Integration lay and nurse-midwifery into the U.S. and Canadian health care systems

Pergamon

Soc. Sei. Med. Vol. 44, No. 7, pp. 1051 1063. 1997

PII: S0277-9536(96)00290-0

~'~ 1997 Elsevier Science Ltd All rights reserved. Printed in Great Britain 0277-9536/97 $17.00 + 0.00

INTEGRATING LAY A N D NURSE-MIDWIFERY INTO THE U.S. A N D C A N A D I A N HEALTH CARE SYSTEMS IVY LYNN BOURGEAULT ~ and MARY FYNES 2 ~York Centre for Health Studies, York University, 214 York Lanes, 4700 Keele Street, North York, Ontario, Canada M3J 1P3 and "Department of Behavioural Science, University of Toronto, Toronto, Canada Abstract--The integration of midwifery into the health care systems in the U.S. and Canada has invoked scholars to speak of a "rise of midwifery". Despite the gains that the profession of midwifery has made in both countries, there are some interesting differences in how midwifery is organized and practised in these two settings. Briefly, in the U.S. midwifery currently exists as a profession divided between nurse- and non-nurse-midwives,or "lay" midwives, with greater acceptance and legitimacygarnered by the former, whereas midwifery in some jurisdictions in Canada has gained legitimacy as a unified profession separate from nursing. An analysis of the differences in the development and organization of lay and nurse-midwifery in Canada and the U.S. highlights the importance of differences in the system of health professions in these two countries, the role of the state in this system, and the relationship between feminism, midwifery and the state on the outcome of efforts to integrate midwifery. ~) 1997 Elsevier Science Ltd. All rights reserved

Key words -nurse-midwifery, lay midwifery,development, organization

INTRODUCTION The state of midwifery in the U.S. and Canada has garnered increasing attention in the last two decades invoking many scholars to speak of a "rise of midwifery" (Arms, 1 9 7 5 ; Barrington, 1985; Bourgeault, 1996; Burtch, 1988; Evenson, 1982; Fynes, 1994; Mason, 1988; Matthews and Zadak, 1991; Reid, 1989; Rushing, 1993; Sullivan and Weitz, 1988). Prior to the 1970s the practice of midwifery other than by licensed physicians was illegal and unregulated in Canada and in several areas of the U.S. In both countries midwives were charged, and in some cases prosecuted, for practising medicine without a license. Recently, however, there have been efforts to integrate midwives into the American and Canadian health care systems. Despite these similarities, there are some interesting differences in midwifery in the U.S. and Canada. Briefly, in the U.S. midwifery is a profession divided between nurse and non-nurse, or lay, practitioners. Each group practises in separate spheres with limited scopes of practice (i.e. nursemidwives work predominantly in institutions and lay midwives work in clients' homes). Nurse-midwives have garnered greater acceptance and legitimacy in the formal system of health professions. In contrast, midwifery in several Canadian provinces exists as a unified profession separate from nursing. In one province, Ontario (and soon in Alberta and British Columbia) midwives have achieved a broader scope of practice than nurse- or lay midss~ ~-7-F

wives in the U.S., in that they are able to work both in home and hospital. Several studies of the professionalization of aspiring health professions like midwifery reveal that the process of seeking integration often features the development of a professional association that leads the integration process and rallies consumer support for their endeavour (Biggs, 1989; Coburn and Biggs, 1986; Donnison, 1977; Gort and Coburn, 1988; Larkin, 1983; Wardwell, 1981; Willis, 1989; Witz, 1992). Often there is also a fair degree of intraprofessional conflict within these associations. In examining attempts of aspiring health professions to become integrated, however, one must also look beyond these "intraprofessional" factors. Larkin (1983), for example, argued that aspiring professions have to negotiate boundaries with other health professions. He conceptualized these competing interprofessional relations as occupational imperialism, which involves "tactics of 'poaching' skills from others or delegating them to secure income, status, and control" (Larkin, 1983, p. 15). The outcome of occupational imperialism, he argued, is largely shaped by the differential access of each group to external sources of power. Abbott (1988) described similar negotiations or conflicts over jurisdiction (i.e. areas of knowledge and skill expertise) in his conceptualization of a "system of professions". Professions, he argued, develop from interrelations with other professions when jurisdictions become vacant. Such vacancies occur in response to external system disturbances, such as technological or organizational change, or

