioner engaged in home birth practice
was under fire by area physicians. A.war of words ensued in
the local paper between his supporters and detractors.

This effort by home birth movement participants to win
support for their cause by activating the public was met
with an intensely negative medical response. Moreover, the
net effect of physician efforts to publicly discredit both
home birth and its advocates appeared to back-fire. The
inflammatory rhetoric of some physicians in particular seemed
only to galvanize home birth advocates and strengthen their
resolve. Apparently, this activism.on the part of home
birth parents was wholly spontaneous and constituted a self-

mobilization--a strategic necessity in an anarchistic movement.

The Legislation

 

In 1979, a state representative from the NERH region
submitted to the Vermont House Health and Welfare Committee
a bill designed to license lay midwives, H302 (See Appendix
F). While the Independent Midwives of Vermont had con-
sidered initiating legislation, it seems this was begun
independently of them. Apparently the impetus came from
the legislator's own interest in the home birth movement.

Nevertheless, independent midwives quickly picked up the

187

legislation as a key strategy. The purpose of the bill

was to set minimum standards in the practice of midwifery
and to license and thus regulate midwifery. Two hearings

on the legislation took place during the period of study,
1979 and 1980. The first was a public hearing and at the
second 8 witnesses selected by the chair of the subcommittee
were called.

Supporters of the home birth movement argue that people
have a free choice about when and where to have their babies,
and that home birth is a viable alternative. They assert
that physicians cannot and should not dictate where people
choose to have their births, and further, that there are
good reasons for not choosing hospital birth, including in—
sensitive and overly standardized hospital treatment. Many
advocates of home birth assert that there are more, perhaps
substantially more, home births in the state than state
health department data would indicate. This is not charged
to inaccurate record-keeping on the part of the health de-
partment, but to either non-registration of births or births
misrepresented as, "on-the-way-to-hospital" etc. These
techniques are sometimes used to obscure midwife-attendance
and keep out medical intervention. Apparently, some people
do not record their children's births in an attempt to resist
mandatory schooling or, for sons, the military draft. In
making the claim that there are more home births than appear

on the face of the data, the advocates are countering the

188

medical charge that it is a handful of extraordinary people
who are irresponsible and should not be taken seriously.
People desiring home births charge that medical per-
sonnel will not attend home births (many also assert they
do not possess the appropriate skills). This necessitates
either the use of alternative care-givers, or birthing
without the assistance of trained attendants. The latter
option is a situation almost all agree is highly undesirable.
Supporters of the legislation want the state to license lay
midwives so that consumers choosing this birthing option
can be guaranteed a minimum of expertise. Also, this would,
they hope, facilitate the medical acknowledgement of lay
midwives, thus making for more inter-occupational inter-
action and less hostility, harassment and discontinuity of
care. Supporters claim that in opposing the legislation,
the medical establishment is only assuring that lay mid-
wives will have no minimum required skills, or in their
absence, that people desiring home births will have to do it
themselves, thus greatly increasing the risks. Surely,
they continue, the medical establishment, so very interested
in medical outcomes would not seek to maintain the status
quo or a degradation of it, thereby assuring increasing risks.
The medical response to the midwifery legislation was
‘mixed. The overwhelming response from obstetricians and
nurses was that home birth is irresponsible and under no

circumstances to be condoned, it is retrogressive. The

189

claim was made several times that better birth outcomes are
the result of improvements in technology and obstetrical
skills and that to turn away from this superior medical care
is a dangerous mistake. It may also be particularly galling
to the physicians in the ob/gyn group practices at the two
largest hospitals, UH/RMC and NCCH, that residents in their
areas account for the largest percentages (in some years) of
people choosing home births. While this may be due to the
fact that the populations are considerably higher in these
areas and may be proportional, it nonetheless indicates

that the hospitals' and obstetricians' presence is not
dramatically inhibiting home birth. (See Table 6.4 and
note particularly the years 1977 and 1978.) Physicians
claimed that support of the licensure of lay midwives is
tatamount to supporting home births and was thus repugnant.
The physicians bemoan the fact that the "botched jobs" end
up at their doorsteps anyway, that they have to clean up

the messes, take on the data from the bad birth outcomes
which enter the hospital for care and thus they are in any
case responsible. Most physician spokesmen believe and
assert that they are responsible for birthing women and
infants and they have a direct interest in birthing out-
comes: they "know" that at home there are greater risks and
in the interest of good birth outcomes they cannot bring
themselves to support home birth. One physician compared

giving prenatal care to women planning home births to

190

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191

jumping off a bridge with someone in the hopes of helping
them at the bottom. Physicians assert that they have
standards of practice which would be compromised by the
midwifery legislation and they would be unwilling to comply
with legislation which facilitated the continuation of home
birth. A discussion from the 1980 legislative hearing
indicates this position as well as one physician's style of
presentation, obviously disturbing to the legislature.

‘Dr. Anderson: The perinatal mortality is
four times lower than it was in 1940. These
things do not happen by themselves: but
because of these (medical) technical advances.
These are some of the things that the home
birth advocates cry out against. They are
anti-science, anti-intellectual and anti-
interference. (Similar movements) were
rebuked and are fading away as will this
one, if properly handled.... Perhaps the
most important point I would like to make
today is that if the law is passed as it

is presently written the University of
Vermont and the Medical Center Hospital of
Vermont will have no part of it. We cannot
support in any way a retrogressive fad put
forward by (interrupted)...

 

‘ Representative May: Excuse me, if we pass
the law, are'you saying the University of ‘
Vermont and you will not adhere to the law?
You would violate the law?...

 

Dr. Anderson: We are saying that we cannot
be a part of a law that you will pass that
would require us to support functions that we
do not believe in. In other words, we are
dedicated to life. We are dedicated to the
lowest possible perinatal mortality. If you
pass a law which we know Will increase that,
there is no way we can aid and abet it....
The mother and fetus at time of delivery are
my responsibility.

 

'RepresentatiVe Regan: Do you--I may say this
awkwardly-~but nothing in this legislation
that we have got, could prevent a mother from
having a child at home. Is that right?

 

192

Dr. Anderson: That is correct.

 

Representative Regan: Would it not help,
if she did decide to have her child at
home, have the best possible midwife, if
she wants that? There is nothing you can
do to stop it.

Dr. Anderson: Well, first of all, I think
that if you are going to aid and abet, as
I say--it is her decision--but, then, if
you are going to supply people, then the
number of home deliveries are going to go
up and by definition we can say that they
are not as safe for anyone concerned.

 

Representative Regan: That is not my ques-
tion. She still can have the baby at home?

Dr. Anderson: Yes. That is true.

 

Representative Regan: That is all.

 

Representative May: Are you saying, that
ifia mother who was having a baby and
having any kind of trouble, that U.V.M.
would not take her in?

Dr. Anderson: Oh! Absolutely not! We take
any patient at any time for any reason and
we will always do that. What I am saying

is we will not be part of a home delivery
service. It is not safe...

Representative Wright: When you speak of--
I would rather not use the term--not co-
operating with the law--are you speaking
just for yourself, you are not speaking

for all the doctors at the University of
Vermont?

 

‘ Dr. Anderson: Yes. I am.

 

Representative Wright: You are speaking
for them?

Dr. Anderson: I think I can safely say
that I am speaking for all the doctors at
the University of Vermont and the Depart-
ment of Obstetrics and Gynecology.

193

Representative Wright: How did you arrive
at that dOctor?

Dr. Anderson: I talked to all of them.
Representative Wright: Did they vote?

Did they sign something saying you may
make that statement?

 

Dr. Anderson: No. I say that I think I

can safely say that I represent the Univer-
sity of Vermont, the Medical Center Hospital
of Vermont, and the state medical society.

Representative Wright: ....Are you speaking
for every doctor at the University of
Vermont that they would not participate

as a supervising physician for a midwife?

Dr. Anderson: As best as I can determine,
yes, that is true...

 

Representative Wright: Well, that is the
question I askedIyou doctor is how you
determined that. It is important to me,
it may not...

Dr. Anderson: My answer was that I talked
to all the doctors in our department.

 

Representative Wright: But, that is not all
the doctors that participate in the medical
facility at the University of Vermont?

Dr. Anderson: Well, they are the only
obstetricians, now if you want an opthal-
mologist to support a home delivery, that
might be possible. I have not talked to
everyone in the hospital....

In a letter to a newspaper, an independent midwife
discussed the medical establishment's response to the pro-
posed legislation.

I am not hopeful that fair "lay" midwifery
legislation will receive support from the
medical experts who have no vested interest

in the continued practice of independent
domiciliary midwifery. It was from the peOple
that the interest and encouragement must

194

come to see that a fair midwifery licensing
bill is passed into law in the state of
Vermont (Nolfi, 1979).

And legislative hearings and support meetings did draw sub-
stantial crowds of supporters who brough their babies and
children with them (Seidman, 1980). Their very presence,

as well as that of their healthy home birth offspring became
a statement in support of home birth and responsible,
committed parenting. It also indicated their cohesiveness
and sense of community. I observed a variation of this theme
at the trial of an independent midwife who had been charged
with administering a drug without a license. (She was later
found "not guilty" under the state's "good Samaritan" law.)
In my field notes of June 11, 1981, I wrote,

What is remarkable (about this trial) is the
support here for her. When I came in, the
lobby was filled with nursing mothers
discussing the case. The courtroom itself
is filled with her supporters, the home
birth parents--young adults with many
babies. Many of the men have long hair
and/or beards. The women wear long print
skirts and their babies are everywhere,
cooing, laughing, cryin . The poor guard
keeps telling them they 11 have to be quiet
or leave: people in the seats look at one
another and smile when he says this. The
courtroom is transformed. The jurors are
taking this all in.

Conclusion

 

Home birth advocates were able to make their presence
and their desires known; newspapers seemed sympathetic and
reported the movement actively. Since birthing parents

and lay midwives adopted the strategy of seeking only to

195

continue to have and attend home births legally without
physician harassment, many observers, including the legis-
lature were inclined to support them. For their part, physi-
cians were typically outraged at the existence of the move—
ment and went to great lengths to portray participants as

a handful of irresponsible or, at best, misguided people.
However, the incoming data on the characteristics of birth-
ing parents did not bear them out, instead they indicated
that those who chose home births were typically older and
better educated than their counterparts who opted for hospital
births. Physicians were forced to take the position of
demanding a "radical monopoly, " that is, demanding that their
potential clientele be forced to consult them. As Freidson
(1979a) noted, this is not a position destined for success.
Here, in particular, the independence and self-sufficiency
ethos of New England seems to have come face to face with

the demands and pronouncements of sometimes arrogant authority
figures. The fact that a profession has achieved state
sanction for its work does not mean that it has a timeless
guarantee. In this case, lay midwifery legislation initia-
tive came from a state legislator whose commitment to his
constituents' freedom of choice took priority over mainten-
ance of professional hegemony. Thus, while during the
period of study, legislation aimed at licensing lay mid-
wives was notenacted into law, it did have supporters

among the legislators. And it was clear from the testimony

196

at legislative hearings, that some legislators were becoming
disenchanted with the presentation of some leading members
of the medical profession in the state.

The independent midwives, who espoused an ideology of
deprofessionalization, were increasingly emerging as a
distinctive occupational group with a collective sense,
emerging standards of practice and occupational turf. These
transformations culminated in an effort to obtain state
sanction to practice. Committed to their clientele, these
midwives whose expertise was marked only by local reputa-
tion, sought state supplied credentials to legitimate their
skills and indicate that they had achieved minimum qualifi-
cations. In this way, they would not only obtain a
recognized symbol of their status and level of skill, they
would also be able to protect their clientele from unskilled
imitators. At the same time, most independent midwives I
spoke with, sought to avoid being drawn into the medical
division of labor. They saw their turf as normal births
outside the hospital and regarded the medical establishment
as useful for consultation and back-up in emergencies. Thus,
they sought formal status, not a niche in the medical
division of labor. At least one physician who defected from
the medical establishment, openly supported home birth and
lay/independent midwifery. That crack in the physician's
armor was to widen considerably. For their part, nurse-

midwives kept a low profile during this debate. Some

197

acknowledged in interview that they sympathized with home
birth parents but for the most part they sought to put con—
siderable social distance between themselves and their
"unprofessional competitors" (Larson, 1977: 75). They did
not make any public statements calling for an end to inde-
pendent midwifery but instead suggested that the legisla-
tion aimed at licensure required too little training. One
independent midwife suggested that they wanted to make lay-
midwifery training into nurse-midwifery training. A sym-
pathetic physician described nurse-midwives' mixed responses
to the legislation as largely a question of "turf."
"It's understandable," he said, "they've gone to school all
these years, and here come these lay midwives claiming
similar skills..."
After the legislation was tabled, advocates of home
birth embarked on another strategy, a joint study with the
Department of Public Health and UH/RMC to examine outcomes
from home and hospital births. This study was in process

as my study was being completed.

Chapter VII

In-Hospital Birth Reform: The Provider-Oriented

Movement To Reassert Hospital Birth

Introduction

 

The medical establishment in Vermont is faced with the
thorny problem of avoiding the defection of its clientele
while maintaining control of the institution of reforms
aimed at placating that clientele. Since freedom from lay
control and intervention is a hallmark of professional status,
that freedom is jealously guarded. At the same time, medi-
cine is a consulting profession and will have a very diffi-
cult time coercing its clientele to consume, or establishing

' especially in Vermont with its counter-

a "radical monopoly,‘
vailing values of independence and self-help.

While the movement for home birth and lay midwifery
clearly represents the interests of a minority among the
birthing population in the state, it is vocal. It serves to
raise birthing parents', and some care-providers', expecta-
tions for birth. At the same time, it challenges hospital,
medically-supervised births which do not meet these expecta-
tions. The success of the home birth movement is measured
in part by the fact that obstetricians in Vermont have been

forced to come to grips with at least some of the arguments

and practices of the movement.

198

199

Complicating the issues, the medical profession is
having trouble closing ranks in order to facilitate a unified
response. As I have noted earlier, a system which is so
physician—centered in the organization and delivery of care
enables defecting physicians to have considerable impact
unless or until organized medicine can stop them.

Non-defecting physicians have undertaken two major
strategies in response to the home birth movement. The
first is to strongly attack and attempt to delegitimize the
movement with the stated goal of improving health outcomes.
This is couched in terms of the profession's commitment to
and responsibility for the well-being of the birthing popu-
lation. Part of this responsibility, it is argued, involves
protecting that p0pulation from the impact of both quackery
and its own well-intentioned ignorance. The second strategy,
related to the first, is the institution of physician-
controlled reforms in hospital birthing organization and
practices. Ultimately, I will pay special attention to the
manner in which nurse-midwives will be employed in the use

and institution of these reforms.

The Medical Response to the Home Birth Movement

 

It is important to note that the response to the home
birth movement by physicians in the state is mixed.
Condemnation of the movement is not universal, several gen—
eral or family practitioners seem to support the option of

home birth and/or lay midwifery, either overtly or covertly.

200

However, the obstetrician, with very few exceptions,
seem to close ranks on the issue and strongly oppose it.
My impression from interviews and committee testimony is that
many seem to take the existence of the movement as a personal
affront. Certainly the movement challenges obstetricians'
claims to being the best qualified person to deal with the
phenomena they claim as their special turf. In addition,
their claims of univeralistic orientation in care-giving
and special concern for the patient's well-being are challenged.
The strategies of those opposed to the movement for
home birth and lay midwifery are several. Physicians have
used many vehicles to curtail or eliminate it. As we have
seen, physicians have worked through the state, often success-
fully, urging medical examiners to critically review bad home
birth outcomes toward indicting the midwife in attendance.
(To my knowledge, no comparable peer surveillance occurs
within hospital practice. NAPSAC and the newly formed
Alternative Birth Crisis Coalition have stressed this point
and suggested a counter strategy of focused attention on bad
outcomes from in-hospital births. In study after study,
researchers have found peer review and other forms of pro-
fessional self-regulation simply do not work and where there
is concern, it tends to be financially motivated, [Freidson,
1970b: Jones, 1980]). In an effort to assure that practicing
physicians in the state are disinclined to aid and abet lay

midwifery, the state board of medical practice sent out a

201

letter warning about potential problems inherent in such an
undertaking (Appendix D). This is perhaps the most overt
example of what seems to be strong peer pressure to bring
defecting physicians, especially obstetricians, into line.

The legislative initiative to license lay midwives
provided another forum for anti-midwifery physicians; while
they were under-represented at the public hearing (which
was largely pro-midwifery), they did appear, when called by
the house subcommittee chair, at the second hearing. At this
point they made very strong statements about the unaccept-
ability oftflmaproposed legislation. In their private practices,
consumer witnesses claimed, some physicians took it upon them-
selves to discourage their patients from considering home
births and some went so far as to harass patients planning
home births.

Meanwhile, some physicians have taken a different tack
moving in the direction of seeking to placate potential home-
birth parents by bringing them into newly developed in-hospital
birthing alternatives. Physicians and hospital administra-
tors may be attempting to reassert monopoly by revitalizing
normative hospital birth. At least some of them are willing
to create birthing alternatives themselves or allow hospital
birth reformers to do so in order to facilitate this goal.
However, the involvement of physicians who actively defect
from organized medicine's position may transform such

initially cynical reforms into substantial alterations and

202

vehicles for further client-centered changes. An example
of this phenomen on is provided at SCCH.

By the end of 1977, the Family practitioner who had
attended home births in the SCCH area for approximately one
and one-half years, decided to bring his practice into the
community hospital; that is, to cease home birth practice.
Midwives, who had been former partners/apprentices carried
on the home birth work and they maintained their cooperation
and friendship. Since this physician was, insofar as I could
ascertain, the only physician to have a primarily home-birth
practice during the period of study, his decision to return
to an exclusiVe hospital practice is significant. It is
therefore important toexamine the factors which facilitated
this decision.

First, efforts by physicians nearby to inhibit or elimi-
nate the practice of lay midwifery eventually reached him.
During an inquiry by the state medical examiner, he was called
into a court hearing to testify about the midwife's training,
as she had been one of the women who had studied with him
informally. He was, as he told me, "grilled for two hours
in front of a court reporter and a judge by the state's
attorney." The case, involving a midwife-attended still-birth
at home, was subsequently dropped, but not before both he
and the midwife had paid lawyer's fees, and been alerted to
the fact that two physicians were pushing the case in an

effort to stop midwifery practice in the area.

203

Shortly therafter, he became the object of public attacks
in the newspaper, by a local physician. Although these
attacks initiated a debate in which he was championed by his
supporting clientele, he understood the relative power of
each and began to fear that his license might be revoked.

"I was sort of thrown into the arena of politics, and I
would have preferred to avoid that. But it didn't take me
long to figure out that everything was politics," he told me.

Meanwhile, as it happened, there was a Spate of compli-
cations in the home births he attended necessitating hospi-
talization for several of his patients. During this period
he had maintained his hospital admitting privileges in a
special or limited capacity. This had exempted him from
more extensive involvement in the hospital. But his increased
presence necessitated by the complications was enough to
cause other physicians, some of whom.were already hostile to
him, to demand that he resume active staff participation in
order to retain his hospital admitting privileges. In the
midst of this increasingly politicized and conflict-ridden
environment, he was not earning enough to "survive and pay
a small mortgage." His home birth practice was not lucrative
and he was supplementing that income by working several
health-related odd jobs around the area. He increasingly
felt, as he said, "tired of that harum-scarum way (of making)
a living." Describing the factors which made the decision

to go into the hospital with his practice seem more viable

204

and necessary, he explained:

Well, one night it came to me. But this was
after the hospital administrator came and

said that the birthing room that I had

been lobbying for almost a year was a distinct
possibility if I would agree to it. So, all
these things came together in about two months
time. And I said to my wife one night, when

I woke up in a cold sweat, "I think somebody's
trying to tell me something.... I've got

to make a decision." So, I decided to st0p
doing home births. Support midwives and train
midwives, but myself, personally, open the
birthing room, put all my eggs in that basket
and work toward a good birthing room, a good
environment. And that's what we did. It
worked out very, very well. Very much to

my liking. I was able to see more patients,

I was able to make a living without running
around, and things just sort of fell together.
All the peer pressure and legal pressure dropped
away. My life was a whole lot easier. I didn't
have to lay awake at night with insomnia.

But the home birth, it was the most beautiful
time of my life. But the life-style I had to
assume was just too radical for me. Too much
pressure.

As his explanation suggests, physicians who deviate signi-
ficantly from standards of medical practice at least outside
the hospital are subjected to intense scrutiny and harass-
ment. Physicians, seeking to maintain the hegemony of their
hospital—based practices and opposed to the deviants'
activities, can create a social environment which makes the
continuation of their deviation/innovation extremely costly
to them personally. The issue then may appear to be one of
personal choice--of course, for lay/independent midwives, no
comparable choice exists since organized medicine refuses
them a niche in the medical division of labor. Thus, pressure

such as this is calculated to bring the erring peer back

205

into the fold while the pressure on the midwives is toward
their elimination. In this case, the choice faced by this
client-oriented physician was not the repugnant decision
faced most in his position: standard hospital practice

or deviant out—of-hospital practice. He helped create a
middle option of an in-hospital birthing alternative.

