Canadian Journal of Sociology Online March-April 2007
Until 1993, when midwifery was made a profession in Ontario, Canada was the only industrialized country that did not recognize midwifery (Bourgeault 1999). Save for a few small religious, remote and Aboriginal communities it was rare that a woman in Canada gave birth anywhere other than a hospital attended by a physician. However, in the 1970s a tiny but growing movement of women sought and took control of their birth experiences by choosing to give birth in their own homes with the assistance of friends. These friends were self-taught midwives whose approach to pregnancy and childbirth was very different than those of their medical counterparts. Unlike physicians who are taught that birth is normal after the fact, midwives treat birth as a normal natural event and see labouring women as their own birth experts. This social movement was taking shape across the country, but it was in Ontario where these lay-trained midwives were the first to make it across the professional finish line. Two new books reflect on this Canadian first and assess its implications for midwifery and for sociological examination of professions.
In the aptly titled Push!, Ivy Lynne Bourgeault documents the long, arduous struggle to professionalize midwifery in Ontario. However, Push! is more than just a chronicle of the painstaking steps taken to integrate midwifery into the provincial healthcare system. It also captures the nuanced and shifting relations between midwives, their clients, professions and the State; as well as those within the midwifery community. Using an analytical framework informed mainly by the work of Larson (1977) and Witz (1992), Bourgeault closely examines this gendered professional "project" and the implications of its success.
The breadth and depth of information presented in Push! can be credited to Bourgeault's application of multiple data collection methods: in-depth interviews, participant observation, and review of historical documents. She acknowledges "[her] success at securing interviews with most of the informants on [her] list is due in large part to [her] initial involvement in the community" (p. 293). Bourgeault's first child was born at home with the assistance of a midwife in 1991 and subsequently she joined a client-based organization that lobbied for the professionalization of midwifery — the Midwifery Task Force of Ontario (MTFO). She also gives a national historical context with a brief review of the literature on the demise of midwifery in Canada and a comparative international perspective with 3 brief case studies of midwifery professional projects in the United States, Australia and the Netherlands. The rest of the book examines the professionalization process that took place in Ontario.
It took eleven years for midwives in Ontario to be fully integrated into the provincial health care system. Bourgeault documents the opposition midwives encountered from both medicine and nursing: physicians tried to claim that midwifery should be under its control while nurses attempted to make nursing education a pre-requisite for midwifery training. Neither was successful. But it is midwifery's relationships with the state, with clients/consumers and among midwives themselves that prove to be the most interesting aspects of the book. Through each step of integration into the province's health care system Bourgeault illustrates how the relationship between midwives and their clients, built on flexibility, friendship and partnership, became a bit more formal and hierarchical.
For example, midwives and their supporters were all members of the Ontario Association of Midwives (OAM) — an organization that promoted midwifery. In 1982 the OAM was approached by the province's Health Professions Legislation Review (HPLR) and asked if it wanted midwifery to become a profession. At that point the organization split into two: the OAM became an organization for midwives only while clients and advocates of midwives formed the MFTO. By the time midwifery became a profession in 1993, none of the midwifery clients/advocates were designated public members of the College of Midwives of Ontario.
Midwives and their advocates were fortunate in having strong supporters within the state. Bourgeault recounts interviews with MPPs in government and in opposition as well as appointed bureaucrats who supported the integration of midwifery as a health care profession. But she also notes that the state mediated the outcomes of that process, which for midwives were often marked by compromises. As Bourgeault notes midwives opted for a provincially-funded baccalaureate-based educational program, not necessarily because it was the best educational model but in order to gain legitimacy in the health care system.
The decision to enter into a professional project set midwives against each other. Conflicts between midwives continued to erupt at every step of the integration process. After midwifery became a profession a program was established to evaluate the skills and knowledge of midwives who had already been practicing in the province — what Bourgeault refers to as a "grandmothering" process. Sixty-three applicants successfully completed the program and were granted licenses. The Committee for More Midwives complained to the province that the evaluation process was flawed and biased, excluding the skills and experience of certain midwives. In spite of these internal conflicts this midwifery professional project was a success — midwives in Ontario are fully integrated within the health care system, have hospital privileges, are fully funded by the state, and have a four-year, state-funded, baccalaureate education program.
Push! makes a new contribution to sociological theory. Bourgeault augments Witz's model of inter- and intra-professional conflicts by situating it within relationships with midwifery consumers and with the state. This is valuable for analyses of contemporary professional projects, given current provincial governments' penchant for delimiting the power of the medical profession and expanding the scope of practice of other health care professions. It is also timely as governments seek public consultation on health care (e.g., the Romanow Commission, the B.C. Conversation on Health).
My one criticism of Bourgeault's book is that it leaves the theoretical analyses until the last chapter. This chapter only gives a very general re-telling of the integration process, leaving out the detailed description of the shifting relationships between the key players. The text could have been strengthened had each step of the integration process been accompanied by an analysis of the specific strategies utilized by all of the players. Why save the best bits until last?
If Push! is the analysis of the compromises taken in order to obtain a professional victory, then Obstructed Labour is an examination of those who were not invited to the celebration. Sheryl Nestel takes a sober second look at this victory from the perspective of those unsuccessful at becoming licensed midwives — specifically, immigrant women of colour with midwifery credentials from jurisdictions outside of Canada. Nestel presents a convincing case of a gendered professional project fraught with systemic racism.