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because an earlier tenant has abandoned it. A profession's success in occupying a jurisdiction reflects on the situation of its competitors as much as it does on the profession's own efforts. The medical profession, as the dominant profession in the health care division of labour, plays a key role in the negotiations around integrating an aspiring health profession. Attempts to integrate aspiring health professions are usually met with opposition from medicine which expresses concern over encroachment of medical territory. In order to achieve integration, aspiring health professions must overcome this opposition. Often this is accomplished by seeking sponsorship from influential members of the medical profession. In exchange for this sponsorship, an aspiring health profession must accommodate its medical sponsors' demands (Coburn and Biggs, 1986; Larkin, 1983). This usually results in a limitation of the aspiring professions" scope of practice, subordination of its practitioners, and medicalization of its ideology. Medical sponsorship, however, is not the only method by which aspiring health professions can achieve integration. In many cases, aspiring health professions have sought sponsorship directly from state elites, often as a result of vociferous consumer support (Biggs, 1989; Willis, 1989). But the state is not simply a neutral arbiter of claims to professional status (Johnson, 1995). It has its own interests, which include, among others, capital accumulation and legitimacy (Simmons and Keohane, 1992). As the state in some countries has come to have increasing power within the health care division of labour (Coburn, 1994), seeking support from the state by aspiring health professions has proved to be a successful strategy (Coburn and Biggs, 1986). Several studies also point to the influence of gender on the process of the integration of aspiring health professions, especially those which are numerically dominated by women (Butter et al., 1987; Collins, 1990; Etzioni, 1969; Grandjean and Bernal, 1979; Hearn, 1982; Witz, 1990, 1992). Witz (1992), for example, argued that "gendered actors engaged in professional projects...have differential access to the tactical means of achieving their aims in a patriarchal society within which male power is institutionalised and organised" (p. 52). Because of this, integration strategies are gendered. Specifically, female professional projects engage in dual closure strategies which include both "usurpation", a countervailing, upwards exercise of power on the part of the professional group seeking inclusion, and "exclusion" of others from the professional project. Witz also described how "legalistic" tactics via the state were more successful for female professional projects than were "credentialist" tactics in civil society. Given the importance of examining multiple factors in the development of aspiring health pro-

fessions, we argue in this paper that the differences between midwifery in the U.S. and Canada are not due simply to differences in the internal relations within the profession of midwifery. Several other factors are influential, including time differences in the development of midwifery, differences in the nature of the related professions of nursing and medicine, differences in midwives' support base and the influence they have, and perhaps most importantly, differences in the state's involvement in the health care system. The data for this paper are derived from multiple sources. For the U.S. case, data include primary and secondary literature and policy documents from midwifery associations. These are supplemented by brief discussions with key informants. For the Canadian case, data include primary and secondary literature, policy documents and interviews with over 50 key informants. Ontario is used as the main referent for the Canadian case because it is the first province in Canada to implement midwifery into its provincial health care system. Furthermore, it is likely that midwifery policy implemented in Ontario will be implemented in a somewhat similar manner in other provinces. We begin our discussion with a brief historical background on midwifery in these countries. Following this, we outline the development and organization of nurse-midwifery and lay midwifery in both countries, highlighting the influence of consumer support, intraprofessional conflict, interprofessional relations (specifically with nursing and medicine), and relations between the professions and the state on this process.