There were several factors which facilitated the dev-
elopment of the birthing room at SCCH. As with his involve-
ment with home birth, the family practitioner became inter-
ested in alternative in-hospital birth at the initiation
of his clients. During the period of his home birth practice,
he received several requests from clients for hospital births
which allowed the women to labor and give birth in the same
bed, with the aid of a support-person, thus avoiding the
delivery room. From individual requests, an organized
effort emerged to reform hospital birthing--or at least
provide in-hospital birthing alternatives for those who re-
quested them. A community group met to discuss these requests
with the hospital administrator, interested physicians and
labor and delivery nurses. However, this initial effort at
reform, begun in 1976, was tabled pending further informa-
tion about the safety of birthing outside the delivery room.

There are several changes implied in this reform which
may not be immediately apparent. For example, since there
are not stirrups on hospital labor beds, women can, with

adequate staff and physician support, labor and birth in

206

any position they find comfortable and effective. This
requires that the physician attending the birth arrange hir-
self in a physically complementary position, rather than
standing center-stage and expecting others to adjust. Friends
and family who have supported the woman through labor need
not be rushed away from the activity and shunted into a
waiting room, but instead may remain actively involved and
supporting throughout the birth.

Reformers made other related requests for changes in
post-partum arrangements, for example, continual "rooming
in," that is, the cessation of the practice of mother-infant
separation and rigid feeding schedules. Obviously, such
innovations require substantial changes in hospital proce-
dures and care-giving by both physicians, and labor and
delivery and nursery nurses. Considering the breadth of the
changes proposed, it is not surprising that SCCH denied
initial efforts to reform hospital birth in this manner.
What is more interesting is that the hospital later embraced
such reforms.

By the end of 1977, a birthing room opened at SCCH.
Several elements coalesced to facilitate its realization.
Information was beginning to appear in the medical litera-
ture suggesting the viability of in-hospital birthing alter-
natives. Mid-year, the family practitioner found an article
in the medical literature describing a birthing center in

the south staffed by a physician and a CNM. They provided

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family-centered, minimal interventive care at low cost with
good outcomes. He showed the article to interested physicians
at the hospital and he and others supportive of the idea
subsequently presented it to the administrator.

Meanwhile, the physician's home birth practice drew
consumers away from the hospital, lowering hospital births,
(see Table 7.1).

There's no question that since I took

my obstetrical practice out of the hospital

I had taken something like fifty births a

year away from the hospital. And they

were only doing something like 150 to begin

with...there would be weeks at a time when the

OB unit would be closed; there were just no

births.
Of course, the hospital continues to pay for the overhead,
even when the space is not generating revenues. Therefore,
overbedding (an excessive number of hospital beds per pOpula-
tion served) is of necessity an issue of concern to hospital
administrators. During this period, however, the concern
was intensified by the threat of regionalization--a term for
the plan by the federal office of Health, Education and
Welfare plan to cut costs and centralize resources. Implemen-
tation of the plan threatened the closure of the Obstetric
units in small and some mid-sized hospitals in the state
and throughout the country. While the plan was never realistic
and major exceptions were eventually made for rural areas,
it did intensify the pressurecnismall hospitals to avoid

overbedding in their obstetrical units and it made the loss

of patients more keenly felt.

209

Impact of the Birthing Rooms at SCCH on Birthing Reform

The birthing rooms at SCCH were so typically regarded
by respondents as "real birthing rooms" that many told me
only of SCCH when I asked them where birthing rooms were
located in the state. In fact, several hospitals have at
least nominal birthing rooms on the premesis. Respondents
who had opinions about birthing rooms all stressed that
making the rooms "home—like" was nice but not nearly suffi-
cient. The essence of a "real birthing room” was the
philosophy and practice of supportive, non-interventive care-
giving. The birth experience was client-oriented rather
tluan physician-centered. At least a partial transfer of
power, authority and decision-making to the family/couple
was necessary. It is frequently characterized as a much
more egalitarian, friendly and uninhibited interaction. As
one respondent said fondly, "...at SCCH, they'll get down
and roll around on the floor with you." As in the rest of
the world, birth in a birthing room is a more earthy under-
taking than in the delivery rooms of hospitals.

When the family-practitioner brought his practice into
the hospital birthing rooms, he retained his commitment not
only to non-interventive birth but also to keeping costs low.
The first year (1978) of his birthing room practice the
total cost for the birth was $300, (the cheapest birth any-
where in the country at that time, he told me). It sub-

sequently rose, but even at an estimated $450 to $500, costs

210

compared very favorably with UH/RMC where a typical delivery
cost $1700 to $1800.

Once in the hospital, his practice quadrupled (see
Table 7.1). By 1980 the two full-time family practitioners
and one part-time CNM at SCCH were attending around 325
births per year, doubling the 1976-1977 figures.

Where were the patients coming from? The birthing
rooms at SCCH drew patients away from other area hospitals,
including NCCH and even a few from UH/RMC. This diversion
was not by design, the family practitioner explained to me,
and he sought to counter it by persuading physicians in the
other hospitals to consider birthing rooms.

Peeple were coming here because they had

choices they had nowhere else. They'd

drive an hour, and a half to get here for a

birth. I think that is definitely not ideal,

I'm not in favor: of people having to come

long distances to get anyplace to give birth.

And so, the pediatrician and I who were so

behind the birthing room began to go to all

these other places and show them what we had

done and to enlighten them as to birthing

rooms. Show them our statistics, which

were very good.
They made presentations at UH/RMC on pediatric grand rounds
(interestingly not on ob/gyn grand rounds). A trip to NCCH
drew only one interested physician, a family practitioner.
The ob/gyns stayed away, as they did at another conservative
hospital southwest of SCCH where a lone pediatrician attended
their presentation. The family practitioner at SCCH expressed

to me the opinion that the absence of ob/gyns was less the

result of passive disinterest than a strategy of active

211

opposition, especially at NCCH and the south-western

hospital. However, because of the financial pressures
exerted by SCCH on nearby hospitals, hospital administrators
in each opened birthing rooms. Not surprisingly, these are
rarely used by the obstetricians who so adamently opposed
them, and some respondents construed them as "window dressing"
strategies to compete for clientele.

Along with nearly every other respondent with whom I
spoke, the family practitioner described NCCH as "a bastion
of conservatism." While he described the south-western
hospital as "even worse" he explained that he drew more clients
from the NCCH area simply because it was closer and the south
western hospital was on the other side of the mountains.

To dramatize the impact his practice and the reforms
at SCCH continued to have on area hospitals, he pointed out
that fully 75% of his practice came from.out of town. And,
not unlike home-birth, the birthing rooms at SCCH drew a
clientele not representative of the general population.

While cost was certainly a factor, he perceived that most
peOple came for the different kind of birth experience avail-
able to them. Interestingly, among those people who sought
out this alternative were many nurses. A respondent from
UH/RMC conceded that several obstetrical nurses on staff had
chosen to give birth at SCCH and that that information had
given some members of the medical staff pause for thought.

The family practitioner reflected on this self-selection.

212

Over the last couple of years, I've had

more nurses come through my practice,

from (the southwestern) hospital, UH/RMC...
and not just nurses from the Ob floor, nurses
from all over the hospital. Particularly
UH/RMC, they really didn't want to have a
baby up there.

As if the alternatives offered at SCCH and their impact
on even the nursing staffs of other hospitals was not irksome
enough to obstetricians in the state, this former home birth
physician continued to train lay-midwives, to whom he still
felt a commitment, while in the hospital. He explained that
both the hospital administrator and other physicians, though
leery at first, allowed him the option and did not attempt
to block it as long as he was prepared to take responsibility
for which he was in any case legally bound. He subsequently
supervised several midwives providing one of the few sites
in the U.S. where lay midwives are trained under physician-
supervision in non-interventive obstetrics. In addition,
he trained medical and nursing students from the state and
the northeast and continued to do so at the completion of
the study.

One may question why obstetriciansixxparticular were so
resistant to the institution of substantial changes in
birthing settings and birthing practices even when market
forces impelled them to examine client demands. Their
reluctance largely stifled the diffusion of the innovation.

Why are some care-givers interested in change while others

so actively attempt to inhibit it?

213

On the face of it, one could say that these new ways
of organizing caregiving conflict with medical standards
of practice. Those standards serve to unify the profession
which claims they serve to guarantee a particular level of
professional performance based on the latest knowledge.
Larson (1977) has emphasized that standards of practice
represent a vehicle by which claims to the reliability
of the producer of services can be made. Standards of
practice may or may not guarantee come collective unity among
members of the profession. They are, in any case, an organized
effort to unify the phenomena (the production of services)
which constitute tile commodity being produced and marketed.
Maintenance of professional standards of practice through
colleague-control of peer-surveillance has been noticeably
absent in terms of quality control (Freidson, 1970a) some—
times even serving as a vehicle to rationalize mistakes
(Millman, 1977). It also serves to restate the boundaries
of the profession by enforcing particular ethical conceptions
or levels of technical competence (Bosk, 1979). Frequently
colleague control centers on concerns about market factors
(Jones, 1981) or conceptions of the appropriate organization
and delivery of care. For example, until the late 1960's
the AMA denounced and stigmatized group practices by physi-
cians and harassed physicians who engaged in them (Freidson,
1970a).

Insofar as the standards of practice are related to

214

the nature of care-giving they derive either from the prag-
matic concern with the maintenance of professional power or
from the paradigm (by which I refer to both knowledge and
practice) upon which the profession built that status. I
think one of the major reasons obstetrician-gynecologists

are so resistant to the acceptance of fundamental reforms in
birthing practices is that they instinctively understand that
it constitutes a threat to their professional dominance. It
does so because it represents the beginnings of a paradigmatic
shift, which could be tied to a concomitant shift in the
organization of care-givers. If birth is essentially normal
and if it is organized around that concept in essentially
non-medical settings (such as birthing rooms) then what is
the justification for an expert in surgery and abnormal
obstetrics to be in charge of the event?

As Rothman (1979) observes, the medical model charac-
terizes pregnancy and birth as something which happen to
women. And, viewing the body as machine, physicians perceive
their function as management and intervention. Both the
patriarchal (a term for the system of male-supremacy and
male exploitation of women) and technological orientation
of the medical model cast the physician as actor (in fact,
benefactor) while the birthing women is viewed as the object
of their actions. The midwifery model, in contrast, centers
the social interaction on the woman who, with the aid of

her supporters, is the actor giving birth. This, I believe,

215

is the critical distinction implied in the different char-
acterizations of childbirth as a "delivery" implying medical
management or "birth" indicating the woman was the central
actor.

If a midwifery model of care-giving enters the locus
of the physician's work (the hospital), a different organi—
zation of care may emerge. If birth is really the rightful
province of parents and their loved ones, as some birth
reformers charge, then why should the birth be physically,
temporally and spatially organized around the physician?
What happened to SCCH is at least the partial transfer of a
home birth, lay-midwifery model of care-giving into an
essentially non-restrictive hospital setting. It is little
wonder that obstetricians elsewhere in the state, deeply
invested in their world—view and orientation to care-giving
from which their claims to pre-eminence derive, would actively
resist such fundamental changes. Where the physicians at
NCCH chose obstructionism as a response, the Department of
Obstetrics and Gynecology at UH/RMC took a different, less
reactionary tack. The source and model of the reform they
instituted derived not from home birth and lay-midwifery but
instead from the movement for in-hospital birth reform which
were considerably less antagonistic to professional authority
and pre-eminence. As we shall see, opting for this relatively
comfortable compromise enabled them to successfully turn back

the efforts of more radical birth reformers in their area.

216

In-hospital birth reform movements have historically
upheld physician pre-eminence even as they have criticized
and sought to alter hospital birth. This was possible
because they aimed to change not so much the activities of
physicians as those of patients and subordinate workers.
Agreeing with "progressive obstetricians," birth reformers
focused on the manner in which care was given (especially
by subordinates) and received by patients (thus largely
accepting of the active-passive model). The notion that the
content of care was essentially acceptable was at the heart
of in-hospital birth reform. In fact, Rothman (1979) has
suggested that prepared childbirth classes may actually
socialize the patient into a more cooperative and self-
controlled patient role. They have, for example, come to
construe as "natural childbirth" hospital births in which the
woman is in lithotomy position (on her back with the legs up
in stirrups), use of forceps for extraction of the baby, and
use of local anesthesia.

As has been noted above, consumers and activists, often
including childbirth educators, have sought hospital reform
in birthing practices in the U.S. since the 1950's. Birth
reformers have spent years educating prospective parents
and attempting to establish rapport with obstetricians and
hospital administrators in order to institute their desired
in-hospital reforms. They have finally begun to experience

some success (Forrest, 1979; Parfitt, 1977).

217

University Hospital/Regional Medical Center - (UH/RMC)

At UH/RMC, the first recent moves toward birth reform
which I could document, appeared in 1970 when a patient-care
committee was formed. It was composed of nursing instructors
at the University, staff nurses, childbirth educators and
at least one physician. This group investigated and con-
sidered in-hospital birth reforms across the country and
generated information on their viability. This method paral-
lels, in a more organized manner, the method used by the
family practice physician at SCCH whose discovery of a
precedent for his concept of a birthing room encouraged both
other physicians supportive of the idea and the hospital ad-
ministrator. This method of reform is clearly related to
the medical profession's efforts to regulate practice through
standards of practice, and once again indicates the hesitation
to innovate, lest those standards appear to be breeched. In
addition, as in any other organization, change requires energy,
resources and the willingness on the part of those involved
to overcome resistance.

After studying alternatives, the group presented their
recommendations in a meeting with the obstetrical, medical
and nursing staffs. Paralleling the national trend, the
first reform sought was the acceptance by the hospital and
attending and house-staff obstetricians of the (restricted)

presence of the father/coach in first the labor room and

218

subsequently, the delivery room. As was the case in most
hospitals, reforms came slowly and after much effort on the
part of those seeking them. One member of the group recalled
during interview that most of the physicians agreed to the
changes, some reluctantly, while a few continued to bar
fathers from the delivery room. Here the reformers encoun-
tered the difficulty of instituting reforms in a situation
where the dominant profession demands and retains ultimate
control over actual practice, and, where possible, the
conditions of practice. Thus, since the delivery room is
the primary site of physicians pre-eminence and control,
reformers can only attempt to persuade each individual
practitioner to institute the desired reform: the admission
to this turf of a previous "outsider."

That some of the would-be reformers had in mind a
larger agenda of changes is suggested by one of the partici-
pants who told me that these changes were, "...the start of
something bigger...(the recognition) that this was a family
affair. . .it was their baby and we were there to assist the
process." I shall question the extent to which this view
was widely shared by either the medical or the nursing staff.
Nonetheless, at least some perceived that these early reforms
laid the ground work for subsequent modifications; for
example, if fathers/husbands were to be allowed entrance to
the labor and delivery room then childbirth preparation for

both parents became more desirable.

219

Following the lead of other hospitals, UH/RMC eventually

allowed "rooming in,"

extended periods of mother-infant
interaction and in some cases total cessation of separation.
Other birthing reforms such as the creation of a labor lounge
and the option to deliver in the labor room came at the end
of the period of study and will be discussed later. These
changes took place over a period of ten years brought about
by interested staff, pressure from consumers and childbirth
educators, forward—looking department leadership (a new ob/
gyn department chair arrived in 1976) and, perhaps the
critical element at UH/RMC, funding from the Private Founda-
tion which enabled reformers to surmount financial barriers.

Consistent with the national trend, childbirth educators
were central in the realization of birth reforms at UH/RMC.
Childbirth educators themselves occupy a pivotal role in
mediating the birthing parents' relationship with the hospital
and care-provider. Childbirth education plays a central role
in preparation of birthing women and their partners. It may
be used to train people to critically examine hospital
birth and consider and/or prepare for the option of home
birth, as did some of the lay/independent midwife-led classes.
In contrast, it may be a vehicle for socialization of
potential parents into a more self-controlled, thus more
c00perative patient status (Rothman, 1979). Or, it may play
some other role in between these options.

In 1978, along with other changes instituted at UH/RMC,

a new parent education coordinator was hired. An ASPO-

220

certified nurse and an active ASPO member (she subsequently
became president of the national organization), she was

also the wife of the physician who headed gynecology at
UH/RMC. She characterized her task, as she perceived it
portrayed to her by the chair of the overall ob/gyn depart-
ment: "Can you satisfy the community (of patients) without
shaking up the medical community?" Toward this end she sought
to facilitate reforms in birthing practices through changes
in the practices of the nursing staff, especially nurse
involvement in childbirth education. From the outset, then,
the parameters of her role in reform were set, excluding
overt pressure on the medical staff.

Once at work, she promptly set about to update the
childbirth education classes taught by the labor and de-
livery nurses. She set new requirements for teaching, in-
cluding ASPO certification. The latter she viewed as a
vehicle for standardizing childbirth education and thus
assuring the quality of its performance. In interview, he
indicated that she regarded herself as a change agent and
saw ASPO as a good vehicle for the creation of progressive
changes in hospital birthing practices. She pointed out that
within the UH/RMC area, the only options available to women
dissatisfied with UH/RMC-birth were home birth or a long
drive to SCCH (obviously a problem with short labors). Since
UH/RMC had a de facto monopoly on care of pregnant and

birthing women she decided to work within the system, as

221

ASPO itself does, to gain the confidence of care-providers
and to create changes.

Whether or not she gained the confidence of the nurses
teaching the parent-education classes, she had (at least the
tacit) support of the chair of the overall department of ob/gyn
(not the position held by her husband). It was support she
needed and she was instrumental in bringing sweeping changes
in the nursing staff.

Meanwhile, a study of the attitudes of consumers of
obstetrical services at UH/RMC was developed in 1978-9 by an
anthropologist and a sociologist (at the initiation of the
department chair). The study consisted of two parts: first,
an ante—partum.questionnnaire was given to women during their
office visits in the eight or ninth month of pregnancy. They
were asked for both personal data and their desires and
expectations for labor and delivery. Of this apparently
quite large population of respondents, a sample of approxi-
mately 250 women was chosen for post-partal interviews--the
second portion of the study. Nearly 200 interviews were
subsequently conducted in the hospital. During the hour-
long interviews held after the birth, patients were asked to
describe in detail their treatment during labor and delivery
and their feelings about it. While the findings were not
formally presented to the department during the period this
work examines, the interviewer reported her informal findings
to the administrative assistant to the chair who, as she said,

"used them to make changes."

222

The interviewer explained that the information made
clear which of the physicians were liked or disliked,
however,

...in terms of physicians, there were no
real surprises...physician satisfaction

was quite high. Basically the labors and
delivery were managed by the residents, most
of whom (were) outstanding. (A feminist
senior resident) probably handled close to
50% of the deliveries.

Incoming information was not inconsistent with hospital
staff and community scuttle-butt; it was perphas more indica-
tive of the practices of the current "house staff" than of
the "attending" ob/gyns. In addition, the person who con-
ducted the bulk of the interviews pointed out to me that
the time at which the interviews were given may have colored
the responses.

At that point in time, just after the

birth, everybody was very high from the

birth and feeling good about whoever

delivered the baby.
In any case, I could find no concrete evidence of change in
obstetrical medical practices at UH/RMC as a result of
the study.

In addition to generating information about the medical
staff, the study inquired about the nursing staff and the
nature of support they gave during labor. Whether or not
this information was substantially more critical, it seems

it was related to substantial changes in the composition and

orientation of the obstetrical nursing staff.

223

As the new parent education\director pushed for changes
in the classes taught by the labor and delivery nurses,
struggles emerged. Many of the nurses resented her hard line
and resisted the changes she demanded. They had made their
peace with the system of care-giving, had accepted customary
work routines in which they had developed competence and prob-
ably some degree of independence from physicians. Now they
faced a younger woman, a doctor's wife who was not even a
physician, giving them orders and demanding that they comply.
No doubt it was a bitter pill to swallow.

Almost all the informed subjects with whom I spoke felt
that most of the labor and delivery nurses had resisted
other changes in hospital birthing practices (e.g., consumers'
desire for less use of medication) and appeared uneasy if not
hostile to more active people who resisted the traditional
passive-recipient patient role. The pressure from reformers
is squarely on nurses, since it is their behavior and care-
giving which most immed iately needs to change in supporting
labors of reform-minded consumers. In the medical division
of labor, the labor support is construed as a nursing function.

The findings of Hofling, et a1. (1960) suggest that at
least some aspects of nurses"work performance are indicative
of over-conformity. But this may tell more about the nature
of the work structure than it does about the nurses themselves.

Ritualism.resu1ts not so much from over-
identification with rules and strong habit-
uation to established practices as from lack
of security in important social relationships

in the organization (Blau, 1963, quoted in
Merton, 1968: 239).