Quirky demographics compelled Nestel to apply a racialized analysis to midwifery in Ontario. At the time of the professional integration process there was a relatively large pool of potential licensees in the province with midwifery credentials earned in other countries. Although almost half of the women who sought information from the College of Midwives of Ontario about assessment for credentials were women of colour, only 1 of the 72 midwives initially licensed in the province was a woman of colour. The rest of the licensees were white.
Nestel steers the reader towards an analysis of systemic racism using Goldberg's (1993) approach which shifts the focus from racism based on intentional personal prejudice to that based on institutional practices that "[give] rise to racially patterned exclusionary or discriminatory outcomes…" (p. 37). She applies this approach throughout the book.
Like Bourgeault, Nestel had an insider's advantage in garnering interviews with research subjects. As a childbirth educator and recognized critic of the professionalization process, Nestel acknowledges that this standpoint made her interviewees feel more comfortable and more likely to discuss issues of race and racism with her than with other researchers. She uses in-depth interviews as her primary data source.
Nestel critically examines the history of the midwifery professional project with a focus on the practices of racial exclusion. She recounts the experience of Aboriginal midwives who had to fight the province and midwifery elite. Critical of the lack consultation with Aboriginal communities, the lack of Aborginal content in the newly established midwifery baccalaureate curriculum, and the lack of Aboriginal students in the program, these midwives were successful at opting out of the process. The predominately white midwifery elite re-framed this as a victory for the midwifery movement as a whole, even arguing that it was an example of how "culturally-sensitive" midwives were compared with other health professions. Nestel argues Aboriginal midwives were not seen as a threat to the white midwifery elite because they were so few in numbers and scattered across relatively remote parts of the province, whereas the majority of the (white) midwifery community was based in the Toronto area.
Nestel most effectively demonstrates the racist exclusion of immigrant midwives of colour. During the "grandmothering" process I described above, credentialed immigrant midwives were not successful at meeting the eligibility requirements. Nestel describes the endless hurdles encountered by immigrant midwives trying to meet those criteria. First, she notes that worldwide, baccalaureate training for midwives is extremely rare, yet was the route chosen by the province's midwifery elite. Immigrant midwives were not part of the established midwifery "network" making it difficult to get apprenticeships with established midwives. Those midwives who did manage to practice were likely to have fewer clients as they served women from their own immigrant communities, who were less able to afford the out-of-pocket costs of a not yet state-funded service. As a result they were less likely to have the requisite number of births necessary for accreditation. Immigrant midwives were also more fearful of practicing outside the law. Most of their white counterparts feared legal prosecution but immigrant midwives, especially those who had not yet received Canadian citizenship, feared greater repercussions. Ultimately, many found it difficult to meet the criterion requiring two years of practice immediately prior to the initiation of the "grandmothering" process. Long delays in the evaluation process also put immigrant midwives in a Catch-22: their most recent experiences becoming less and less "recent" as the accreditation clock ticked on.
In spite of these disadvantages, immigrant midwives of colour were keen to find out as much as they could about what the process entailed. But as Nestel notes, when the Equity Committee of the Interim Regulatory Council of Midwives (IRCM) sought these women out it was to address (the IRCM's) concerns about oppression in other countries, not immigrant midwives concerns about how to get licensed. Seeking to overcome its financial disadvantage in applying for midwifery licenses, a group of Filipino midwives applied for funding from the College of Midwives for outreach and education regarding the licensing process. Their application was denied. Complaints about bias or lack of fairness in the evaluation process were countered with claims of feminist heroism —professionalization of midwifery was a victory for (all) women.
The irony of this exclusion of midwives of colour was that many of the midwifery elite in Ontario went to developing countries to meet the requisite number of births for the licensing process, learning how to be a midwife from women who would be denied a license in Ontario. In an excellent chapter entitled "Midwifery Tourism" Nestel describes how white Canadian midwives went to midwifery clinics in Texas on the border with Mexico. These clinics serve a client population made up of mainly Mexican and Mexican-American women. Nestel draws a comparison between this midwifery tourism and sex tourism in South East Asian countries in that they are both practices where women's bodies are seen as natural resources. It is a contentious argument but Nestel refers to interviews with the white midwives who travelled to these clinics and describe the benefits to themselves through these journeys: a high volume of births in a short period of time and respect from the medical profession for learning how to deal with difficult births. Few of the midwives who traveled to the clinic spoke Spanish although 88% of the clients spoke only Spanish. This seems very far from the goal of creating a partnership with a woman who is ultimately in control of her birth experience.
Nestel also includes analyses of other who were excluded from or marginalized within the profession: poor women, lesbian women, disabled women, women who practice midwifery with a spiritual approach. Along with Aboriginal midwives and midwives of colour, none of these groups fit the bill for the "ambassadors of midwifery" — a united, conservative, logical, rational and homogenous public face in the push for a midwifery profession. But ultimately it is her focus on race that is the most interesting. As she notes the licensing outcomes for white British midwives were very different from their women of colour counterparts.
Obstructed Labour should be mandatory for all midwifery colleges and in all midwifery education programs. The only recommendation I have for the book is the addition of a table that would simply illustrate the number and proportion of applicants vs. number of licensees by race in the introductory chapter. I believe this could make Nestel's argument visually stronger.
Nestel's theoretical analyses are also important for sociology and I suggest that her work could be used to expand Bourgeault's analytical model of gendered professional projects to include a systematic analyses of practices of exclusion based on race. At the end of Push! Bourgeault ponders whether it might be time for a review of the literature with respect to research on midwifery in Canada. With the volume of research present in these two books alone, I say most definitely yes.
References
Rachael McKendry
University of British Columbia
http://www.cjsonline.ca/reviews/midwifery.html
April 2007
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