HISTORICAL BACKGROUND

Before the 20th Century, the practice of midwifery in the U.S, and Canada was accomplished mainly by neighbour women known to the pregnant woman and who had experience in childbirth. These "midwives" served as birth attendants, nurses, and housekeepers. Their training was often acquired informally through observation and participation; some also had training through a more formal apprenticeship. Midwifery at this time was far from an organized profession. It existed largely as a local system of women helping other women in time of need, and payment was usually in kind (Mason, 1987). In both the U.S. and Canada, this system of lay midwifery was eclipsed due to various influences, including the rise and opposition of many within the medical profession, concomitant state regulations, changes in cultural perspectives on childbirth, and the inability of midwives to organize (Biggs, 1983; Buckley, 1979; Connor, 1989;

Integrating nurse-midwifery into U.S. and Canadian health care Donegan, 1978; Ehrenreich and English, 1973; Kobrin, 1966; Leavitt, 1986; Litoff, 1978; Mason, 1987, 1988; Rushing, 1991; Wertz and Wertz, 1977). Midwifery, however, was far from completely eliminated. In a few districts in the U.S. and Canada nurse-midwifery was beginning to take form as a countermovement to the decline of the traditional lay midwife.

MIDWIFERY IN THE U.S.

Nurse-midwifery In the U.S., the nurse-midwifery movement arose during the early 20th Century out of the efforts of concerned groups of women who lobbied the government to establish programs for better maternity and infant care. One of these women, Mary Breckenridge, was impressed by the quality of care delivered by nurse-midwives in Britain and was convinced that the nurse-midwife was the person to deliver better quality maternity and infant care in the U.S. (Hogan, 1975).* Other women within the Public Health Movement supported the idea of nurse-midwifery, as they felt it would be easier to convince medical authorities that trained nurses could deliver women more safely than could the few remaining lay midwives. The first nurse-midwifery practices were established around 1920, one in a poor, inner-city area of New York City, the Maternity Center Association (MCA), and the other in the remote mountains of Kentucky, the Frontier Nursing Service (FNS) (Hogan, 1975). British-trained nurse-midwives and American public health nurses sent to Britain for midwifery training were recruited to work in these practices, as it was not until 1932 that the first school for nurse-midwives in the U.S. was established. Three other schools opened within five years. These early nurse-midwives were quite unlike the rapidly disappearing lay midwives and nurse-midwives strongly emphasized this difference. Unlike the stereotypic old, illiterate black or immigrant granny women, nurse-midwives were predominantly young, white, middle-class educated professional women who had achieved some support by the state to practice among the urban and rural poor (i.e. where medical services were unavailable). This movement was based on the willingness of nursemidwives to go where physicians did not want to go, and as Flanagan (1986) noted, there was a deft*Although midwifery in Britain existed as a profession independent from nursing, elite midwives (most of whom had prior nursing training) were struggling to make nursing training a prerequisite to registration and thus exclude "untrained" midwives from licensure (see Heagerty, 1990). It is likely that American reformers wanted to make a fresh start by lobbying for nurse-midwifery from the beginning.

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nite "missionary strain" that characterized the early practice of nurse-midwifery. Nurse-midwifery in the U.S. did not develop without significant divisions. These largely stemmed from the ideological disagreement between the FNS and the MCA regarding the autonomy of the nurse-midwife. Given that FNS nurse-midwives were independent by default, as there were few doctors in the mountains of Kentucky and fewer who would treat the poor, the FNS nurse-midwives tended to regard the nurse-midwife as an independent health care provider. MCA nurse-midwives, who had greater access to physician services, regarded the nurse-midwife more as an assistant to physicians (Langton, 1991). These two groups in turn developed separate professional organizations: the American Association of Nurse-Midwives (AANM) established in Kentucky in 1941; and the American College of Nurse-Midwifery (originally a special section of the National Organization for Public Health N u r s e s - - N O P H N - - w h i c h later developed into a separate professional organization in 1954) (Hogan, 1975). This division, it has been argued, partly explains the slow development of the occupation (Langton, 1991). It was not until 1969 that the American College of Nurse-Midwifery and the A A N M joined to create the American College of Nurse-Midwives (ACNM). The main agenda of the ACNM was to improve the legal status of nurse-midwives (Litoff, 1978). In the 1960s and early 1970s nurse-midwives experienced an increase in demand for their services from middle-class clients, due in part to the development of the Natural Childbirth Movement and the proclaimed physician shortage. This created a more socially and economically powerful clientele than before, as prior to this time nursemidwives worked almost exclusively among the poor. The number of nurse-midwives increased rapidly and there was a consequent increase in clinical opportunities and training programs (Rooks and Fischman, 1980). Practices were not only expanding, they were also increasingly moving from their clients' homes to tertiary care centres, reflecting the general trend in the U.S. (Devitt, 1977; Teasley, 1983). Training programs also moved from public health facilities to mainstream, university-based nursing and medical educational centres (Teasley, 1983). During the 1960s nurse-midwives became more involved in state-sponsored maternal-infant programs. The outcome data from these projects, in combination with the excellent outcome data from the FNS and MCA, increased the legitimacy of nurse-midwifery. Nurse-midwives came to be valued by some state agencies for their safe obstetrical outcomes, potential cost-effectiveness and patient satisfaction (Matthews and Zadak, 1991). Along with increased state support, nurse-midwives came to acquire more acceptance from a few physicians. For