224

Not in decision-making positions formally themselves, the
nursing staff nonetheless forms the front ranks of the
hospital staff in patient care and most immediately encounters
the patients' demands and complaints. This double-bind
situation has been pointed out by Shaw (1974) and is not

at all uncommon for women comparably located in hierarchical
structures who elsewhere, as in this case, come to be seen

as the problem themselves (Kanter, 1977).

The outcome of the struggles between the parent-education
coordinator and the resisting labor and delivery nurses was
that several of the nurses either quit outright or were
transferred to other floors. Both the head nurse on labor
and delivery and the nursing supervisor resigned. It is likely

that these blustery changes were kept in-house; none of the

hospital outsiders" with whom I spoke seemed to know exactly

how and why the staff changes had come about, though they
were all well aware of the changes. However, insiders'
descriptions indicate conflict:

All but one of the (labor and delivery)
nurses are gone. What happened was an
incredible change in the last just two
years, (79-80). The head nurse on labor
and delivery, the nursing supervisor, they
were bastions of conservatism who knew that
consumers were asking for more and were
trying to accommodate them. But in their
heart of hearts they really didn't believe
in any of it...they really resented it and
they really resented (the parent-ed coor-
dinator) who was extremely vocal.... They
actually resigned under real hostilities.
There were some incidents that happened
that just really blew up and got people
furious.

225

While more orderly reform may have been hoped for by
the department head the conflict within the nursing staff
erupted before the data generated from the consumer-attitude
study was complete and analyzed. As noted above, the data
seenn not to have been used to alter practices by residents
and attendings. In retrospect, the parent—ed coordinator
characterized the ob/gyns as basically apathetic about things
outside their immediate sphere of practice. "Do what you
want as long as it doesn't bother me. Don't structure or
assist in patient activism and demands," she felt implicitly
instructed by them. While she aimed to use her position to
upgrade the childbirth education, and thus brought about
changes in the nursing staff, she also brought an activist
orientation to preparation of prospective parents. Concern-
ing the apparently rising expectations of the incoming
patients, the head of the department said to her, "I thought
the classes would answer their questions." That is, he hOped
that by changing those things which surrounded the practice
of the ob/gyns, the consumers could be satisfied. She re-
flected, "(the physicians) didn't care about consumer satis-
faction, apart from economics--do you break even (do these
surrounding changes pay for themselves?)."

After the nursing staff changes, the task of child-
birth education was turned over to full-time childbirth
educators who were ASPO-certified, and were not on the nurs-

ing staff. Although they were in the employ of the group

226

ob/gyn practice, they were hired as consultants and as such
were at least nominally independent. In so doing, the ob/gyn
chair acknowledged the importance of childbirth education

and facilitated its institution as part of the standard pro-
cedure for care within the practice. After facilitating the
dramatic changes, the woman who headed parent education re-
signed and withdrew from.the local childbirth education scene.
When I spoke with her, she expressed concern that the de-
partment chair had recently dropped the prerequisite of ASPO-
certification for childbirth educators. That outside tie

to a childbirth education organization, she felt, would
facilitate independence on the part of the teachers and

loss of it might mean they would become handmaidens of the
institutions.

The nature of the strategies attempted to reform
hospital birth at UH/RMC may be indicative of the physicians'
formulation of the problem, insofar as they acknowledged
that a problem exists. The changes which did and did not
take place make sense if one assumes that the core of the
activity—-medical practice by physicians--is sound and
right-headed. If, in addition, one assumes that it is the
manner in which the care is given which tends to make the
hospital impersonal, it would seem reasonable to make changes
in the nursing staff and childbirth education to meet what
are perceived as consumers' desires for a better "birth

experience." This might help to explain both physicians'

227

reluctance to make changes and their narrow range of interest.
Behind this definition of the situation is acceptance of a
medical model which assumes mind/body dualism and organ sys-
tems (potential pathology sites) conceptually separated from
the social person (who is someone else's concern) (Berliner,
1975: Goffman, 1967). Maintaining their belief that their
work is central and nothing is wrong at the center, they
retain fundamental autonomy in practice and facilitate changes
in surrounding activities and personnel to improve the
"experience." As several authors have noted (Larson, 1977;
Friedson, 1970a, 1970b), absence of lay control over both
medical practice and the creation of medical standards has
been critical in allopathic medicine's development and
recreation of its monopoly. Thus, while lay-intervention in
actual practiceijsshunned, particularly by the colleague-
centered physicians who comprise the UH/RMC medical staff,
responses to lay concerns about "non-medical" aspects of
care giving may be entertained.
A nursing instructor at the University described the

birthing options available at UH/RMC:

The patient has the option of being in a

labor lounge, up and about during labor,

delivering the baby in bed with no anesthe-

sia, no stirrups.... So right now, our

criteria is: as long at it s safe for both

the mother and the bab , it's OK with us...

this is available to a 1 who are "low risk/

normal."

By 1979-80 a labor lounge on the labor and delivery

floor was created with funding from the Private Foundation.

228

It looks like a relatively small living room extracted from
an upper-middle-class home or perhaps a hotel lobby. Thickly
carpeted, it was expensively furnished including comforable
stuffed chairs, a rocking chair and a TV. It could be called
home-like; certainly it stood in sharp contrast to the hospital
rooms in which women labor. There have been other efforts to
temper the aesthetic sterility of the hospital labor rooms,
for example, colorful curtains and/or wallpaper have been
added. In spite of this, the too small rooms, dominated by
a hospital bed with equipment attached to the wall, seemed
to me relatively unchanged from the standard fare. As we
shall see, most women still gave birth in the delivery room.
It was difficult for me to ascertain hOW'mUCh the labor
lounge was actually used by laboring women--some respondents
felt that it was underutilized, but I could get no concensus
on this. During my brief visit to the labor and delivery
floor, it seemed that the hallways were used primarily by
the staff as they moved about in the course of their work.
Patients who felt a bit tentative about using the labor
lounge might be deterred by this. Some respondents pointed
out to me that the most private space on the floor (though
in fact it was hardly private with staff coming and going)
were the labor rooms, both the hall and the labor lounge were
much more public.
At the same time, the labor lounge provided a comfort-
able space created for patient use and it might well facili-

tate interaction between laboring women, breaking down the

229

separation and isolation which is common in hospitals of
this sort (see Scully, 1980: 69-70). It was clearly a non-
medical space.

One of the latest changes which occurred during the
period of study was the patient's option to give birth in
the labor room. (The labor room is the small room in which
women labor before being taken into the delivery room in
typical hospital births). The labor room birthing option was
instituted in 1980 and was available for those patients whose
labors and deliveries were "normal." Several respondents
characterized it as a response to the competition from SCCH
birthing rooms which was an embarassment. Again, we will
see that there is a difference between the nominal avail-
ability ofan in-hospital birthing alternative and its actual
utilization. The data I was able to obtain suggests that
womanwho actually give birth in the labor room constitute
under 10% (some staff estimates ran as low as 3%) of all
birthing women at UH/RMC. How can we explain this? We
shall see that it is either not requested (it is an alterna-
tive, not standard fare), not demanded, or the patient pre-
viously characterized as "normal," nonetheless "risks out,"
that is, a "complication" arises such as meconium staining,
which has been previously specified by the physicians as
necessitating delivery room birth.

Again and again respondents at UH/RMC, particularly the

nurse-midwives, stated that they felt that patients and

230

potential patients were not adequately informed about the
various in-hospital birthing alternatives available at UH/RMC.
Every reform—oriented person with whom I spoke (including
independent midwives and childbirth educators), felt that

the bulk of patients were still alarmingly docile and felt
the need to educate potential patients/clients to available
options. Some felt, in addition that the hospital had some-
thing of a bad reputation in the area among those interested

in alternatives, ...some people still think we're gonna slip

them a 'mickie,‘ one reformrminded obstetrician told me.
All the hospital insiders felt the reputation was undeserved.
Some attributed it to critical child birth educators, others

to some homebirth parents, still others regarded its source

as outdated "talk over back fences." A lay/independent mid-
wife with whom I spoke suggested that many alternative-oriented
people would self-select out of UH/RMC: the low usage of
birthing options could be explained in part by the fact that
many people who desired them didn't think they can be realized
at UH/RMC and traveled to SCCH or had a home birth.

As difficult as it may be to inform and activate birth-
ing women and parents to desire and request in-hospital
birthing alternatives, the reality is that simply requesting
the Options is often not sufficient. Bad reputation aside,
birthing alternatives at UH/RMC often had to be continually

renegotiated and not infrequently demanded.

The interviewer for the consumer-attitude survey

231

described to me her interpretation of the study's findings
regarding the labor room delivery option and its minimal
utilization even by those who indicated a desire to employ
it.

As long as physicians are delivering babies,

it seems that their orientation is so much

toward intervention and delivery tables that

it is very hard for someone ahead of time to

say, "I want to deliver in the labor room"

and then be able to follow through with that.

Because the physician could say, "Well, I

would feel more comfortable in the delivery

room, but if you reall want to stay here,

I'll do it." And then, predictably, the

woman would say, "Oh, well, if you feel more

comfortable in the delivery room...(then

I'll go).
The decision-making ability appears to be negotiated, rather
than explicitly demanded by the physician, nonetheless it
occurs in a context loaded with symbols and staff inter-
actions restating the centrality of the physician in the
birthing process. The outcome of the negotiation is fre-
quently the apparently concensual recreation of the physi-
cian's role as decision-maker in birth. A.nurse-midwife

told a similar story.
We also have a percentage of physicians who,
although they verbalize that (labor room
birth) is a good idea, it is hard for them
to really put it into practice. They don't
encourage it.
And this disinclination on the part of many physicians taps
into the patient's inhibited ability to define the situation
in a manner contrary to that of the physician, the authority

figure who is located in what he regards as his appropriate

arena of work and expertise. The nurse-midwife continued.

232

There are a lot of people who still think...

if my doctor says so, then it's all right.

If my doctor thinks it would be better for me
to go to the delivery room, then that's what

I'm going to do.

As in the case in other innovations in large bureaucratic
institutions of this sort, standard operating procedures
dominate and typically preclude alternatives, the latter, in
order to be viable, require active support by at least some
non-subordinate component staff. Even where there is no out-
right obstructionsim, passive acquiescence is no method of
instituting changes. Furthermore, change cannot be created
wholly from without. In the absence of active staff support,
it is difficult if not impossible for activist patients to
demand particular kinds of medical practice (cf. Danziger
[1978] for a fuller discussion of potential range of physician-
patient interactions in the care of pregnant women, and their
outcomes in terms of the free flow of information and the
recreation of the authority of expertise). In so doing they
challenge the profession's claims to freedom from lay inter-
vention while within the context of the physician's domain:
the hospital; it is at best an unlikely proposition. As many
feminist activists have stressed for years, concern with
health and the provision of health care is a struggle best
fought when one is well and on one's feet, not while one is
flat on one's back with one's feet up in the air, as in a
gynecological exam, or, more relevant to this discussion,

while a woman is in labor. Laboring and birthing women can

hardly be said to enter the hospital and thus the arena of

233

negotiation in a position of strength and firm resolve. The
physically and emotionally arduous nature of labor and birth
disincline them to struggle for power. A former lay-midwife,
questioning the notion that birthing women can be autonomous
during labor and birth, explained the quandry she had
encountered in home birth practice.

It's ingrained in you that there's somebody

else who's going to have that power to make

everything OK. And when a woman's in labor,

no matter what she says prior to that about

taking full responsibility, it changes. It's,

"please help me," "I need some assistance,"

whatever.
And certainly, to the extent that the hospital operates in
the mode of a total institution, where the woman is separated

from the bulk of her pr0ps for her social personhood, the

position becomes even more problematic (Shaw, 1974).

Diorth East Regional HosPital - (NERH)

 

Considering birthing options available at NERH, two birth
attendants from the area explained that there has been con-
siderable changes in the recent past. Discussing the years
immediately before the 1977 arrival of the obstetrician, they
described conservative physicians and traditional birthing
practices. Upon the arrival of the obstetrician, changes
began to occur and word moved quickly through the lay-referral
network that he was "liberal." This physician was the only
obstetrical specialist in a 50-mile radius. Although the
area outside the community is relatively sparsely p0pulated

the scarcity of obstetric personnel quickly created a

234

situation in which he had more work than he could realistically
handle. This gave him considerable economic impact on the
hospital. The reforms he sought to institute were welcomed
as a condition of his presence. Immediately upon entering
practice he set about to create a birthing room. At the

time I conducted interviews, the hospital had one birthing
room with comfortable lighting and furniture (including the
ubiquitcnis rocking chair) colorful curtains and wallpaper.

A fetal monitor was in a corner and other medical equipment
was at the ready. However, both the nurse-midwife with whom
he worked and the birth attendants emphasized that the equip-
ment was not pushed. They explained that the equipment and
delivery room birth are available but are not used unless
requested by patients or strongly medically indicated.

All other rooms could function as birthing rooms if
necessary. During their pregnancy all patients are given a
checklist, by the CNM or the physician, of the available
options among which they will have to decide. The CNM des-
cribed the typical birth at NERH.

A.woman comes in (to the hospital) and is
checked and put to bed. She showers. Rocking
chairs are available and she will be encouraged
to move around. There is a refrigerator for
food storage (thus she can eat, instead of being
given an IV drip). She receives no "prep."

She can ssume any position in bed, except flat
on her back.

235

At-Risk and Risking-Out: The Medical Rationale for an

 

Obstetrician-Centered System

 

Several authors (Scully, 1980: Lorber, 1975: Shaw, 1974)
have observed that physicians (obstetricians in the first
two cases) found dealing with patients who displayed pathology
more interesting and more gratifying than dealing with patients
who did not. Lorber noted that this coincided with their
ability to generate clear-cut diagnoses, for which they had
been trained. Further, physicians are particularly trained
to avoid the error of not detecting pathology (Scheff, 1963,
cited in Oakley, 1980: 22). Thus, since obstetricians have
claimed all of women's reproductive functions as their exclu-
sive province, no birth can be regarded as wholly "normal"
while it is underway. As Oakley (1980: 22-3) explains,

(T)he doctor views reproduction as a

potentially problematic condition, reserving

the label 'normal' as a purely retrospective

term. Every pregnancy and labour is treated

as though it is, or could be, abnormal, and

the weight of the obstetrician's medical

education acts against his/her achievement of

work satisfaction in the treatment of

unproblematic reproduction.... The equation

of 'normal"with.'unusual' (uncommon) illustrates

the medical rationale, for if this equation

did not hold, obstetricians would presumably

have no valid role in managing reproduction.
A physician, responding to a discussion of a nurse-midwifery
service at an AMA Conference cautioned his colleagues about
the implications for the profession as a whole.

(I)f we cannot have everything, we must make

a decision as to whether we are going to give

away 'normal' obstetrics. If we are, then I
think the time will come that we must also

236

decrease residency programs by a third or
50 percent (Zuspan, 1978: 924).

In order to avoid the potential loss of their centrality in
the delivery of care to (and the control of the reproductive
functions of) normal women, physicians make counter claims

about the potential abnormality of all birthing women. For

 

example, Dr. Louis Alfano, Chairman of the Committee on Leg-
islation of the Massachusetts Medical Society, sought to
explain the committee's opposition to granting nurse-midwives
hospital privileges in the state with this statement from his
testimony to the Committee on Health, Senate and House of
Representatives, Massachusetts General Court:

There is no way to predict with absolute
accuracy that any woman about to deliver will
have a normal delivery. There are many cases
of sudden vaginal hemorrhage, prolapse of the
umbilical cord, premature separation of the
placenta, or immediate post-partum shock.
These conditions can occur in a matter of
seconds and the obstetrician must be present
to recognize the problem of immediately and
institute immediate surgery in order to save
the life of the mother or new born or both
(Alfano, 1977: 1126).

While Alfano's sentiments were stated to me by several sub-
jects interviewed,several birth reformers disagreed with
what had become for them an often heard argument for obste-
trician pre-eminence. Writing in reply to his statements
another physician challenged his argument (Hunter, 1977: 282).

I do not share Dr. Alfano's belief that

physicians are available at all times in labor

and delivery rooms to recognize the problems

of sudden vaginal hemorrhage, prolapse of

the umbilical cord or premature separation of
the placenta--problems that he rightly states

237

could happen in seconds. Quite to the
contrary, it is the nurse who first
witnesses the events and it is usually her
responsibility to institute immediate
first aid and summon the physician.

If a physician had his practice so organized
that he could provide continuous coverage
to patients in labor it would be ideal. In
fact, he has so many other commitments to
surgery and office that the major part of
labor is supervised by nursing personnel.
How is it that the intricacies and responsi-
bilities of an unconscious patient during
anesthesia may be delegated to a nurse-
anesthetist...and yet the supervision of
intra-partum care is something that only a
physician can do?
In response to home birth participants' charge that over
90 percent of all births are normal (NAPSAC, 1979)
physicians have countered with the argument that no "non-risk"
population can be identified. That is, all women are
potentially "at-risk." The family practitioner at SCCH
disputed this claim.
That's all (the people who come to me) have
heard, "risk, risk, risk." I really dislike
the terms and I do not use the terminology
in my practice. You're putting a woman
"at-risk" or "not at risk" that automatically
spells trouble.

While not all physicians accept arguments for the
centrality of obstetricians, those arguments appear again
and again in both the medical literature and the responses
of the subjects with whom I spoke. They are also typically
used to justify the necessity of hospital births. These
arguments are a critical component of the medical profession's

ideological justification of its hegemony. In addition, it

238

appears to be not only a strategy but a strongly held
belief-—part of the world-view developed and accepted by most
practitioners. Interestingly, in my research, it also appeared
in statements by many nurse-midwives. The point here is not
that childbirth is not a risky undertaking, indeed it may be.
The question is whether or not that inherent risk necessitates
obstetrician-attended hospital delivery. At this point, it
is interesting to compare the outcomes generated by the
Maternity Center Association and the Frontier Nursing Service
(both home birth services serving higher risk clientele) with
those generated by obstetricians. The reader will remember
that the nurse-midwives' outcomes were significantly superior.
Risking out is also a way in which previously agreed-upon
informal contracts with patients prescribing the nature of
the care to be given (for example a labor-room birth) may be
overridden. In this manner, the purported client-orientation
may be legitimately pre-empted for colleague-oriented care-
giving based on standards of practice. Furthermore, all this
can be done in the best heroic medical tradition, enhancing
the prestige and apparent power of the obstetrician. Certain-
ly this explains in part why many women seeking to give birth
in the labor room at UH/RMC end up in the delivery room. The
pressures to locate and treat pathology are intensified in

a large teaching hospital.

239

Summary

Birth reform came in very different ways to the hospitals
examined in this study but many changes occurred during the
period of 1970 to 1980. I have argued that the changes
instituted at SCCH were fundamental and represented a para-
digmatic shift. However, whether or not a midwifery orienta-
tion can coexist with a hospital, even one which is supportive,
remains to be seen. Certainly the birthing practices and
organization of birth there have had far-reaching effects in
the state. The birthing rooms at SCCH both met and stimulated
consumer need and raised the expectations of both birthing
parents and care-givers who are reform-oriented. The fact
that this birthing option is 1191; characterized as an antidote
to home birth and lay midwifery-~as are the reforms at
UH/RMC and NCCH--but is instead supportive of home birth as
a viable option, is especially important in this regard.

In contrast, the reforms undertaken at UH/RMC were
obstetrician-controlled and largely conservative. Several
actors, including nurse-midwives, were required to bring
about reform and they did so working from several starting
points. While important changes were made, the essence of
the obstetricians' practice was left untouched. Physicians
who viewed patient's demands as something other than an
unpleasant fad seemed to regard them as focused primarily
on the manner in which care was given. In order to placate

consumers, the nursing staff was changed as were the rooms

240

in which women labored. While these reforms were real
enough, physicians continued to practice much as they had
before, and that practice was interventive and delivery—room
based. Furthermore, since UH/RMC had a large group practice,
patients who were attended by obstetricians had to take who-
ever was on call when they came in. In this system, the
least progressive physician.was the potential birth attendant
for any birthing woman and the development of pre-existing
agreements was problematic.

The Option to deliver in the labor room at UH/RMC was
an effort to deal with consumers' interests and the SCCH
competition in the realm of the "birthing room." The phenome-
non of the development of the birthing room is interesting.
It is a reformed location in the hospital repeatedly sought
by reformers and often widely touted by participating hospitals.
This variant hospital birth setting is described in newspaper
accounts and hospital literature, both in Vermont and else-

where, as "home-like;' it is portrayed as a comfortable place
staffed by caring workers in which consumers will have a good

birth experience. ‘(Remember, many physicians regard consumer

 

criticism as centered on the patient's experience of the care

 

they receive). It is stated that, unlike the home, the
birthing room provides readily available medical back-up
should anything go wrong. Interestingly, the back-up at SCCH
is provided not by obstetricians but by surgeons in the

surgical wing of the hospital. It is sometimes explicitly

241

stated in literature describing the birthing room, as it

was stated to me by several respondents about both the birth-
ing room at NERH and UH/RMC that this alternative aims to

bring those who had planned a home birth back into the hospital.
In addition, the birthing room is often suggested as the
antidote to the segmentalization and routinization of typical
hospital delivery since both labor and birth take place in the
same room.

However, nearly all the birth reformers and home birth
supporters with whom I spoke emphasized that there are "real"
birthing rooms and rooms which pretend to be birthing romms.
All agreed that what distinguishes the two is that the "real"
one is based on a philOSOphy of woman-centered (or family
centered), non-interventive, care-giving providing the woman
and her supporters with the maximum.amount of freedom and
self-determination possible. They all recognized that there
were many more birthing rooms that were false than were
authentic. Thus, the birthing room is not merely a space,
though the idea of extricating birth from.the delivery room
is important. It is a way of organizing care-giving and,
as we have seen, one which some obstetricians avoid. How-
ever, it should be noted that the birthing room at NERH was
instituted by the new obstetrician who proceeded to use it
regularly. Observers attributed the naturecflfhis practice
and his willingness to work with a nurse-midwife to his
training. Thus some obstetricians may be more willing to

innovate than are others.

Chapter VIII

Nurse-midwives and Negotiations Toward Professionalization

Introduction

 

At the same time that the home birth movement was cre-
ating out-of-hospital birthing alternatives it served as a
catalyst for in-hospital birth reform. Those who sought
reforms in hospital birthing practices at places such as
UH/RMC were able to translate consumer demands and criti-
cism into changes in some hospital procedures and some
aspects of the physical plant. A critical factor at UH/
RMC in both birth reform and the related deve10pment of
nurse midwifery was the financial assistance supplied by
the Private Foundation.

Nurse-midwives were among those actively seeking re-
forms at UH/RMC. Nurse-midwives at NERH and SCCH entered

practices and settings already largely reformed and their

presence enhanced and sometimes broadened the reforms.

The birth reform orientation of nurse-midwifery is consis-
tent with the historical role of the occupation and is an
outgrowth of its orientation to caregiving. At the same
time, birth reform may be a vehicle for CNMs to attempt

to redefine the turf in the care of pregnant and birthing
women. Informed and active consumers with raised expec-

tations for care-provision.tnay well turn to nurse-mid-

242

243

wives. CNMS may be able to utilize rising market demand
as a vehicle for expanding their scepe of practice or at
least establishing a firm foothold in the medical division
of labor.

While birth reform may facilitate the development of
nurse-midwifery, it is within the parameters of legal,
institutional and economic structures that nurse-midwives
have to endeavor to translate their resources into turf
and autonomy. Within these structures, nurse-midwives are
explicityly subordinate to physicians. Physicians in Ver-
mont and elsewhere have created a structure in which the
market for nurse-midwives' services is subordinate to and

a component of that market controlled by physicians.

Locating a Niche in the Division of Labor

Nurse-midwives came into the state as subordinates to
physicians. Their location in the medical division of
labor had been devised for them at UH/RMC largely by ob-
stetricians. The changes in the legislation which enabled
them to practice had been facilitated by the support of
leading obstetricians in the state. Nonetheless, while
the early development was strongly influenced by physic-
ians, nurse-midwives were also involved in shaping both
the occupation's role and its location in the medical
division of labor.

The initial involvement of nurse-midwives at UH/RMC,

their first site of practice in the state, was construed

244

by the obstetrician heading the department as a demonstra-
tion project aimed at developing models for care in rural
areas. The subsequent development of nurse-midwifery prac-
tice at UH/RMC was a transformation of that model, a pro-
cess in which nurse-midwives were actively involved. CNMs
also worked with the state nursing organization in the cre-
ation of new guidelines for nursing practice through the
state Board of Nursing, assuring significant nursing input
in the development of enabling legislation. Thus, the
emerging role of nurse-midwifery in the state was the pro-
duct of obstetrician initiation and oversight and nurse-
midwife influence.

Several structural factors, some of which are codified
in the laws, delineate the parameters of nurse-midwifery
practice in the state. Nurse midwives worked under pro-
tocols1 in all settings. That practice was consistent with
the 1971 Joint Statement and the 1975 supplement which spec-
ified the role of nurse-midwives in the obstetrical divis-
ion of labor. In addition, the relationship is mandated by
state law. One respondent described the legal relationship
between CNMS and physicians.

Under the law--the nurse practice acts,
state law--we all practice under medical
protocols. It's spelled out under each

physician so it just depends on the relat-
ionship with the physician. The physician

 

1Protocols are written sheets listing what nurse-midwives
should and should not, can and cannot do and the appropri-
ate circumstances under which they may be undertaken.

245

is still legally responsible, that's

why (CNMS) have to involve them when-

ever we make decisions; whenever there

are complications they have to be in-

volved.
In addition, in all settings in which CNMs worked in hospi-
tals, they had hospital admitting and discharging privileges
as well as the ability to write orders for care and medi-
cation as specified by the protocols.

A critical factor in the nature of nurse-midwifery
practice and its prospects for professionalization is the
financial relationship with physicians. In Vermont, all
but one of the CNMs was an empolyee of physicians. The
lone exception was the CNM in the NCCH area who was em-
barking on an independent practice near the end of the
study period. Even she was initially employed at a local
clinic doing normal gynecological work. At UH/RMC, CNMs
were formally employees of the ob/gyn group practice even
though after 1976 they were funded by the Privat Foundation.
It is worth noting that they were by far the highest paid
nurse-midwives in the state. At both NERH and SCCH, nurse-
midwives sought employment and were hired by physicians in
solo or small group practice. Thus, all CNMs in the area
studied entered into the medical division of labor as sal-
aried employees of physicians. There were no associate
practices, although CNM employees in NERH and SCCH funct-

ioned more like partners since the full range of their

skills was needed in busy practices. An external factor

246

inhibiting the independence of CNMS was the inability of
nurses, even those in "expanded roles" to receive direct
third-party payment for their services. This component
of the law governing nursing practice required that CNMS
receive reimbursement through a physician. There was thus
no financial competition between the CNMS and the physic-
ians for whom they worked. On the contrary, the physicians
in private practice whose incomes were tied to patient fees
probably benefitted economically from the employment of
nurse-midwives by expanding their practices. As one obste-
trician explained,

Obs, by and large, are threatened and

oppose nurse-midwifery generally....

We have an abundance of ob/gyns around

the country....If there are too many

doctors, they don't have enough patients

to pay them a big enough salary a year...

they are not going to be very anxious

to have nurse-midwives taking over. But

they're not very smart because if they

had two nurse-midwives in their office,

their patient population would double

or triple, because patients appreciate

that.

Since nurse-midwives worked as employees of physicians
in different locations and different kinds of practices,
what CNMS actually did in practice varied by setting and,
at UH/RMC in particular, changed over time. There was also
variation in the extent to which the work they performed
was consistent with the occupation's claims to special

contribution in care-giving. While CNMS in partner-like

relationships with individual physicians in busy practices

247

tended not to be significantly restricted in the scope of
their practice, at UH/RMC nurse-midwifery practice had to
be fitted into a large teaching hospital.

Nationally and at UH/RMC nurse-midwives were being
drawn into the medical division of labor at a time when it
was becoming more highly articulated. Their entrance thus
coincided with that of the nurse-practitioners. At UH/RMC,
where physicians were almost exclusively specialists, the
expanded role of the nurse tended to be divided along med-
ical specialist lines. For example, gynecological nurse-
practitioners performed normal gynecological work such as
pelvics and pap smears on non-pregnant women while CNMS
focused their work on the care of pregnant and birthing
women. Initially and for a substantial period of time that
work was limited to pre-natal and post-partal care. One
nurse-midwife explained that she felt somewhat limited by
her inability to do normal gynecological care (or ”well-
woman care" as she called it) for which she had been train-
ed. But she recognized that it was out of the question
under the circumstances since NPs performed those tasks.
Thus, nurse-midwives' ability to provide continuity of care
to women throughout their child-bearing years was signifi-
cantly curtailed at UH/RMC.

Another change which occurred as CNMs were being drawn
into the hospital division of labor was the emergence of

fetal monitoring as a normal part of obstetrical procedure

248

(Goodlin, 1979). Fetal monitoring was:h1itself an outgrowth
of the trend toward active management of and technological
intervention in labor and birth. At both UH/RMC and NERH
external fetal monitors were available. (This device con-
sists of a strap placed around the woman's abdomen leading
to a machine which produces an electronic graphic read-out
of the fetal heart beat.) UH/RMC also had available inter-
nal fetal monitors, in which the source of the electronic
impulses is an electrode inserted into the scalp of the
fetus after partial cervical dilation has occurred. While
fetal monitors seemed to be rarely used at NERH, every woman
in labor at UH/RMC received 20 minutes of external fetal
monitoring upon admission. If no abnormalities appeared,
the monitor was discontinued, otherwise it was continued.

I could not discover the specific rationale for the length
of monitoring suggested. The external monitors have been
criticized by birth reformers for several reasons. While

a woman is being monitored she cannot walk or move about,
and extensive touching, such as massage, interferes with
the monitoring. Furthermore, monitors are expensive and
add to the cost of hospitalization. In many hospitals,
improper interpretation of the read-out was linked to
rising Cesarian section rates. That did not seem to be the
case at UH/RMC which had a fairly conservative C-section
rate. In terms of nurse-midwifery practice, extensive use

of fetal monitors meant that CNMs' training in non-electri-

249

cal (that is, aural) assessment of fetal heart beat was
neither fully trusted nor fully utilized.

As the obstetrician who brought the nurse-midwives into
Vermont acknowledged, CNMS were not required at UH/RMC. A
plethora of attending and resident obstetricians and interns
were available to perform deliveries and/or monitor labors.
One of the reasons the idea of a nurse-wifery school was
not pursued was the relative scarcity of "clinical material."
A nurse-midwifery school would have too greatly intensified
competition for patients. Even with only four practicing
nurse-midwives, competition for patients was potentially
keen enough. As one CNM explained, "There are so many
people who could catch that baby it's ridiculous."

While nurse-midwives' structural relationship with phy-
sicians was the primary determinant of the parameters of
practice, CNMs' relationship with nursing was equally com-
plex. As nurse-midwives attempt to locate turf somewhere
between those task activities monopolized by physicians and
nurses typically each of the other occupations may experi-
ence some incursion. However, while physicians have struc-
tural power and may choose to delegate tasks, nurses have
few legitimate means of resistance. Every CNM with whom I
spoke had strong feelings about nursing and most had anec-
dotes about their experience with nurses. It should be
noted that within the national nurse-midwifery organization,

ACNM, debates about the continued relationship with other

250

nursing organizations and the necessity for an RN prior to
advanced training in midwifery had begun to emerge. Further,
as nurse-midwifery became more visible, more women who had
commitments to feminism or midwifery but not necessarily
nursing, entered the occupation. The population of nurse-
midwives in Vermont mirrored this trend. While many con-
sidered themselves primarily nurses and had strong ties to
nursing, others felt less affinity with the occupation of
nursing. Nonetheless, all had had some difficulties with
nurses and all described these with regret. For some, the
initial encounters with nursing created a "no-win" situation.

(My work relationship with nursing) has

been kind of mixed. Overall, it has been
very positive. There was some confusion
about, for example, how much nursing care

am I going to give? Am I going to usurp
their bedside care? Some people would say,
'You're a nurse, if you are going to be
with a patient, why aren't you doing the
vital signs?’ and so forth. Why should I
have to do that? There are some people you
can't please. If I come in and do nursing
care, they're mad because I'm usurping their
job. If I don't do nursing care, they think
I'm lazy.

For some nursedmidwives, particularly those who did not
feel an affinity with nursing, their day-to-day work with
nurses could be problematic and frustrating.

It's very tcnigh to get along with nurses
because of their passive-aggressive behavior,
especially if you're trying to raise people's
consciousness or work with women and here you
have women fighting each other. Nursin is
very jealous of the power that they don t have
and they take it out in all kinds of devious
ways. In some ways (the nurses) see us as a
greater threat than (female physicians) because

251

we're nurses; we're 'super-nurses.‘
Another nurse-midwife reluctantly admitted similar exper-
ience.
There may be times and places where there
is a lot of mutually destructive (behavior)
going on. I guess I have seen it. Which is
again, a lot of the same women back-biting
each other. I see it more in straight nurs-
ing, staff nurses, people within the standard
administrative structure of nursing than I
do with clinical specialists. Because that's
the standard female attitude. You see it an
awful lot in nursing.
Of course such patterns of behavior are typical of subordi-
nates whose fortunes rest with the pleasure or displeasure
of their superordinates in other structures as well. Nurses
accurately judge the power of nurse-midwives to be subordi-
nate to that of physicians and understand that acting out
displeasure at their competition may produce less direct
consequences than similar behaviors directed toward physi-
cians. By withholding their willingness to work supportive-
ly, nurses can make daily work for nursedmidwives extremely
uncomfortable. One nurse-midwife described the initial ten-
sion which existed between the nurses and herself in task
performance.
I used to, when I was walking up (to labor and
delivery) feel like I was going onto (a) battle-
field. I used to literally shudder going (there).
I used to dread it. Someone was going to get
after me. Someone was going to come down (on me).
But now there's nothing of that. I'm very confor-
table.
One of the most interesting and graphic examples of the in-

hibiting effects of nurse's resistance to both birth reform

252

and nurse-midwives came from another nurse-midwife who was
describing her second birth. She was well into labor but
was trying to hold out going to the hospital till a nurse
she wanted to avoid was off-duty. As it turned out, the
baby was born, at home, before her co-worker's shift ended.
On the whole, the nurse-midwives were extremely con-

cerned about their working relationship with nurses and
sought to avoid competition and, ultimately, establish
rapport with them. In part, the establishment of a cooper-
ative working relationship was a pragmatic necessity. But
there were several other reasons CNMS avoided conflict with
nurses. Some felt a strong sense of colleagueship with
nurses; for others feminist concerns made them unwilling
to engage in power struggles with other women. Several
CNMS recognized that it was physicians who were calling
the tune to which they all danced. Sometimes nurse-mid-
wives themselves were discouraged about the emergence of
a successful division of labor within nursing. More than
one nurse-midwife occasionally wondered if, in the context
of a reform-oriented nursing staff, much of their work
wasn't redundant. But for most nurse-midwives, effective
ties with the nursing staff were actively and hopefully
sought and maintained. As a nurse-midwife noted,

It just took time (to defuse the mis-

trust). It just took them getting used

to seeing us there. Getting them to

realize that we weren't trying to boss

them around or take over their role.
They still had a role there. We had a

253

role, but we could work together.
Of course, at UH/RMC the dramatic changes in the nursing
staff both undermined the rapport nurse-midwives were try-
ing to develop with the original nursing staff and brought
in a new reform-oriented nursing staff. The progressive
nurses were closer to the nurse-midwives in philosophy and
that probably facilitated cooperation.

Thus, nurse-midwives in Vermont, found the location of
turf in the obstetrical division of labor a lengthy and
complex process. Many articles in the nurse-midwifery lit-
erature attest to the universality of this problem (Kimbro,
1978; McCormick, 1976: Monnig, 1976). Further, the nature
and extent of the difficulty may very by both the setting
and the philosophy and orientation to care-giving of sur-
rounding workers, especially the structurally dominant

physician.

Negotiating for Autonomy

 

The nurse-midwives' larger inter-occupational relation-
ship with physicians is both played out and negotiated in
the work setting. Bucher and Strauss (1961) suggest that
this is one of the major arenas in which their respective
positions are negotiated. The division of labor means the
performance of different tasks by different care-givers or
sometimes the performance of similar tasks on different

kinds of patients, for example, those characterized as

254

"high risk" as opposed to those characterized as "low risk."

Nearly every CNM with whom I spoke expressed a desire
for greater autonomy, although the nature and scope of that
independence from external control was differently construed.
Acknowledging the legal and structural parameters within
which they worked, nurse-midwives recognized the centrality
of a cooperative relationship with the physician(s) for
whom they worked. They understood too that for the time be-
ing the nature of this relationship determined the nature
of their practice.

Nurse-midwives worked under protocols in all settings,
but what appeared to differ by setting was the extent and
nature of nurse-midwife involvement in setting up the pro-
tocols. Although I did not explicitly ask respondents
about the manner in which protocols were derived, several
of their responses suggested that the physicians at NERH
and SCCH worked more closely and less formally with the CNMS
in this area than did the obstetricians in group practice
at UH/RMC. Further, the protocols at UH/RMC seemed to be
more restrictive than those at the other two sites. One
nurse-midwife indicated that UH/RMC's protocols were cur-
rently being rewritten and that she hoped that "...it will
get more liberal on some protocols that we constantly run
into problems over, things that recurr and they're not that
dangerous."

Thus the nature of the protocols may both structure the

255

physician-nurse-midwife division of labor and reflect the
underlying nature of their relationship. One CNM suggest-

ed that,

A lot of it seems to hinge on the personal
philOSOphy of the doctor. If the physician
seems to feel that someone other than a phy-
sician can practice medicine, what they see
as the practice of medicine, without an M.D.
license...that is, can take on some of the
skills and do some of the things that have
normally been restricted to doctors; if they
believe (it) in their guts and you can dem-
onstrate to them that you're good and you're
competent, that you know what you're doing,
that you're going to blow the whistle when

it needs to be blown, (then) you're going

to get along. You can do it and create your
own sphere of autonomy. (But) if they don't
believe that and it's kindof done grudgingly
or done because it looks good or because con-
sumers are demanding it, it doesn't work.
Because that's when protocol sheets get drawn
up. That's when somebody's practice gets cur-
tailed to be 'exactly this' or 'exactly that,’
and there's not much leeway to play with.

Another nurse-midwife suggested that "the ideal would be to
have a small practice with a physician who is fairly liber-
al." Describing a practice in which she was basically sat-
isfied, one CNM observed.

This is a job where I can almost write my
own ticket, as far as I am compatible with
this physician. If either of us were diff—
erent persons, it would be a different story.
(But) like a marriage, as long as we're
reasonably compatible in terms of philosophy
(it works).

While philosophical complementarity is important, the
structure of the practice may be equally critical in deter-
‘mining the scope of nurse-midwives' practice. CNMS were

strongly supported and granted wide scope in practice by

256

their solo or small group physician employers. These phy-
sicians recognized that the nurse-midwives shouldered a
substantial portion of the work-load in their busy practices
at a wage well below that of another physician. In practices
where obstetrician's incomes were tied to patient fees, the
nurse—midwife's work in normal obstetrics enabled the obste-
trician to focus his attention on the more lucrative special-
ist work. As one respondent explained, "Ob is not real
profitable. What it mainly does is bring in gyn practice...

Surgery is much more profitable than what (CNMS) do.‘ Clear-
ly, this division of labor does not obtain in a nurse—mid-
wife-family practitioner team in which neither is trained
as an obstetric specialist. In this structure, both practi-
tioners would perform similar work.

At UH/RMC where all ob/gyns in the group practice were
salaried and physicians and residents feared competition
for patients for non-economic reasons, physicians were less
inclined to embrace nurse-midwives. Some obstetricians
were disinclined to give up the performance of certain tasks
to nurse-midwives, perceiving it as a threat to their
status. After the Private Foundation committed funds to
nurse-midwifery practice and several CNMs were hired, the
nurse-midwives began to expand their work from exclusively
pre-natal and post-partal care to work with patients in

labor and delivery (the turf of obstetricians and obstet-

rical nurses). Every week day one CNM worked on labor and

257

delivery attending those patients who sought their assist-
ance. However, since CNMS didn't work on weekends, they
were unable to make commitments to patients. Nonetheless,
even this limited involvement on the labor and delivery
floor was carefully watched by physicians and nurses and
several respondants characterized it as a trial or prov-
ing period.

At that point, some of the physicians were

a little resistant to having (the CNMS) see

their patients. It took a while before the

physicians would use (the CNMS, whose) sched-

ules weren't really busy at first, because

(the physicians) wouldn't refer. Because

it all depended on physician referral.

By 1978 the nurse-midwives at UH/RMC collectively de-
cided to seek a CNM service in which they would take on a
case-load of patients who, with periodic physician visits,
they would care for through pregnancy, birth and the post-
partum. They were able to make commitments to patients
to attend their births by rotating call between the CNMs.
The mid-year employment of another CNM via federal MIC
(maternal and infant care) funding facilitated this under-
taking.

The CNMS proposed the program to the ob/gyns in group
practice and the physicians approved of the idea, though
some reluctantly. The service began functioning on a small
scale that year. Among other effects, the service served

to further differentiate the CNMS from the nursing staff

who worked 8-hour shifts. At least one influential

258

physician in the department disapproved of the service fear-
ing that the goal of better obstetrical care for all would
be subverted by differentiating the services.
The Maternity Center Association is attempt-
ing to show that for properly selected women,
the nurse-midwife is an adequate care-giver
(with obstetrician back-up). That isn't what
(UH/RMC) is trying to show. Rather, (UH/RMC)
is attempting to demonstrate that an obste-
trician-nurse-midwife team, alternating visits,
provides the best obstetrical care.
For this reason and others, CNMS were not allowed to "ad-
vertise" their newly formed service. Nonetheless, patient
demand continued to grow.