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many years the ACNM worked diligently to garner the support of physicians for backup services and their policy statements strongly endorsed the necessity of physicians' cooperation, consultation and backup (Sharp, 1980; Tom, 1982). The result of these efforts was the "tacit approval" of the AMA. The most significant vote of confidence came from the American College of Obstetricians and Gynecologists (ACOG) when they issued a joint statement in 1971 with the ACNM, officially recognizing nurse-midwives as members of the obstetrical care "team". Nurse-midwives as "team" members were seen to be able to manage "normal" labour and delivery under the direction and supervision of an obstetrician-gynaecologist (Langton, 1991). Although a few physicians came to support nurse-midwifery in specific circumstances, many do not. The American College of Family Physicians, for example, strongly opposes nurse-midwifery, arguing that nurse-midwives could displace family physicians from normal maternity care (McCormick, 1983). Resistance towards nurse-midwifery expressed by individual physicians, medical societies, departments of obstetrics and gynaecology, physician-controlled malpractice insurance companies and medical practice boards includes refusals of practice privileges, unreasonable restrictions on practice, unreasonable demands for liability insurance, misrepresentations of nursemidwifery practice to the public, and professional ostracism of those physicians who collaborate with nurse-midwives (Tom, 1982; McCormick, 1983). In several cases certified nurse-midwives (CNMs) have responded with suits claiming restraint of trade (Kammerer, 1992; Teasley, 1983). Despite this opposition, state legislation regulating and legalizing the practice of nurse-midwives has spread. In 1968, only two states had licensure laws for nurse-midwives (Crawford, 1968), whereas currently all states have legislation recognizing the practice of nurse-midwifery (Barickman et al., 1992; Bidgood-Wilson et al., 1992; Evenson, 1982). Fifteen states have legislation expressly for nursemidwives, while others have special legislation under the practice of nursing. Some nurse-midwives were also successful in attaining third-party reimbursement, due in large part to the argument that nurse-midwifery is a cost-effective form of care (Tom, 1982). As a result of this increased recognition, the number of nurse-midwives in the U.S. doubled between 1968 and 1976 from approximately 800 to 1700 (Evenson, 1982). Thus, organized nurse-midwifery in the U.S. has been able to gain a degree of acceptance and partial integration into the American system of health professions. *For the sake of simplicity, the term "lay midwifery" will be used in this paper to refer to independent, directentry, non-nurse-midwives.