The willingness of the obstetricians to allow nurse-
midwives to embark on even this restricted service is in-
teresting. The head of the department seemed to understand
the benefit of conservative reforms and may have viewed the
development of this service as one of them. Since he re-
fused an interview with me I cannot be sure. Certainly the
CNMs posed no threat since they were salaried employees
of the group practice, had no control of their budget and
worked under physician determined protocols. The protocols
were extended to describe the characteristics of patients
who could choose the nurse-midwife service and the circum-
stances under which even those could be shifted to obste-
trician management.

While obstetricians at UH/RMC had ongoing qualms about

losing some patients to CNMS who would otherwise be avail-

able for teaching, other factors encouraged their acceptance

259

of the altered division of labor. One respondent pointed
out that physicians accepted the plan for differing reasons.
While some felt the CNMs "added something" to the care of
birthing women, some others saw it merely as a vehicle for
lightening their work load. The latter attitude is not
unique, Keetel (1973) in his presidential address to ACOG
suggested that the use of nurse-midwives could minimize
obstetrician attendance at night-time deliveries. The fact
that ob/gyns were neither trained in nor intrigued by nor-
mal childbirth and gynecological care was a facilitating
factor suggested by several respondants. A lay-independent
midwife offered, "Most obs. don't attend births anyway,
they just arrive to catch babies." When I asked a CNM if
she thought ob/gyns would be willing to give up or delegate
normal ob/gyn work she responded,

I think the answer is 'Yes.' Because they

don't like it. The more sick you are, the

more pathology you can demonstrate, the more

interesting case you become. The whole med-

ical model is pathology oriented. The phy-

sicians are not interested in normal....

They aren't interested in 'yearly check-up

and pap smear' etc. They don't like it.

They don't like to do it and they are de-

lighted to have nurse-practitioner people

involved. They're giving up or turning over

something that they don't want to do anyway.

Plus we do it better. That's what we're

trained to do.
Insofar as physicians construed treatment of pathology as
more important and more central to their practice than care

for normal labor and birth, they could regard the new divi-

sion of labor as one in which secondary and less difficult

260

tasks could be delegated to subordinate "team members."
Thus, as one obstetrician asserted, "The nurseemidwife is
more challenged by the whole process of (normal) labor and
delivery than is the more highly trained obstetrician."

And obstetricians'ability to define "normal" and make the
definition stick in practice enabled them to retain ultimate
control. As one CNM observed, "They could define us right
out of existence."

It is also possible that some of the obstetricians und-
erstood that nurse-midwives could serve and satisfy those
patients who had been vocally critical of the hospital, in—
cluding some who had advocated or chosen home births. The
nurse-midwives were able to advance their idea for a CNM
service partly by citing strong consumer demand. As sev-
eral CNMS explained, consumer demand for their services was
their wedge to establish their turf in the obstetrical
division of labor in a variety of settings.

Nurse-midwives in smaller practices serve obvious func-
tions. For example, one physician with whom I spoke noted,
"I wouldn't be able to take the time to talk with you if
(the CNM) weren't covering for me." In contrast, at UH/
RMC, consumer demand was the nurse-midwife service's

raison d'etre. A CNM explained,

 

We're here because patients want us. They
want to have somebody they know there. They
want to have a trusting relationship with
somebody who's going to deliver their baby.
And they believe that we're their advocates.
We are.

261

As her statement suggests, for patients who chose the nurse-
midwifery service, unless they "risked-out" they could be
assured that one of four midwives, rather than one of four-
teen obstetricians, would attend them. Further, the CNMS
made sure that their patients saw each of them at least
once during prenatal care. In this way, consumers were
offered an alternative to the "take whoever is on call"
problem many actively criticized. Further, many who opted
for the nurse-midwife service intended to take a more active
role in what they hoped were more natural births. Another
CNM explained,

A lot of people who choose us want all the

options and trust us to root for them and

make sure they get the options.

The CNM service (officially dubbed by physicians as

the nurse-midwife-physician service) at UH/RMC provided a
group of middle-level health practitioners who actively
supported consumer desires for non-interventive births.
Thus, the hospital birth reforms, which were minimal in the
absence of sympathetic in—house supporters with some degree
of autonomy, were championed by CNMs. Their patient advo-
cacy and client-centered orientation served to increase the
likelihood that the options formally instituted by birth
reformers would be realized. As one nurse-midwife pointed
out to me, the CNM works to keep the labor and birth normal
since when significant pathology appears, she turns over

management to an obstetrician. This is in sharp contrast

262

to the active-management orientation of pathology-oriented
obstetricians.

By the end of the study period, the CNM service at
UH/RMC was formally offered as an option to prenatal pat-
ients in a check-list of labor and delivery options. None-
theless, people with whom I spoke credited lay-referral
for most of the patients who chose nurse-midwife attendance.
Consumer demand continued to grow and by 1980 the service
was "booming" as one respondant put it. While at least
some childbirth educators were busy attempting to both in-
form prospective patients and raise their expectations for
birth, it seemed likely that nurse-midwives were also draw-
ing their clientele from among those who had considered
home birth. Many nurse-midwives agreed with that assess-
ment.

I think it's possible. Most of the people
we deliver say after the birth, 'I thought
about home delivery and I'm really glad I
didn't do it. I hear that all the time.
There are definately times when people feel
very angry that because of complications
they had to have intervention....I think
there's one piece of data in (the consumer
attitude survey) where they asked, 'Would
you have preferred to have a home birth?‘

or 'Would you do it next time?‘ And they
got an overwhelming 'No.' ....If we didn't
exist, if what was available was traditional
delivery, if you had to take whoever was on,
both the home birth movement and consumer
reform would be stronger.

Thus, a supporting clientele, constituting a signifi-

cant and growing market demand enabled CNMS at UH/RMC to

263

enlarge their scope of practice. In so doing, they bene-
fitted from the home birth movement and in-hospital birth
reform efforts, both of which raised consumer expectations
and altered the birthing environment in the state. Having
formally expanded their task performance to include not
only prenatal and post-partal care but also management of
labor and birth within parameters delineated by protocols,
CNMS had to translate their success into day-to-day prac-
tice. In this altered context, some of the nurse-midwives
found the team structure facilitative of their autonomy
since they had ready access to obstetrician consultation
and back-up. One CNM emphasized that "Nurse-midwives are
the ones who make the decision as to when to refer a pat-
ient." (Of course, that decision had to be consistent with
the protocols). For others, the team structure in a teach-
ing hospital continued to pose problems. In an effort to
resolve the problem of competition for "clinical material"
CNMs suggested that they should teach normal obstetrics in
practice. Apparently the ob/gyn group was more or less

persuaded by the argument. As one CNM describing her job

quipped, ...and, we are unpaid faculty.‘ While attendings
may have been persuaded to grant nurse-midwives autonomy
within their scope of practice, residents presented more
problems. One CNM who officially had a faculty appointment
said she was not unwilling to send out bothersome residents

when necessary. The problem was less easily solved by

264

CNMS who were unable to pull rank. As one CNM explained,
The residents, a lot of times, want to get
their hands in there whether things are
normal or not. It's wanting experience.

Also, they're responsible. I have a pro-
blem.with the number of people present at

a delivery. People come to us because they
don't want a cast of thousands....(But)
what happens depends on who's on (duty). I
can't just tell the resident to leave. I
quite often do say, 'Would you like to
help?‘ or 'Things are alright. I can
handle it on my own.‘ And it's up to the
resident at that point if they want to be
there. (They don't interefere intention-
ally)...but they're used to getting in
there and doing stuff.

CNMS found themselves resisting incursion into their task

boundaries from competitors for their turf. Between the

restrictions on their scope of practice imposed by the
protocols and the attempts at intervention from the resi-
dents, a substantial number of their clients were trans-
ferred into medical management. Information I obtained
from those involved in the CNM service indicated approxi-
mately a 50 percent "risk-out" rate during the period of
study. That is, of those patients who, according to the
protocols, "qualified" for the CNM service and labor—room
birth, at least half ended up in the delivery room in lith-

otomy position. Of these, approximately 15 percent had C-

sections and another 5 percent had low forceps deliveries.

Assuming that this medical intervention was required, this

left another 30 percent of patients who did not require

this level of medical intervention who nonetheless gave

birth in the delivery room and did not achieve their

265

desired in-hospital alternative birth.

Since, during the study period many of the labor room
births were attended by physicians it is not surprising
that many women who began in the labor room ended up in
the delivery room where physicians felt more at ease. Even
though during the study period only approximately one third
of the labor room births were attended by nurse—midwives,
this physician disinclination to perform deliveries in the
labor room does not adequately explain the high rate of
risking-out. There were several other intervening factors,
one of which was the size of the room, more like a cell.
There was simply not enough room for actors whose presence
might have allowed the birth to continue unaltered, for
example, a pediatrician needed to check babies who had in-
dicated minor distress. In any case, the resulting figures
indicated that access to substantial in-hospital birthing
options was still severely limited. For the period July
to December 1979, only 3.8 percent of all patients gave
birth in the labor rooms. By the period of January to
June 1980, the figure had risen to 4.7 percent. CNMs point-
ed out that in the post-study period, as the nurse-midwifery
service continued to grow, nearly two-thirds of the labor
room birth were attended by nurse-midwives and only one-
third by physicians. They also suggested that less restric-
tive protocols might diminish the percentage of patients

who "risked-out."

266

In spite of the high rate of traditional delivery
room births among CNM patients during the study period, one
obstetrician observed that patients were still more satis-
fied with the nurse-midwife service and felt they had a
good birth experience. In light of previous discussions of
the separation of the patient's birth experience from the
medical management of the patient's body, this observation
is especially intriguing. Nonetheless, a lay-independent
midwife concurred with patients' assessment. She noted
that the involvement of CNMS at UH/RMC had served to "hum-
anize the hospital" and that the CNM service represented a
qualitative improvement over traditional hospital birth.

Nurse-midwives with whom I spoke, described projected
plans for an alternative birthing space in or near the
hospital. Early in my interveiwing I was told about a
committee of nurses, nurse-midwives, childbirth educators
and obstetricians which was considering the development of
a birthing center. Apparently this idea had originated,
or the impetus derived from out-of-hospital birth reform-
ers in the area, including lay—independent midwives and
some childbirth educators who called a meeting to discuss
the idea. Nurse-midwives attended as representatives of
UH/RMC. The lay-independent midwife who related this story
felt that the CNMs had been assigned this task by their
department. By the next meeting, the head of the department

of ob/gyn had developed an interest in the idea and the

267

hospital sent several representatives, including their law-
yer. At least some of the lay-people at the meeting re-
garded this action as a rather indelicate take-over attempt.
It did seem to undermine the group and reasserted UH/RMC's
monopoly over childbirth in the area. UH/RMC considered
the idea for some time and then abandoned it.

While some CNMs regarded a birthing center as an im-
portant and progressive step which would enhance hospital
birth reform while it broadened their scope of practice,
some others were more cautious. One CNM explained that she
had,

...played it down. I didn't want the

doctors to support it for the wrong

reasons: to get CNMs out of their hair.

I wanted it inside so that more patients

had access to it. I wanted to create an

(alternative) environment where patients

didn't have to be 100 percent normal (to

use it).
So she focused her energy on improving the physical plant
as UH/RMC, including revamping the labor rooms, developing
the Private Foundation-funded labor lounge and facilitating
non-interventive labor-room births. Ultimately, however,
the birth center concept appeared to be discarded by phy-
sicians, who were in any case the ultimate decision-makers
along with the hospital administrator. The probable reasons
were the expense of the project, increased competition for
patients, inhibited control of nurse-midwives and signifi-
cant modification of the particular team concept, "partner-

ship,‘ which had been the founding vision of the obstetric-

268

ians who most strongly supported nurse-midwifery at UH/RMC.
Nurse-midwives had thus, at least temporarily, hit the
limits of their professionalization project at UH/RMC. How-
ever, the ideas for the birth center were modified and re-
spondants assured me that in late 1982 or early 1983 a
birthing room suite was to be constructed in the hospital.
This would be a large space with facilities for food-stor-
age and possibly cooking as well as space for supporters to
sleep-over. If coupled with an appropriate philosophy of

" for

practice, it could function as a "real birthing room
those patients who had access to it. Nurse-midwives seemed
pleased at the prospect of it, anticipating, among other
things, that it would be a physical manifestation of their
turf.

Still, CNMs' turf was fragile at UH/RMC. Funding from
the Private Foundation was renegotiated in 1980 and contin-
ued on a year-to-year basis. Nurse-midwives continued to
be structurally and immediately subordinate to obstetric-
ians and they recognized the parameters of their birth re-
form efforts. As one CNM noted, "We have to be careful
not to become anti—physician." Several subjects had charac-
terized the nurse-midwives at UH/RMC as unwilling to take
risks or disinclined to push as hard as they might, par-
laying their consumer support into greater autonomy and

more profound birth reform. When I asked a knowledgable

respondent what to make of these criticisms, she explained

269

that she thought their caution was realistic.
CNMS are still cognizant of the fact that

if they get too aggressive, they could get
drummed out of the roll-call.

Independent Practice

 

While more than one nurse-midwife had considered inde-
pendent practice, only one actually engaged in it in the
northern two-thirds of the state during the study period.
This CNM did not enter into independent practice entirely
by choice. She had begun working as a salaried employee in
a clinic in the NCCH-area and had been fired and lost her
hospital privileges when she had not ceased attending home
births. Instead of leaving the area, as she might have
under other circumstances, she remained, in part because
her husband, a physician (not an ob/gyn) had a practice in
the area.

As previously noted, independent practice by CNMs in
Vermont was inhibited by the restrictions on third-party
payment and the necessity for physician back-up and practice
under protocols. Given the conservatism of the overwhelm-
ing majority of obstetricians on the question of indepen-
dent nurse-midwifery practice, I was not surprised to find
that her back-up physician was the family-practitioner at
SCCH. Of course, he, in turn, had to refer complicated
cases to obstetricians or surgeons, further segmentalizing
care. She pointed out that neither of them considered it

an ideal situation.

270

She had not wanted an exclusive home birth practice but the
cessation of her hospital privileges and the antagonistic
relationships with the conservative obstetricians at NCCH
allowed her no other choice. This placed her practically
in a position similar to that of lay—midwives and the
analogy was not lost on her. In fact, more than most other
midwives, she maintained contact with lay-midwives and had
entertained the idea of a joint practice.

Obstetricians fearing independent nurse-midwife prac-
tice, have made the option as unattractive as possible. As
one CNM pointed out, in a situation where a nurse-midwife
left employment by a solo or small group ob/gyn practice
and embarked on an independent practice in the same area,
her earning power might or might not be enhanced, she would
have to carry the financial overhead for her practice and
related small business concerns and she would be working
with the same people in the same hospital in an antagonistic
relationship. Another CNM described the case of a nurse-
midwife in another state who left her independent home-
birth practice after she found herself transferring 3 out
of 5 of her patients to the hospital because of restrictive
protocols.

While nationally, successful solo or group inde-
pendent nurse-midwife practices do exist, they are
often harassed by obstetricians who fear competition and

attempt to subvert them. As I observed previously, the

271

struggle for nurse-midwifery autonomy has begun to take
place in the courts and before Congress where nurse-mid-
wives are charging obstetricians with restraint of trade.
Describing the situation at the city in which she attended
nurse-midwifery school, one CNM explained,
As the consumer support for (nurse)mid-
wifery goes up, (so does) its competition
with the medical community. In an urban
area, for instance, where there's a spec—
ialist under every rock and a given number
of uteruses to be exploited, they can be
at odds.... (Obstetricians then inhibit
CNM access to hospital privileges). (Then)
they have no choice but to deliver at home
or sit on their skills. That is part of the
radicalization of the nursedmidwife. You
deliver at home or you don't deliver. That
is the reality. Whereas ten years ago people
were perhaps willing to say 'Yes. Dr.‘ and
do paps for the rest of their life, they're
not now.

The CNM in the NCCH area explained that she was con-
sidering a suit against the hospital and obstetrician group
practice to restore her hospital privileges charging them
with restraint of trade. However, she recognized that it
would be expensive, time-consuming, unpleasant and arduous.
Still, she wanted to be able to pursue both in-hospital
and out-of-hospital birthing alternatives.

Interestingly, the other nurse-midwives supported her,
pointing out to me that her attendance at home births was
not illegal and that she should not have had her hospital
privileges withdrawn. Had this incident had the effect
of radicalizing the nurse-midwives at UH/RMC? I asked

one CNM.

272

No. They know what they want (to support
in-hospital birth reform). They're getting
a salary. They've got their nine-to-five
job. They don't have to take call all the
time....Compared to what they can get in
the area...we've all chosen to live in this
crazy place...and so we have to sort of
carve out what we can get.

While other CNMS had considered independent practice,
the example of the CNM in the NCCH area might have served
to dissuade them. Still, CNMS throughout the study area
hoped for and worked for greater autonomy. They were also
developing a sense of unity: at the end of the study period,
nurse-midwives at UH/RMC organized a state—wide chapter of
ACNM and the nursedmidwives met several times a year to ex-
change information and support. Most of the CNMs were fair-
ly new at the work and were still waiting to see how much
autonomy they could achieve inside the hospital and the
"team." For some, the inability to legitimately attend
home births was felt as a significant constraint. If CNMS
were able to successfully extend their practices to include
home births, they might strengthen the home birth movement

at the same time that they infringed on the task boundaries

of lay—midwives.

Chapter IX

Summary and Conclusion

Introduction

 

This is a case study of the changing division of labor
in an arena of health care, the care of pregnant and birth-
ing women. I examined the process by which a dominant pro-
fession (obstetrics) emerged and ultimately achieved hegemony.
The subsequent development of broadly-based client movements
to reform professional practices and less widespread, but
equally active and vocal, client revolts challenged both the
profession's hegemony and its freedom from lay-intervention.

The significant alteration in the lay-professional
relationship poses fundamental challenges to a consulting
profession such as medicine. It also created the opportunity
for other occupational collectivities (LMs, CNMs) to emerge
and coalesce, and seek new markets for their services. Their
strategies challenged the boundaries of existing occupations
by either collecting delegated tasks or creating new turf
in the larger division of labor among occupations.

I examined shifts and conflicts in the processes of
collective challenges to obstetrician hegemony as well as the
dominant profession's responses to these challenges. The
profession is faced with the task of reasserting its claims

to a mandate for the exclusive performance of its work

273

274

(cf. Hughes, 1964) while manipulating its resources, such
as control of licensure and access to hospitals, in an effort
to resist competition.

Obstetricians have attempted to retain their monopoly
on their clientele and their dominance in the division of
labor. While within medicine there are segments with diff-
erent interests, the professional organization of obstetric
specialists is conservative--actively resisting the erosion
of their professional power. Competing occupations, mean-
while, have tried to undermine the hegemony of obstetricians
by either acquiring a privileged position in the obstetrician-
headed division of labor (the strategy of CNMS) or by freeing
themselves from professional regulation (the strategy of lay-
midwives). Competing groups have tried to locate and monopo-
lize a market for their work while asserting a definition of
the situation (for example, childbirth) which complements

their claims to special expertise.

Professionalization and the Medical Division of Labor

I have previously discussed in some depth the manner in
which allOpathic medicine emerged as a profession. The
occupation was able to unify (even as it stratified), and
develop both a cognitive base1 and minimum standards of

training and practice. In an innovative reorganization of

 

1Freidson refers to this as "expert knowledge."

275

work around the cash-nexus this and other emerging professions
engaged in a "collective mobility project" translating one
order of scarce resources, expertise, into another, status
and money (Larson, 1977). The occupation did this by making
claims of unique expertise, asserting a complementary defini-
tion of the phenomena toward which their skills were directed
and asserting their trustworthiness. In the case of medicine,
the occupation's successful bid for state mandate and license
for the excluse performance of its work was facilitated by
financial and political assistance from leading industrial
capitalists (Berliner, 1975). Medicine's professionalization
project consisted of the construction and monopolization of
a market for its services, which involved the elimination of
its competition, both lay and expert. The profession achieved
freedom from lay intervention and the ability to regulate
itself. In addition, it came to dominate an extensive medical
division of labor (Freidson, 1970a). Its professional organi-
zations continued to mold and control subordinate occupations,
such as nursing, in a rapidly growing and increasingly
institutionally-based labor-intensive industry (Brown, 1973).
So successful was medicine at professionalization, that it
has become the archetypal profession in sociological literature.
Certified nurse-midwifery was one of the new and sub—
ordinate occupations which developed in the emerging division
of labor. It developed as an uneasy blend of elements of

autonomy and heteronomy and combined subordination to an

276

allopathic paradigm with the infusion of an alternative
paradigm from British midwifery. The occupation achieved
a substantial scope of autonomy in practice (1930's) in some
regions of the country since physicians granted it a de facto
monopoly on a market of less desirable clientele attended
outside medical insitutions (e.g., rural areas). Nurse-
midwifery's special occupational jurisdiction accounts for
the separation of its occupational trajectory from that of
nursing. In the 1930's and 1940's, the market for other
independent nursing services collapsed while the market
physicians had constructed and monopolized expanded. The
hospital was emerging as the central institution of modern
medicine and as nurses were drawn into it their practice
became immediately subordinate to that of physicians'.
However two decades later, nurseemidwifery's path changed
and began to parallel that of nursing. As third-party pay-
‘ment became available for indigent patients, physicians
began to compete with nurse-midwives for portions of their
clientele. Concurrently, organized obstetrics began to reshape
the occupation to meet anticipated needs in the delivery of
hospital obstetricial care, specifically, the "physician-
shortage" and the "baby-boom," The dmminant profession re-
newed its effort to gain full control over nurse-midwifery
and to mold the subordinate occupation to fit obstetricians'
varied needs, seeking to determine the turf and function of

nurse-midwifery in practice. Thus, nurse-midwifery's marginal

277

location in the obstetricial division of labor wasrewevaluated
by the leadership of organized obstetrics which sought to
bring CNMs into hospital obstetrical care as subordinates

to obstetricians. Meanwhile, segments within the medical
profession competed for the market of obstetrical patients

and obstetric specialists edged out generalists.

Nationally in the 1960's, nurse-midwifery shifted its
turf from the care of marginal and high-risk underserved
pOpulations, where it had considerable autonomy in practice,
to the care of paying hospital patients within the obstetrician-
headed team. Where previously medical restrictions had
applied primarily to whom CNMS served, they now applied to
the tasks certified nurse-midwives performed. This was legally
manifested in the development of physician-created protocols,
ultimate physician responsibility for care of patients and
physician supervision of nurse-midwife practice. Nurse-mid-
wives first entered Vermont in the late 1960's as subordinates
in the obStetrician-headed team.

During its thirty years of existence, nurse-midwifery
had been attempting to professionalize. By the early 1960's
the occupation claimed it had developed a cognitive base and
had made significant progress toward upgrading and standardiz-
ing its education and training programs. The occupation had
gained significant control over these programs; in Larson's
(1977) terms, it had gained control of the critical "produc-
tion of the producers of professional services." In addition,

Nurse-midwives' claims to expertise and the reliability of the

278

professional producer were enhanced by their remarkably
good birth outcomes. However, nurse-midwives were few in
number and their status and incomes were low.

In some ways, the occupations' move into hospital obste-
trical care enhanced the occupations' collective mobility
project. During the period of the 1960's and 1970's, CNMs'
incomes rose significantly along with the occupation's status,
legitimacy and visibility. Substantial federal monies were
made available to upgrade nurse-midwifery education, thus
strengthening the basis of the occupation's claims to
appropriate expertise and standardization in education.

However, in this rapidly changing context, the problem
for nurse-midwifery became: How can the occupation radically
and heteronomously (other directed) change its trajectory
and market without suffering the fate of nursing, that is,
having its aspirations for professional status short-circuited?
The transition to hospital practice enhanced the collective
mobility project at the apparent expense of the occupation's
autonomy in actual practice.

It is possible for an occupation, such as nurse-midwifery,
which poses a potential threat of competition to physicians,
to successfully pursue professionalization within the
institutional matrix of medicine's professionalpower?

The case study examined this question. In obstetrician-headed
teams, physicians delegated CNMS specific tasks and restricted

their autonomy in practice. In most settings, CNMS functioned

279

as physician-extenders or physician substitutes, performing
routine tasks. In this structure, nurse-midwives negotiated
with the dominant profession in an attempt to locate turf,
and by developing bundles of monopolized tasks, to delineate
a new occupational jurisdiction.-

Nurse-midwives thus reinitiated their professionalization
project by making modified claims to special expertise and
a special contribution to care-giving. They sought a mandate
for their altered services, sometimes nudging out potential
competitors such as maternity nurses, and, with physician
acquiescence, they obtained state licensing for nurse-midwifery
practice in most states, including Vermont. Having been
drawn away from an independent market for nurse-midwifery
services, the occupation was faced with the problem of locat-
ing another market which was distinguishable from that monopo-
lized by physicians.

While in the late 1960's nurse—midwives were facing the
prospect of rapid underdevelopment of their occupation, client
movements aimed at reforming birthing practices and profes-
sional-lay relationships were emerging. Birth reformers under-
took the strategy of cooperative lay-intervention in hospital
birthing practices. They activated and raised "prepared

parents expectations for their birth experience through
childbirth education: however, they also socialized them into
a more cooperative patient role (Rothman, 1978) and accepted

the dominant profession's separation of birth experience from

280

physician practices, leaving the core of physician practices
essentially uncriticized.

In contrast, the client revolt, embodied in the home
birth movement, sought to deprofessionalize the work of birth
attendance and to deinstitutionalize the event of birth in an
attempt to circumvent physician hegemony and augment the
laity's autonomy. They reconceptualized the process of
pregnancy, labor and birth (seeing them as normal processes)
and attempted to gain individual expertise to manage them,
thus challenging physician's claims to cognitive exclusivity.
The client revolt, if uncontained, presented the threat of
market collapse, but more immediately, it presented challenges
to the traditional professional-client relationship. Clients
in revolt not only attempted to manage their interactions
with professionals, but also gave rise to yet anothercompetitor
for physician's turf: the lay-midwife.

During the period of study (1970-1980) this new work,
laydmidwifery, began to emerge in Vermont as a distinct
occupational collectivity. While lay-midwives espoused the
movement ideology of deprofessionalization, they simultan-
eously sought state acknowledgement of minimum standards
of care and training via licensing. The state legislature
pondered legitimizing a realm of practice outside that which
medicine monopolized; this shows the extent to which medicine's
claims were being questioned.

Lay-midwives' efforts to obtain licensure for their

281

practice was both a response to physician efforts to eliminate
them.and an outgrowth oftfluaproblem of a new occupation
attempting to claim expertise but having only local reputa—
tion to indicate efficacy and reliability. Unless practi-
tioners acquire some external vehicle for the indication of
their capabilities, they are unable to distinguish them-
selves from inept competitors (Larson, 1977). In Vermont,
since educational credentialing was unavailable, lay-midwives
and their supporters sought state enforcement of minimum
standards of training and skill.

Like early nurse-midwifery, lay—midwives had low-incomes
and low occupational status. However, unlike early nurse-
midwives, they were hounded by physicians who sought to elim-
inate them and their challenge to professional expertise.

The dominant profession attempted to establish a "radical
monopoly" (Illich, 1976) on its market by claiming as its
domain each pregnancy and birth among its desired clientele
and attempting to coerce that clientele to consult it.

While lay-midwives were attempting to acquire a state-
sanctioned mandate for work in the newly developing market
of home birth, the dominant profession began to respond to
the movement for lay-intervention and the client revolt.

Not surprisingly, the client revolt had the effect of making
cooperative birth reform.more attractive to many physicians
and hospitals. However, segments within the dominant profes-

sion responded differently, suggesting their own different

282

and sometimes conflicting trajectories.

With some exceptions, two major segments of the medical
profession could be distinguished in Vermont. Conservative
physicians (the majority group) were those who most explicitly
shunned lay-intervention. They were colleague-oriented phy-
sicians attentive to professional standards of practice, who
worked in group practices associated with larger hospitals.
Progressive physicians in contrast, were more client-centered
in their practices, and thus more oriented to reform. Family
practitioners in solo or small-group practices associated
with smaller hospitals typified this minority segment.

Many conservative physicians spoke out against the home
birth movement. However, the behavior of the state legisla-
ture soon indicated that professional efforts to eliminate
the laity's right to self-care would serve only to further
delegitimize the medical profession. Instead, these physi-
cians attempted to use their professional power and authority
to retain control of the entire obstetrical. work terrain,
delegitimizing self-care in the process.

Conservative physicians had difficulty maintaining control
of the division of labor outside the hospital. However, they
were able to exert some control by restricting access to the
hospital, (for example, withdrawing hospital privileges from
deviant medical workers or blocking lay-midwives from enter-
ing the hospital with their clients). Outside their insti-
tutional base, conservative professionals attemtped to use the

state to inhibit competition. While they were instrumental

283

in bringing civil or criminal charges against lay-midwives
for bad birth outcomes, they were unable to outlaw the
practice of lay-midwifery while the client revolt was mobil-
ized. Using the state professional association, conservative
physicians inhibited progressive physicians' and other health
workers' association with home birth. Potentially deviant
health workers who were conservative physicians' or hospital
employees were held in check by the threat of loss of employ-
ment. Here, a}; elsewhere (cf. Freidson, 1970a; Jones, 1981)
professional regulation served the interests of dominant and
conservative segments of the profession.

However, in a system centered around a dominant pro-
fession, these progressive segments are able to significantly
augment lay-intervention, client-centered reforms and/or
client revolts. The case of Vermont provided an example of
the impact of progressive physicians and their varied strate-
gies for support of fundamental birth reform and home birth.

While conservative physicians at UH/RMC embarked on
the restricted institution of provider-oriented birth reform,
obstetricians at NCCH avoided all but the most obligatory
reforms necessitated by competition from other hospitals.

At SCCH, a physician who had aligned himself with the client
revolt and lay-midwifery eventually succumbed to the pressures
associated with his deviance and returned to exclusive hospi-
tal practice. However, he continued his alliance with the

client-revolt from within the institution. The hospital's

284

deteriorating market position had made the significant and
relatively inexpensive reforms he advocated both more
attractive and more necessary. They were successful: the
hospital's market share increased considerably.

The mixed medical response to client-oriented reform
movements and the client revolt had a significant impact on
the development of both nursedmidwifery and lay-midwifery.
While conservative physicians attempted to eliminate both lay-
midwifery and an independent market for midwifery services,
the communicated to nurse-midwives the fact that any overt
involvement in this market would result in loss of employment.
Nurse-midwives recognized that however attractive they found
home birth, independent practice was fraught with problems
and drawbacks. While independent nurse—midwifery practice
was not illegal in the state and one CNM undertook it, it was
inhibited by laws designed by and for the dominant profession,
(for example, third-party payment structures). Nurse-
midwives realized that outside the "team” they would face
physician opposition similar to that faced by lay-midwives.

Furthermore, birth reform, both conservative and pro-
gressive, drew a significnat portion oftfluahome birth move-
ment into the hospital, substantially diminishing the poten-
tial growth of the market for independent midwifery services.
Physician-sponsored hospital reform.was much more effective
at turning back the client-revolt than physician opposition

had been. The client revolt was increasingly reduced to its

285

core membership--and in Vermont that core was more a counter
or sub-culture than a social movement; this core clientele
continued to be served by lay-midwives.

Meanwhile, nurse-midwifery began to locate a distinct
market within their hospital practice. It consisted of a
clientele seeking an altered client-professional relation-
ship and was drawn from both the periphery of the home birth
movement and prepared parents whose expectations were raised
by childbirth educators. However, the primary vehicle for
nurse-midwifery referrals was a system of friendship communi-
cation networks in the lay-referral system.

In small, partnership-like practices with progressive
physicians, nurse-midwives were granted substantial autonomy
almost from the outset, but in a large group practice such
as that found in the university teaching hospital, they had
to actively negotiate with physicians in an effort to locate
and monopolize turf. In these negotiations, their supportive
clientele was their key resource (Kronus, 1976). In this
context, their monopolized tasks were either bundles of tasks
passed down from physicians (and codified in the protocols)
or newly created turf: the birthing room and reform-oriented
births. Their claims to special contribution to care-giving
began to emphasize their client-orientation (distinguishing
them from physicians) and their training which enabled them

to manage normal births (distinguishing them from.nurses).

 

' I . ' ) - l | ) hr 4 I’ll, I b III |' II? II, ’ ’ I' r I’ 4.1

286

Conclusion

 

Nurse-midwifery's newly constructed market, which was
largely created by external forces, remains inherently sub-
ordinate. As long as nurse-midwives are structurally sub-
ordinate to another profession which mediates the occupation's
relationship with its clientele, nurse-midwives will never
emerge as an autonomous profession.

There are several collective strategies available to
nurse-midwifery, some of which are being undertaken nationally.
Nurse-midwives may attempt to use this period to entrench
in their hospital turf and consolidate the power and limited
automony they have already achieved. The occupation may
embark on an ambitious campaign to undermine professional
hegemony by challenging physicians' restraint of trade in
the courts and legislatures. This would involve competition
with physicians on their own turf. Finally, nurse-midwives
may ally themselves with client/revolt, and seek to eXpand the
existing market for independent midwifery services. In
this strategy, they may either attempt to edge out lay-mid-
wives, or they may formally ally with them, altering once
again the function of and market for nurse-midwifery. Both
nationally and in Vermont the conservative strategy of
entrenchment seems to predominate at this time, though the
other strategies are also being pursued by segments of the

occupation.

APPENDICES

(1
.1
y.

Aspen” A

Interview Schedule

I will ask you a series of questions about nurse-midwifery,
lay-midwifery childbirth, obstetrical practices and the social,
professional and "political" relationships among various groups.
I will also ask you for some information about yourself and your
opinions. If a ouestion is unclear or off the mark, feel free
to let me know.

What is your occupation?

If it is associated with childbirt , what is your education trainin_?

Degrees; Certification: License

Source of training

Length of training

Nature of training (classroom. clinical, apprenticeship, etc.)

Location of training (nursing graduate school, nursing school.

physician's office, hospital, U.S.. or foreign).
What did you do before you became a (Nurse/Lay Midwife, Ob/Gyn,
Childbirth educator, etc.)?

Do you have any children?

Where were they born?

Any comments about their births?

How old are you?

Do you belong to any organizations associated with your work and/or
associated with childbirth? Which ones?

Are you actively involved in these organizations and/or other aCtions
having to do with childbirth? If so,why? If nOt, why net?

Birthing Practices and Birthing Options in Vermont

In your view, what birthing options are currently available to the
average birthing woman in Vermont?

Are there more options available to the informed consumer?

Have these changed in the last 5-10 years? If so, how?

In your view, what birthing options should be available to women in
Vermont? Why?

What are the current typical obstetrical practices in Vermont?
(e.g., C-section rates, fetal monitor use, father/coach in

delivery room, episiOtomies).

Have there been noticeable changes in obstetrical practices in
Vermont in the last ten years or so? Do these practices vary by
physician, locale, income of the patient, etc.?

What is the typical c05t of an obstetrician-attended hospital
delivery?

287

288

continued -- Appendix A

What is a birthing room?

Who Staffs them?

In what positions do women give birth in them?

In what settings do FMS (LMs) attend births in Vermont?

In what settings should NMs (lMs) attend births in Vermont?

(Do LMs and NMs have a de facto division of labor?)

How would you compare childbirth in birthing rooms with typical
hospital births? (What makes it similar/different?)

How would you compare birthing rooms with birthing centers? (What
makes it similar/different?)

How would you compare birthing rooms/birthing centers with home
birth? (What makes it similar/different?)

Would you characterize Home Birth and Hospital Birth/Birthing Rooms
as: Complementary: Competitive: ContradiCtory?

Would you characterize NMs and LMs as: Complementary: Competitive;
Contradictory?

Is the setting of the birth a determining factor in the nature of the
birth.

Is the birth attendant (and philosOphy/training) a determining/key
factor in the nature of the birth?

What percentage of the Vermont populationie capable of having a
successful home birth? Explain.

What percentage will probably choose a home birth?

How do you feel about the choice to have a home birth?

Some articles in the medical literature specifically suggest birthing
rooms in hospitals as the safe and proper solution to the home
birth movement. How do you feel about this? Do you hear this
argument presented in Vermont?

Why do some people choose to give birth at home?

Why do some people choose to give birth in birthing rooms?

Why do some people choose (traditional) hospital deliveries?

Does the medical community's attitudes toward birth setting affect
people's decisions in this regard? Media?

Nurse—Midwifery

Why do people choose to become nurse-midwives?

Has the status and practice of nurse-midwifery changed with its
closer association with team practice in hospitals?

What are NMs' expectations for practice? Are they being met?

Reality shock?

NMs are structurally placed in the middle of change in obstetrical
practices and the contest about the future of childbirth practices.
Do you feel the pressure of this?

(How) will changes in the practice and Status of NMs affect their
ability to professionalize (turf/autonomy/special contribution/etc.)?

In your view, what is the future of Nurse-Midwifery in Vermont?

In the United States? What is the future of Lay-Midwifery? The
home birth movement?

289

continued --Appendix A

Nurse-midwives and Lay (Independent) Midwives in Vermont

What is the legal status of the nurse-midwife in Vermont? (LMs)

How long have Nfls (LMs) practiced in Vermont?

Has their status changed in the laSt 10-15 years?

What is the role of the Nurse-midwife (LM) in current practice in
Vermont?

What is her relationship to obstetricians? To General Practitioners?
(How) has this changed? (work organization and larger professional
relations)?

In your view, what should be the role of the nurse-midwife (lay-
midwife) in Vermont.

Do Nurse-midwives have a special or unique contribution to make to
the care of pregnant and birthing women? Lay-Midwives).

Where do nurse-midwives (LMs) work?

What do they do at work?

What percentage of their time is devoted to: attending births:
prenatal care: post-natal care?

How does this compare with obstetricians: general practitioners:
family nurse practitioners?

How is the nurse—midwife (lay midwife) compensated?

How much is she compensated?

Who does the nurse-midwife (LM) work for?

Do nurse-midwives work in teams with other health care providers?

Explain. (LMs)?

If so, what is the structure of these teams and how do they
operate (no pun)? e.g., physician-led: democratic: autonomous
but cooperative, etc.

Is this a desirable structure?

Do nurse-midwives work or cooperate formally or informally with:
Other birth attendants? medical practitioners? childbirth
educators? other health-promoting groups?

Is there a difference between nurse-midwives and Obs in their
philosophy of childbirth? Explain. (e.g., their relationship
with the pregnant or birthing woman, attendant's role in child-
birth, in the coach/partner's role?)

How do you (NMs. LMs) feel about the critique sometimes made about
hospital birth being too mechanistic and insensitive?

How do you (NMs, LMs) feel about the critique sometimes made about
hospital birth that it produces unnecessary risk and intervention?

Do NMs and LMs serve different populations? (e.g., income, educa-
tion, region)

Are birthing rooms available in Vermont hospitals or clinics? (other
reforms if not already mentioned. otherwise. restate. you said
that....) What is the criteria for use/access to alternative?

Who instit ted these reforms/options? How?

290

co. tinued -- A.pendix A

What is the relationship of NMs to nursing in general? Other
nursing specialties?

In your view, what does the future hold for obscetrical practice
in Vermont and the relationship of Nurse-Midwifery to obscetrics?

As a NM (LM) do you find your work (role) satisfying? What (if
anything) would you change?

These are all my questions. Do you have any comments? Who else
should I talk with?

Appendix B

AMERICAN COLLEGE OF NURSE-MIDWIVES

1012 Fourteenth Street. ~.w.. Suns 801. Weshmgton. D. C. 20006 2021347“

 

 

PHILOSOPHY
AHIIICAI COLLEGE OF NOISE-HIDHIVIS

The Pbllospby of the Anerican College of Nurse-Midwives is based on the beliefs
that:

' Every childbearing fsnily has a right to a safe, satisfying experience with re-
spect for [mean dignity and worth: for variety in cultural for“: and for the
parents' right to self deternlnation.

Conprehensive naternity care, including educational and anotional support as vell
as nnnsgennnt of physical care throughout the childbearing years. is a nnjor nnans
for intercession into, and inprovenent and nnlntenance of, the health of the nation's
fandllee. Conprebensive naternity care is neat effectively and efficiently delivered
by interdependent bealtb disciplines.

lursennddvdfery is an interdependent bealtb discipline focusing on the fandly and
exhibiting responsibility for insuring that its practitioners are provided‘vdtb

escsllnnce in preparation and that those prstitloners dnnonstrste professional
behavior in keeping with those stated beliefs.

Adopted. 1972

FUNCTIONS. STANDARDS Am QUALIFICATIONS

Qualifications for the Pgacsicg of Nurse-Higgggggz
1. Certification by the Lnerican College of lures-lldvdves

a. Active licensure as a registered nurse in one of the 50 states or
Territories including the District of Colunbia

b. Conpletion of a nurse-nidvifery educational progran approved by the
Anerican College of lures-Midwives

2. Conpliance with legal requirenents of the jurisdiction in which nurse-aldvdfery
practice will occur

291

292

FUNCTIONS. STANDARDS AND OUALI F ICATIONS

for the Practice of Nuts dwife

lures-nidwifery practice:

1.

2.

A.

5.

10.

Strives to provide continuity of care to the wonan and her fanily during the
serenity cycle, continuing interconceptionally throughout the childbearing
years.

fosters the delivery of safe and satisfying care.

Recognises that childbearing is a fsnily experience and encourages the active
involve-ant of fanily nsnbers in care.

Upholds the right to ulf-deternination of consunsrs within the boundaries of
safe care.

focuses on health and growth as develop-anal processes during the reproductive
years.

Stinlates «acuity muses .d reqonsivsness to the needs for delivery of
quality idly-catered care.

Occurs interdepadutly within a health care delivery systan.

Occurs within a foul written alli-cs with a obstetrician: or another
'physician. or a gm of physicins, who has/have a for-l consultative arrange-
nnt with an obstetrician-gynecologist.

Ixists within a fruworh of nadically approved protocols.

Occurs within the reels of professional consume.

ll. Inquires opportmities for continuing professional growth and developesnt.

12.

Includes an on-going process of evaluation.

Mtg; for the Prestige of Eng-flaring
The lures-Midwife:

l.

2.

3.

A.

Assn-es responsibility for the mags-ent and conplete care of the essentially
healthy won and newborn related to the childbearing processes.

Develops with the wonsn an appropriate plan of cars attentive to her interrelated
needs.

Participates in individual and group comeling and teaching throughout the child-
bearing processes.

Isnages. through eutual agreenent and collaboration with the physician. that part

of care of nedically coqlicated wonsn which is appropriate to the skills ad
knowledge of nurse-nidwives.

. 2-

293

FUNCTIONS. STANDARDS AND QUALIFICATIONS

Functions for the Practice of Nurse-Midwifery - Continued

5. Collaborates with other health professionals in the delivery and evaluation of
health care.

6. Assesses own professional abilities and functions within identified capabilities.

7. Assunns responsibility for own self-deternination within the boundaries of pro-
fessional practice.

8. Maintains and pronotes professional practice in concert with current trends.

9- Refer: to Guidelines for Evaluation of Nurse-Midwifery Procedural Functions in
Development and evaluation of practice (Appendix A).

10. Pronotes the preparation of nurse-nidwifery students.
ll. Assists with the education of other health care personnel.

12. Supports the philosophy and official policies of the Annrican College of lures-
lidsives.

Accepted. 1913.
m
GUIDELINES POI EVALUATION OP unesz:g;gg;g§!; PIDCIDUIAL IUICTIOIS

The following guidelines were adopted by the Executive board of the A-nric-
College of lures-Midwives as a way of approaching the clinical practice of the nurse-
nidwife. Practice is continually evolving and it varies depending upon the institution
and the denands for service within each setting. because of this, the nurse-nidwife
any frequently be in a position of having to eveluste s new function for possible in-
clusion into her practice. This need for evaluation any be stinulated by the
obstetrician, the denands of the patient or con-unity. pressure fron other groups. or
desires of the nurse-nidwife herself. in any case, the answer as to the worth and
safety of a new procedure for inclusion into nurse-nidwifery say not be clear.

In one of these guidelines can stand alone. It is only be snploying each of then
and then surveying the whole that an accurate feeling for the safety and suitability
of the procedure for nurse—nidwifery practice can be obtained. Guidelines help to
direct but they do not necessarily guarantee that the direction will be coqletely
clear. Systsnatic review of new procedures will help to assure that the 1.8. a Q.
stats-ants are up to date.

1. The procedure assists the nurse-nidwife in nanaging the care of the nornal child-
bearing wonan and infant.

a. It does not conflict with the basic philosophy of nurse-nidwifery as out-
~3-

3.

A.

5.

.294

APPENDIX A - Continued

GUIDELINES FOR EVALUATION OF NURSE-MIDWIFERY PROCEDURAL FUNCTIONS - Continued

lined by the ACNM and with that outlined by the nurse-nidwifery service.

b. The procedure can be done conpetently by the nurse-nidwife. i.e.. the
practitioner has obtained sound theory and supervised clinical experience
fron qualified faculty.

c. The nurse-nidwife is prepared to handle possible conplications fron the pro-
cedure until help arrives.

The procedure is within accepted obstetrical practice within the institution.
a. It is presently an established procedure.

b. It is a new procedure that is being instituted by the obstetric service.
The procedure fills a denonstreted need.

a. There is consular densnd.

b. Hithin the obstetric tsan it is appropriate that the nurse-eidwife carry
out the procedure.

c. The nurse-nidwife feels the procedure will contribute to the provision of
optinnl care.

The procedure is evaluated in the literature and/or in practice.

a. The literature has been reviewed with both indications and contraindications
identified.

b. There in consideration of what other institutions and other nurse-nidwives
are doing.

The procedure is within legal linits.
There is an on-going plan for the evaluation of the procedure.

a. The plan is filed with the Clinical Practice Connittee at the ties of initia-
tion of the procedure.

b. Progress reports are periodically subnitted to the Clinical Practice Connittee.

The Connittee requests that if a nurse-nidwifery service or a nurse-nidwife in-

tends to initiate a new procedure. the Clinical Practice Connittee be notified. This
will enable the Connittee to record changes in practice throughout the United States
and will also facilitate the dissenination of infornation of nurse-nidwifery practice.
It is hoped that periodic reports to the Co-ittee will be nade which are evaluative
and in sunnary fore. The collection of this type of data is inportant to the develop-
nent of nurse-nidwifery and will provide a resource for other services which say be
considering the initiation of the seas procedures.

Accepted January 27, 1972

-‘_ Revised, 11/77 and 2/79

295

AMERICAN COLLEGE OF NURSE - MIDWIVES

 

1000 Vermont Avenue. N.w.. Washington. D.C. 20005 202/6234642

 

mmoumnmn

The Anerican College of Nurse-Midwives considers the hospital or naternity
hone as the preferred site for childbirth because of the distinct advantage
to the physical welfare of nother and infant. "here hone births are
indicated. the obstetric ts- nust develop guidelines which will ensure the
safety of nother and infnt. w. encourage the “are of the obstetric
ts-inallssttingstonsstthspersonalneedsof childbearing f-ilies
by wining s f-ily centered etnosphere with the safety of readily avail-
able obstetrical resources, including the physician.

“Second ldition

'Iirst ldition Adopted by the ACI‘ Executive board 1973

'Second Edition Adopted by the m Worship 1976

 

296'

AMERICAN COLLEGE OF NURSE-MIDWIVES

1012 Fourteenth Street. N.W.. Suits N1. Washington. D. C. 20005 202/3476445

 

POSITION STATEMENT ON NURSE-MIDNIFERY
LEGISLATION"

PREAMBLE

The patterns of health laws in the United States vary
widely and are changing rapidly. The complexity of this
situation presents a barrier to the optimal growth and
development of nurse-midwifery due to serious ambiguities in
the legal base for practice. The American Colle e of Nurse-
Midwives (ACNM) has received increasing demands ran the
public and from professional organizations for recomendations
on legislation. The following position statement is a result
of the desire of ACNM to respond to these demands.

BEL—TEES

The ACT!!! believes that accessibility to comprehensive
care is the right of all persons. Cor ti ified nurse-midwives
have demonstrated that they are capable of making significant
contri bu ions in provision of this care. The ACNM believes
that legislation which re lates the practice of the profession
of mes-midwifery shoul be so-dssigned that it promotes and
protects the health and welfare of the lie. To achieve
these objectives nurse-midwives must no laborate with other

ch share their primary concern of quality maternal
and infant health care for all population groups.

STATMNT

A nurse-midwife who is currently certified by ACNMi
qualified to practice nurse-midwifery throughout the United
Stated and its jurisdictions.

eAInerican College of Nurse-Midwives. as the recognized
authority governing nurse-midwifery practice is responsible for:

 

certification of nurse-midwives,

establishment of qualifications, standards, and
functions for the practice of nurse-midwifery,

approval of nurse-midwifery educational programs.

development of guidelines for nurse-midwifery services.
and

 

III ,1 III- .}IIIITI|

297

-2-

development of guidelines for continuing education of
nurse-midwives.

Separate statutory recognition is recounended as the
basis for nurse-midwife practice. To the extent possible.
this legislation should e uniform throu bout the United States
and its jurisdictions. Until such legis ation is enacted.
nurse-midwives may practice under a variety of legal arrangements.

Nurse-midwives should be involved in the licy making
process of those re latory bodies which admin star and/or
influence the pract es of nurse-midwifery. Nurse-midwives
who act in these capacities should be representative of and
accountable to the practicing nurse-midwives within their
respective areas.

Information and consultation on legislation pertaining to
nurse-midwifery is available through the Anerican College of
hares-Hidwives.

L)

 

*Prepared by the ACE! Legislation Col-litres based upon recon-en-
dations from participants in the ACNM Workshop on the Legal
Status of Nurse-Midwifery. held in Cincinnati. Ohio. June
lit-15. 197A.

Approved by board of Directors. July 30. 1974.

Additional copies available upon request.

“\
‘1)

Appendix C

JOINT STATEMENT
ON
MATERNITY CARE (1971)
AND
SUPPLEMENTARY STATEMENT (1975)

The American College of Nurse-Midwives
The American College of Obstetricians and Gynecologists
The Nurses Association of The American College
of Obstetricians and Gynecologists

298

299

JOINT STATEMENT ON MATERNITY CARE (I971)

The American Cocht of Obstetricians and Gynecologists, The Nurses Association of
The American College of Obstetricians and Gynecologists and the American College of
Nurse-Midwives recognize the increasing needs for general health care and. more specifically,
the deficits in availability and quality of maternity care. The latter. which are not confined
to any social class, can best be corrected by the cooperative efforts of teams of physicians.
nurse-midwives. obstetric registered nurses and other health personnel. The composition of
such tcams will vary and be determined by local needs and circumstances. The functions
and responsibilities of team members should be clearly defined according to the education
and training of the individuals concerned.

To achieve the aims of providing optimal maternity care for all women the following
recommendatioru are made:

I. The health team organized to provide maternity care will be directed by a qualified
obstetrician-gynecologist.

2. In such medically-directed teams, qualified nurse-midwives may assume responsibility
for the complete care and management of uncomplicated maternity patients.

3. In such medically-directed teams. obstetric registered nurses may assume responsibility
for patient care and management according to their education, training and experience.

4. In such medically-directed tcems. other health personnel who have been trained in
specific areas of maternity care may participate in the team functions according to their
abilities and within the definitions of responsibility established by the team.

SJhittsnpolicissdcacrlbingthespccific functions ofeachofthctssm membersshould
bopropmeddheyshouubemviewedandmuodpaiodianyaccomuuwchamingmcds

In endorsing the above statement, The American College of Obstetricians and
Gynecologists. The Nurses Association of The American College of Obstetricians and
Gynecologists and the American College of Nurse-Midwives recognize as their common goal
the need for improvement and expansion of health services now being provided for women.

In order to maintain a continuing evaluation of the health services being provided for
women and to plan for needed improvements and expansion. a mechanism for continued
communication betweenallthoorganizatiornrcsponsiblefortheirprovisionisbcing
developed.

I-M—‘II

300

SUPPLEMENTARY STATEMENT (1975)

Many questions have arisen concerning the meaning of the recommendation in the Joint
Statement on Maternity Care (1971) that the health care team be “directed by a qualified
obstetrician-gynecologist." These questions are justified and are accentuated by other
deve10pments in the specialty of obstetrics-gynecology which include the changing birth
rate, formalization of new roles for personnel, emphasis on preventive care, HMO’s, plans
for national health insurance. PSRO, and regionalization of health services.

It is recognized that the obstetrician-gynecologist cannot under all circumstances be
physically present to direct the health team; therefore it is essential that mechanisms of
communication be clearly established for him or her to provide direction. Thus, the nature
of the direction of the health team indeed becomes crucial.

"The obstetrician-gynecologist working within a team giving health care to women has
many responsibilities. These range from the direct provision of services to community health
efforts and include:

a. The supervision of the medical care provided by all team members.

b. The direct provision of care for complications of pregnancy and for complex medical
and surgical gynecological conditions.

c. The setting of medical care standards.

d. The provision of consultation to other team members.

e. The surveillance of task distribution within the team.

f. Participationin theomoinseducationalactivitiesofthe team.

g. Theintroductionofnewmediealtechniqueaastheybecomeavailable.

h. The development of medical triseu'ch.M

In viewofthe diversity ofhealthcaresystemsin which the obstetric-gynecologic health

team currently functions, no universal systems model can be applied. Generally, however. the
team is found in the following broad contexts:

1. Urban (intramural, on site, immediate referrals);

2. Rural (with institutional affiliation):

3. Rural (without institutional affiliation but with obstetric consultation available):
4. Private office (urban or rural).

The lfltics of consultation and referral may vary with geomphic and climatic
conditions, but the following basic principles of team interaction are valid regardless of
these conditions:

I. There must be a written amement among members ofthe team clearly specifying
consultation and referral policies and standing orders. The representatives of each
practice discipline should participate in the development of and be signatory to the
agreement.

2. The obstetrician-gynecologist. upon signing protocols, must accept full responsibility
for direction of medical care rendered by the team in accordance with his or her
orders.

3. ln circumstances wherein the functions of the team leader are necessarily performed
by physicians without specialty training in obstetrics-gynecology, medical direction
should be provided through a formal consultative arrangement with a qualified
obstetrician-gynecologist who is available to team members for continuing
consultation and assurance of quality care.

‘From “Medical Practice in the Obstetric-Gynecologic Health Care Team," lnterorganizational
Committee on Ob/Gyn Health Personnel, September, 1973.

8-1-75

 

ihrv..i5fl.“‘

Appendix D

ELISABETH M. asanv. M.D. ‘81 sauna w. reams
m River 3 Executive Dhecmr
JOHN L. camoov. M.D. '32 x ,5, ‘
mm? c. MERRIAM. run. '80 d) . 3, we” M 0m:-
“M g. ‘ ,... is aura-rum
MALCOLM J. PAULSEN. MD. '32 sir-5.”): momma. merom- asses
rau- 4m 3m (sot) see-am
H. CARMER van suaeu. M.D. 'si *
Marten
u, 3...... STATE OF VERMONT
222mm. 5. cross. 1n. 'n BOARD OF MEDICAL PRACTICE
W
MRS. Funnies now '32
St. W

POLICY STATEMENT OF THE BOARD OF MEDICAL PRACTICE
CONCERNING PHYSICIAN SUPERVISION OF MEDICAL CARE DELIVERY

The BoardofMedicalPracticeischargedwiththeresponsibilityofregtdating thepracticeofmedicineinVer-
momroemurethatthecidzensofthestatemceivethebestheakhcuepossible. Healthcaredeliveryhasbecorne
complex,invol notonlymdiealdoctorsaudhospitals, butalsoahoetofotherhealthcareprovidersandde-

Boardrecogniaesthevalueoftheseother vidersworkingwiththe ysiciansinthepractice
ofmedicineinthisseate. pro Pb

“Medicalpractice”includesths andtreatmentofdisotdessofhealth, curingoralleviatingdisease,
bodilymgunas orphysicalor mm. prescribing. advising orgrvmgtoanypeuonanydrugmedicsne
orgentforthetreatmentofsuchinfirmitiea; andthepmvisionofcertainpreventiveandwellcareservicea. Unless

snow yassigneduudathehwtomhetmauthority, ,theperforrnanceofanymedicalactswhichare
t provinceoftheprofeaaionalpracticeofmedscin comeuuderthepurviewofthehoardofMedicalPractice.

Anyuon-physician offeringmedicalservieea,e emergencieswithorwithoutfee,mustbeproperly
lieensedorrefisteredamipracticeinareasspecrfically speaficaflymsedbyarespohsiblesupervisingpbysiciau.

Medicalactsmayonlybeperformedby,oratthedirectionofalicensedphysician. Physicians’ assistantsmust
beemployedflinthepncdaofandmpmhedbyhcenndphyndmwhospecificaflydelegaudefinedarcuof
medical practice to these individuals and supervise their performance. Any physician who agrees to a relationship
. withaphysiciauauudawkhomaformlhedwrntumntwfllbemnsidcedmbeengagedmapmdaof

medidnewhichhnmmndwentwiththesundardsofmednlmeuabhshedmthhm.

Thereisnolawatthepreaenttimewhieh about?“ rnguhteamidwifery. ThaBoardconsiderstbe
provisionofpernatalcare,conductoflaboranddelivery partumservicestomotherandchildtobethe
practice ofmedicine. theprovinceofaspedakywihinthepmhpracticeofmedicddoctorsforoveraceutury.

Any non-physician offeringsuchservices.withorwithout fee.exceptinemergencies, mustbero regis-
orhcensedaaphynaansaenstantornumepncutmnerandpnmufin‘mareu “5%me

responsible physician This hysician must have appropriate in obstetrics and musttake
responsibilityor allaspects of the msdwigrypracties

Inadoptingthis policy, theBoardofMedicalPracticeho toensurethe best ualityofhealthcare'
deliveryforthepeopleoftheStateofVermont. P“ very q

October, 1980
Montpelier

301

 

Appendix E

NO. 192. AN ACT TO ADD 26 V.S.A. CHAPTER 28
ANDTOREPEALNVSACWWREIAT-
ING TONURSING. '-

CHAPTER 28. NURSING
3 1571. PURPOSE AND EFFECT
In order to safeguard the lite and health of the
people of this state, no person shall practice, or
offer to practice, professional or practical nursing
unless registered and currently licensed under this
chapter.

5 1572. usrrurrrous

As used in this chapter:

(1) “Board” means the Vermont state board of
nursing.

(2) “Professional nursing” or the “practice of
professional nursing” means the performance of
aei'vices requiring substa ntial specialized know-
1 ge, judgment and skill for carrying out the
n g regimen based upon the principles of the
b logical, physiological, behavioral and social

iences in the: , ‘\

(A) Olnervation, assessment, problem identifica-
on, care or counsel, and health teaching of the

.lnjuredorlnflrm,or in the maintenance of
health or prevention of illness of others;

3(3) Administration, supervision, delegation and
evahtation of nursing practice;

(0) Teaching of nursing;

(1)) mecuuon of a medical regimen as delegated
by 'a licensed physician or licensed dentist who
need not be physically prment; or

I

1

302

 

 

 

 

303

(E) Performance of such additional acts requiring
education and training and which are recognized
jointly by the medical and nursing professions as
proper to be performed by registered and licensed
professional nurses.

(3) “Practical nursing” or “the practice of practi-
cal musing” means the performance of services re-
quiring the specialized knowledge, skill and Judg-
ment necessary for carrying out selected aspects
of the designated nursing regimen at the direction
of a licensed registered professional nurse, licensed
physician or licensed dentist in:

(A) Health teaching and health counselling;

(B) Provision of cans which is supportive or
restorative to life and well-being directly to the
patient or through supervision of nursing assist.
ants; or

(C) likecution of a medical regimen at the direc-
tion of a licensed physician or licensed dentist,
who need not be physically present. ,

(4) “Nursing regimen” means, in the context (if
the practice of professional nursing, a systems
therapeutic plan to carry out nursing‘ practice
defined in thb chapter.

(5) “Medical regimen” means, in the context (lit
the practice of professional or practical nursing,
that aspect of care which implements the medical
plan as prescribed or delegated or directed by a
licensed physician or licensed dent“.

(6) “Registered” means having met all require-
ments for initial licensure to practice nursing in

———-—-—~—-~— 0 v ”-..a. ...Ffl

3014

this state. Once granted, a registration need not be
renewed under this chapter.

(7) “Licensed” means holding a current authoriza-
tion to practice nursing as a professional nurse or
practical nurse in this state. A license shall be
subject to renewal under this chapter.

(8) “Ecsmination” means a licensing examination.

5 1573. VERMONT STATE BOARD OF NURSING

(it) There is hereby created a Vermont state
board of nursing consisting of four professional
nurses, two practical nurses, and two public members
all of whom shall be appointed by the governor.
The present members of the board holding oflce
under this chapter on July 1, 1900, shall serve until
the expiration of their respective terms. Thereafter,
all appointments shall be for terms of three
years or until their successors have been duly
appointed. No person shall be eligible for more
than one reappointment. . .

(b) Appointments of- professional and practical
nurse members shall be made in a manner design-
ed' to be representative of the various types of
nursing education programs and nursing services.

(c) Each member of the board shall be a citizen
of the United States, and a resident of thb state.

(1) The professional nurse members shall:

(A) Hold a license to practice professional nurs
ing in Vermont;

(B) Have at least five years’ experience in the
practice of professional nursing. Three of these

 

 

 

305

five years shall have been immediately preceding
appointment.

(2) he practical nurse members shall:

(A) Hold a license to practice practical nursing
in Vermont;

(B) Have at least five years’ experience in the
practice of practical nursing. Three of these five
years shall have been hnmediately preceding ap-
pointment.

(8) The public members shall not be members of
any other health-related licensing boards, licensees
of any health-occupation boards, or employees of
any health agencies or facilities, and shall not de-
rive primary livelihood from the provision of health
services at any level of responsibility.

(d)Anyvacancyoccurringontheboardshallbe
filled for the unexpired term by appointment to be
made by the governor. . ‘

(e) Each member of the board shall be entitled
to reimbursement for necessary and actual expenses
incurred while engaged in the discharge of omcial
duties and compensation in the amount of $30.00
for each day of omcial duties.

5 1574. POWER: AND DUTIES

The board shall:

(1) Hold annual meetings at which it shall elect
a chairperson, a vice-chairperson and a secretary-
treasurer from its members; and hold such other
meetings as may be deemed necessary to transact
its business; '

306

(2) Conduct business at any meeting only if five
members are present to constitute a quorum; and
keep a record of its proceedings which shall be 5
public record; ' -

(3) Prescribe standards for educational programs
preparing individuals for registration and licensure
under this chapter and approve such nursing edu«
cation programs in Vermont as meet the require-
ments of this chapter and board rules;

(4) Establish standards for registration and licens-
ure of individuals for the practice of nursing, in-
cluding nurse practitioners and those in special
areas of nursing practice which require additional
education and training; ' A

(5) Examine, register, license and renew the li-
ceases of duly qualified applicants and keep a
record of all persons registered by this state, all
persons currently licensed as professional nurses
and practical nurses, and all persons meeting
standards which may be established in defined
special areas of nursing practice;

(6) Provide standards for and approve training
programs for the benefit of nurses who are re-
entering practice following a lapse of five or more
years;

(7) Investigate complaints and charges of un-
authorised practice, unprofessional conduct or in-
competency against any person and take proper
action under sections 1582 or 1585 of this title, as
the case may be; ' .

- -H. --.... a. ..,....-_.-._. .—

 

 

 

 

307

(8) Adopt rules under the administrative pro-
cedures act which may be necessary for the im-
plementation of this chapter.

3 1575. EXECUTIVE OFFICER; STAFF

' (a) The board may appoint a qualified person,
who shall not be a member of the board, to serve
at the pleasure of the board as an executive officer,
and with the approval of the governor, fix the
compensation of the executive officer. The executive
officer shall be a graduate of an approved school of
nursing and hold a master’s degree with prepara-
tion in nursing administration and education; shall
have at least five years experience in nursing ad-
ministration, or teaching; and have been active in
nursing for at least three years immediately pre-
ceeding appointment.

(1)) With the approval of the secretary of state,
the board may employ or contract for such other
persons as may be necessary to carry on the work
of the board. Such persons may be exempt from
the clasified service.

3 1576. PROFESSIONAL NURSE AND PRACTICAL
NURSE REGISTRATION AND
LICENSURE
(a) Qualifications of applicants.

An applicant for registration and a license to
practice professional or practical nursing shall sub-
mit to the board evidence deemed satisfactory to it
that the applicant has completed all requirements
. in an approved nursing education program prepare

‘ing individuals for the practice of either profess-

 

 

308

ional-or practical nursing, or has received equiva-
lent practical nursing education and training. ’

(b) Registration and licensure by examination.

(1) The applicant shall be required to pass a
written examination in such subjects as the board
considers necessary to determine the ability of the
applicant to practice professional or practical nuro
ing.

(2) Upon passing the required examination, the
board shall register and issue to the applicant a
current license to practice as a registerd nurse
(RN) or .a licensed practical nurse (LPN).

(3) The board shall hold at least one examination
annually for professional nurse candidates and one
for practical nurse candidates at such place and at
such time as the board shall determine.

(4) Any qualified applicant shall be entitled , to
reexamination.

(c) Registration and licensure by endorsement.

The board shall register and issue a current
license to practice professional or practical nursing
to an applicant who has been duly licensed by
examination as a registered nurse or a practical
nurse under the laws of another state, territory, or
foreign country if the applicant meets the qualifica-
tions required in this state and has previously
achieved passing scores on the licensing examina-
tion required in this state or its equivalent as de-
termined by the board, and has practiced nursing
within the past five years.

 

 

 

 

309

3 1571. FEES

(a) The board shall establish fees which shall not
exceed:

(1) $40.00 for initial registration and licensure;
. (2) “.00 for renewal of licenses.

(1)) Fees for examination shall be established un-
der section 114(c) of Title 8.

Q 157.. EXISTING LICENSES

' Any person registered or licensed to practice
professional or practical nursing by the board on
or before July 1, 1980 shall retain all rights and
privileges granted thereunder as if registered or
licensed under this chapter.

3 1579. RENEWAL OF LICENSE

(a) Licenses shall be renewed by the board for
periods of up to two years according to a schedule
for renewal established under section 114(c)(5) of
Title 3.

(b) Any registrant who has held a valid license
and practiced nursing within the past five years
may apply for renewal without further examina-
tion or qualifying requirements not otherwise im-
posed on current licensees.

(c) All applicants for renewal of a license to
practice shall have practiced nursing within the
last five years as defined in section 1572 of this
title or comply with the requirements for updating
knowledge and skills as defined by board rules.

 

310

9 IS”. DISPOSITION OF FUNDS

(a) All fees received by the board and monies
collected under this chapter shall be paid into the
general fund of the state.

(b) The board shall submit a proposed budget to
the secretary of state who shall prepare a separate
budget for the board. The secretary of state’s budg-
et for the board shall be submitted together with
the board’s proposed budget to the governor for
review, amendment and submission to the general
assembly.

5 1581. NURSING EDUCATION PROGRAMS

(a) A postsecondary educational institution within
the state of Vermont desiring to conduct a nursing
education program to prepare professional or prac-
tical nurses shall apply to the board and submit
evidence that:

(1) It is prepared to carry out a professional nurs-
ing curriculum or a curriculum for practical nurs
inc:

(2) It is prepamd to meet such other standards
as shall be established by this chapter and by the
board.

(1)) Upon application, a survey of the institution
and .its entire nursing education program shall be
made by the board and its executive emcer. A
written report of the survey shall be submitted to
the board and the institution being surveyed. If, in
the opinion of the board. the requirements for an
approved nursing education program are met, it
shall be approved.

 

 

 

 

311

(c) From time to time as deemed necessary by
the board, it shall be the duty of the board to sur-
vey all nursing education programs in the state.
If the board determines that any approved nursing
education program is not maintaining the standards
required by the statutes and by the board, notice
thereof in writing specifying the defects shall be
immediately given to the nursing education program
and the controlling institution. If the controlling
institution receiving the notice falls within a year
after receipt of the notice to correct the specified
defects, its authority to conduct a nursing educa-
tion program may be revoked by the board. A con-
trolling institution may, at any time before the ex-
piration of one year from the date it receives the
notice, demand and shall be granted a hearing be-
fore the board. In that case, the board shall not
take action until after the hearing.

§ 1582. REGULATORY AUTHORITY

(a) The board may deny an application for reg-
istration, licensure or relicensure; revoke or sus-
pend any license to practice nursing issued by it;
discipline or in other ways condition the practice
of a registrant, or licensee upon due notice and
opportunity for hearing in compliance with the
provisions of chapter 25 of Title 3, if the person:

(1) Has made or caused to be made false, fraud-
ulent or forged statement or rcpresentation in pro-
curing or attempting to procure registration or re-
new a license to practice nursing;

(2) Is convicted of a crime or felony relating to
the practice of nursing as defined in this chapter;

10

 

 

 

‘ -....~._ .. “-..a... --

 

312

(3) Is unable to practice nursing competently by
reason of any cause;

(4) Has wilfully or repeatedLv violated any of the
provisions of this chapter;

(5) Is habitually intemperate or is addicted to
the use of habit-forming drugs;

(6) Has a mental, emotional or physical disability,
the nature of which interferes with ability to prac-
tice nursing competently; or ,

(7) Engages in conduct of a character likely to de
ceive, defraud or harm the public.

(b) Proceedings.

(1) Any person may prefer charges setting forth
a violation of this chapter. The board may also on
its own motion prefer charges based upon its in-
vestigation and reasonable belief that unprofesshnal
conduct has occurred. Charges against a person
shall be in writing and shall set forth the partic-
uiars of the claimed misconduct and shall be filed
with the executive officer of the board;

(2) The board may dismiss the charges without
hearing by a majority vote of its members but
shall retain a written record of its reasons;

(3) The time and place of a hearing shall be fixed
by the executive officer of the board and a copy
of the charges, together with a notice of the time
and place of hearing, shall be served by certified
mail. return receipt requested, and addressed to the
last-known address of the person complained against
and to the complainant at least 14 days prior to the
hearing;

(4) The attendance of witnesses and the furnish-
ing of evidentiary material in connection with a

ll

 

 

 

 

 

 

313

hearing may be compelled by subpoenas issued by
the executive oficer of the board with the ap-
proval of the board and which shall be served in
accordance with law;

(5) At any hearing, witnesses may be sworn and
any member of the board authorized by the board
todosomayadministertheoath;

(6) The board shall not be bound by rules of
judicial procedure or by the laws of evidence in
the conduct of its proceedings, but the findings of
fact and conclusions of law shall be based upon
legal evidence which will sustain its orders and in
compliance with chapter 25 of Title 8 and this
chapter and the board’s rules;

(7) The person complained against is entitled to
appear personally and to be represented by coun-
sci, to cross-examine witnesses appearing in support
of the complaint, and to produce evidence and wit-
nesses in defense;

(8) A record of all complaints and charges pre
sented and heard under this section and the dis
position of those charges shall become a part of
the permanent public record of the proceeding
of the board.

(c) Appeals.

’(1) Any person or institution aggrieved by any
action of the board under this section or section
1581 of this title may appeal by one of the follow-
ing procedures: to the appeals panel as provided in
chapter 25 of Title 8; or to the superior court for
the county where such person resides or if such
person is a nonresident, such appeal may be to the
Washington county superior court. '

12

 

314

(2) The questions raised by such appeal shall be
thereupon heard de novo, and the parties shall have
the right to demand a trial by jury.

(d) There shall be no liability on the part of, and
no cause of action for damages shall arise against,
any member of the board for any act or proceed-
ing undertaken or performed within the scope of
the functions of the board, if such member acts
without malice, has made a reasonable effort to
obtain the facts of the matter as to which he or
she acts, and sea in reasonable belief that the
action taken by him or her is warranted by the
facts known to him or her after such reasonable
effort to obtain facts.

3 15.3. EXCEPTIONS

This chapter does not prohibit:

(1) The furnishing of nursing assistance in an
emergency;

(2) The practice of nursing which is incidental to
their program of study by persons enrolled in
nursing education programs approved by the board,
or graduates of approved nursing education pro-
grams pending the reailts of the first licensing
examination scheduled by the board following grad-
uation. Graduates shall so practice under super-
vision of a professional nurse and shall have an
application for registration and licensure by exam-
ination on file;

(8) The practice of any nume who is employed
by the United States government or any bureau,
division or agency thereof, while in the discharge
of her or his omcial duties;

13

 

 

 

 

 

315

-s~’~‘v _ ..... “-..a—M-..

(4) The practice of nursing by a nurse currently
licensed in another state or United States territory
for a period of sixty days pending licensure in
Vermont, if the nurse upon employment, has fur-
nished the employer satisfactory evidence of cur-
rent licensure and evidence of having submitted
proper application and fees to the board for regis-
tration and a license by endorsement before begin-
ning employment;

(5) The practice of nursing in this state by any
currently licensed nurse whose engagement was
made outside of this state but required the nurse
to accompany and care for the patient while in
Vermont. This exception shalL not exceed six
months; ‘ ’ ' ’

(a) The normal work and duties of medical secre-
taries, laboratory technicians and x-ray technicians,
physicians’ assistants and dental assistants in the
employ of the doctor or dentist and while they are
actually under the direct control of the physician
or dentist; —

(7) The care of the sick by domestic help of any
type, whether employed regularly or because of
illness, provided such person is employed primarily
in a domestic capacity;

(8) The work and duties of attendants in the Ver-
mont state hospital at Waterbury and Brandon
training school at Brandon. ‘

g 1585. VIOLATIONS OF CHAPTER; PENALTIES

(a) It shall be a violation of this chapter for any
person, including any corporation, association or
individual, to:

14

 

316

(1) Sell or fraudulently obtain or furnish any
nursing degree, diploma, certificate of registration,
license, or any other related document or record,
or to aid or abet therein; '

(2) Practice nursing under cover of any degree,
diploma, registration, license, or related document
or record illegally or fraudulently obtained' or
signed or issued unlawquy or under fraudulent
representation;

(3) Practice nursing unless duly registered and'
currently licensed to do so under the provisions
of this chapter; '

(4) Use in connection with a name any designa-
tion tending to imply that a person is a registered
professional or practical nurse when not regis-
tered under this chapter;

(5) Practice nursing during the time a license
issued under this chapter is suspended or revoked;

(6) Conduct a nursing education program pre-
paring lndividuals for entry into the practice of
professional or practical nursing unless the pro-
gram has been approved by the board;

(7) airplay unlicensed persons to practice as pro-
fessional nurses or as practical nurses;

(8) Otherwise violate this chapter.

(b) Violations of this chapter shall be punishable

by a fine of not more than $1,000.00 or imprison-
ment for not more than six months, or both.

(c) Violations of this chapter shall be prosecuted
by the attorney general or the state’s attorney of
the county in which the violation occurred. In ad-

15

 

 

 

 

 

 

317

dition, the attorney general, or a state’s attorney
may seek an injunction in any court of competent
jurisdiction to enjoin any person who is not cur-
rently licensed from practicing as a professional
or practical nurse. ‘

Sec. 2. REPEAL
Chapter 27 of Title 20, V.S.A. is repealed.
Sec. 3. 20 V.S.A. § 3102(b)(4)(D) is amended to read:

(D) Chapter 28 of Title 20, V.S.A. on nursing;

See. 4. EFFECTIVE DATE; TRANSITORY
PROVISIONS

This act shall take effect July 1, 1000. The Ver-
mont state board of nursing established by Sec. 1
of this act is intended to be a continuation of and
successor to the state board of nursing repealed
bySec.Zofthlsact. Allmembersofthe board
shall continue in once untll replaced under the
terms of this set. All funds appropriamd to the
state board of nursing shall be transferred to the
Vermont state board of nursing established by this
set. All records, documents and personnel of the
state board of nursing shall be transferred to the
Vermont state board of nursing established by
this set. All rules promulgated by the state board
of nursing shall remain in full force and effect
until amended or terminated under this act.
Approved: May S, 1900

16

 

~o a: ~i o~ u: a~ or re La

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15
16
17
18
19

20

22
23
24

25

31i3

Appendix F

1979 - H.302 p.l

H.302
Introduced by Mr. Chaloux of St. Johnsbury
Referred to Committee on
Subject: Professions and occupations; midwifery; licensing
Sponsor's statement of purpose: It is the purpose of this bill to
license the practice of midwifery, establish standards for admission
to practice, and establish procedures for regulation and discipline

of the practice

 

0'“ V“ W" V“.
Was No Date Senate W Yes No Date Common

 

 

 

AN ACT TO ADD 26 V.S.A. CHAPTER 24 RELATING TO REGULATION OF THE
PRACTICE OF HIDWIFERY

It is hereby enacted by the General Assembly of the State of Vermont:

~o a: ~i 0\ u: e~ us so L-

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11
12
13

16

16
17
18
19
20

22
23
26
25

1979 - H.302 p.2

Sec. 1. 26 V.S.A. Chapter 24 is added to read:
CHAPTER 24. MIDWIFERY
§ 1425. DEFINITIONS
As used in this chapter, unless a different meaning clearly appears
from the context, the following words shall mean:

(1) "Board", the state board of midwifery established under sec-
tion 1426 of this title.

(2) "Midwifery", thggpractice of attending a woman in childbirth
for compensation, or advertising as such,gbut nothing in this chapter
shall be construed to prohibit gratuitous service in the case of
emergency, nor the service of any legally qualified physician or
gggggon of this state.

5 1426. BOARD OF NIDVIFERY
(a) There is hereby established a state board of midwifery com-
posed of five members including:

(1) a nurse-midwife certified by the American College of Nurse-
Hidwives;

(2) a midwife not certified by the American College of
Nurse-midwives;

(3) a pediatrician licensed to practice in the state;

(A) an obstetrician licensed to practice in the state;

(S) a member of the public having no financial connection to the
midwifery or medical professions.

(b) Members of the board shall be appointed by the governor for

fivefyear terms, except that of the initial appointments one shall

\

-..-

(n

so a: s: 0‘ u. s~ C: to La

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12
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19

20

22
23
24

25

320

1979 - H.302 v.3

serve for one year, one for two years, one for three years,fione for
four years and one for five years. For official duties, members
shall receivepper diem compensation in the amount of $30.00 and reim-
bursement for actual and necessary expenses.
§ 1427. LICENSES REQUIRED

A person maypnot practice midwifery or hold himself or herself out
to the public as a midwife in a manner that is intended to indicate
or calculated to induce members of the public into believing that he
or she is a qualified midwife without first being licensed under this
chapter.
§ 1428. QUALIFICATIONS FOR LICENSE

Appgrson may be licensed as a midwife if he or she:

(1) is at least 18 years of aggi

(2) is a resident of the state;

(3) has satisfactorily passed an examination administered by the
board under section 1429 of this title, or has been certified by the
American College of Nurse-Midwives.
§ 1429. EXAMINATION

(a) The board shall examine all applicants for a license to prac-
tice midwifery in the following subjects:

(1) Anatomy and physiology of the pelvis, female generative
organs, menstruation and pregnancy;

(2) Fetal development;

(3) Maternal-fetal nutrition,

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18
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20
21
22
23
24

25

.3221

1979 - H.302 p.4

(4) Diagposis and management of pregnancy. fetal presentation
and position;
(5) Mechanism and supervision of normal labor and birth, includ-
ing early detection of abnormalities requiring physician assistanggg_ ‘3

I

and post-partum;

 

(6) Injuries to genital organs following labor, including
repairs of first and second degree tears of perineum, performance of

small episiotomies;

 

(7) Knowledge of changing familial relationships during child

bearing years;

 

(8) Hygiene of mother and infant in birth environmeng;
(g) Anatomy and physiology of lactation;

(10) Resuscitation of newborn,gdetection of other abnormalities
such as malformations, asphyxia, jaundice and failure to thrive;

(11) Development and care of normal newborn;

(12) Causes, effects and treatment of opthalmia neonatorium;

(13) Knowledge of the physiology of pain and the various methods
of childbirth preparation;

(14) Knowledge of current modes of management of complications,
including medications and methods of analgesia, anesthetics, and
surgery. 2)}

(15) Counselling for family planning.

(b) The examination shall be sufficient to test the scientific and

practical ability of candidates to practice midwifery, and the board

 

(3

so an x: as U a u NL-

10
11
12
13
14
15
16
17
18
19

20

22
23
24

25

322

1979 - H.302 p.5

may reqpire examination on other subjects relating to midwifery from
time to time.
§ 1430. FEES

(a) The board shall charge the following fees:

 

 

(1) application for license $10.00
(2) examination fee $15.00
(3) license and license renewal $20.00

 

(b) The fees so collected shall be paid into the general fund of
the state.
§ 1431. LICENSES, RENEWAL

(a) Licenses shall be renewed every two years upon payment of the
required fee.

(b) On or before April 15 in each apprqpriate year the secretary
of the board shall forward to the holder 3 form or application for
renewal thereof. Upon the receipt of the completed form and the
renewal fee on or before June 15, the secretary shall issue a new
license for the year beginning July 1. Any application for renewal
of a license which has expired shall in addition require the payment
of a renewal fee, or in such cases as the board may by rule
prescribe,gby a newjgpplication fee.
§ 1432. REFUSAL, REVOCATION 0R SUSPENSION OF LICENSES; HEARING

The board may refuse to grant, or may revoke or suspend, a license
for any of the following reasons: the conviction of a crime involv-
ing moral turpitude; application for examination under'fraudulent

representation; neglect or refusal to make proper returns to a health

 

 

.9 a: NJ 0‘ u- a~ u: s: Ld

10
11
12
13

14

16
17
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19
20

22
23
24

25

3223

1979 - H.302 p.6

officer or health department of births, or a puerperal, contagious or
infectious disease, within the legal limit of time; failure to secure
the attendance of a reputable physician in case of miscarriage,
hemorrhage, abnormal presentation or position, retained placenta,
convulsions, prolapse of the cord, fever during parturient state, in-
flammation or discharge from the eyes of the newborn infant, or
whenever any abnormal or unhealthypsymptoms appear either in the
mother or infant during labor or the puerperium. Before any license
shall be revoked or suspended, the accused shall be furnished with a
copy of the complaint andjgiven a hearipg before the board, in person
or by attorney, and any midwife refused admittance to the
examination, or whose license has been revoked or suspended, who at-
tempts or continues the practice of midwifery, shall be subjgct to
the penalties hereinafter prescribed.
§ 1433. PENALTIES

Any personjpgacticing midwifery in this state in violation of the
provisions of this chapter shall be liable to a fine of not more than

$500.00 or imprisonment for not more than six months or both.

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