Lay midwifery The late 1960s and early 1970s not only marked a rise in nurse-midwifery, they also saw a resurgence of interest in the idea of lay midwifery.* This interest stemmed from the consumer backlash against medicalized childbirth promoted by the counterculture Home Birth Movement. Home birth proponents argued that birth is a normal life process that should take place naturally within the supportive, familiar environment of one's home, and should not be a medicalized, mechanized and technologized event under the direction of a physician in a hospital (Reid, 1989; Hosford, 1976). Within this counterculture birth environment, some women who had had a home birth or who had attended a home birth were invited to attend others, sometimes acting as assistants. These birth assistants were like traditional lay midwives in that they were usually friends or neighbours who had experience with birth, had observed some births and had begun to help out at births; their training was derived from experience and participation in the home birth culture (Mason, 1988; McCool and McCool, 1989). But unlike the old lay midwives, these new lay midwives were more likely to be young, white, educated and from middle-class backgrounds, and have a clientele with similar racial and class backgrounds. Originally, these birth helpers did not regard what they were doing as a career or a profession, but the demands on their expertise and time from clients and apprentices grew beyond their close group of friends. In response to this increased demand, these birth helpers' practices became more formalized. They began to organize into small groups to share information, expand their educational repertoire and to get social support from others doing this kind of work (Reid, 1989). Rapidly expanding lay midwifery practices were regarded with increasing concern by many physicians. Physicians tended to dislike lay midwives even more than nurse-midwives because their concerns over competition were compounded with concerns about the safety of home births and lack of formal training of lay midwives. Because independent midwifery practice was officially illegal in most states, several physicians concerned with the encroachment of lay midwifery practices laid charges against lay midwives for practising medicine without a license. This resulted in a flurry of trials against midwives in the 1970s and 1980s. In response to these trials, lay midwifery organizations, which had originally formed for self-education and social support, formalized around the issue of legalization and third-party reimbursement (Sullivan and Weitz, 1988). Concurrent with this legal harassment of lay midwives, women's health activists became increasingly concerned with the fate of midwives. Although the women's movement was originally engaged in

Integrating nurse-midwifery into U.S. and Canadian health care "freeing women from the shackles of childbirth and mothering" (Barrington, 1985, p. 151) by lobbying for access to contraception and abortion for women (Ruzek, 1978), some activists later began to focus on the oppression of women through maternity care practices (Arms, 1975; Corea, 1977; O'Brien, 1981; Rothman, 1981). Midwifery soon came to be seen as a symbol of women controlling the reproduction process (Rothman, 1989) and trials against lay midwives a "feminist cause celebre" (Ruzek, 1978). Efforts to legalize lay midwifery, some more successful than others, were initiated in several states (DeVries, 1982; Sullivan and Weitz, 1988; Tjaden, 1987). Lay midwives have also been successful in securing insurance reimbursement from a few (though not from the major) companies based on the argument that people are entitled to "alternative" health care.* General trends across the efforts to secure legislation and reimbursement are that most midwives and consumer and feminist groups strongly advocated legislation, and physicians, nurses and nurse-~aidwives opposed it. Certified nurse-midwives, many of whom have only recently been granted legal recognition, in particular did not wish to see another licensed practitioner with less training and more autonomy achieve recognition (Tjaden, 1987). In fact, in many of the states where licensing provisions have been set up for nurse-midwives, existing lay midwifery licensure provisions were simultaneously repealed (Evenson, 1982). It is during the efforts to legally recognize lay midwives that the division between lay and nurse-midwifery has been exacerbated. W h o are the "real" midwives?

Lay midwives differ from nurse-midwives mainly in terms of the content and context of their educational background and in their relative recognition and legitimacy. New lay midwives are educated in a direct-entry format often apprenticing with currently practising lay midwives attending home births. Nurse-midwives, on the other hand, are educated first as nurses and later specialize in midwifery, usually within an institutional setting. Furthermore, whereas nurse-midwifery is legalized in all 50 states, lay midwifery is currently legal in 32 states and regulated by state governments in 18 states (Barickman et al., 1992; Bidgood-Wilson et al., 1992; Midwifery Communication and Accountability Project, 1994). Stemming in part from these differences in their education and legitimacy, there are important differences in their views regarding relations with the medical profession and the requirement of nursing education for the practice of midwifery. *Lay midwives may not think of themselves as being in the same category as other "alternative" practitioners, but many have come to realize that this is exactly the way much of the public regards them.

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Nurse-midwives tend to work in collaboration with physicians (Haas and Rooks, 1986). This collaborative relationship was secured with the ACOG/ A C N M Joint Statement in 1971, and has been strengthened by subsequent agreements in 1975 and 1982 (Langton, 1991). Many nurse-midwives are unwilling to jeopardize the provisional acceptance they have recently garnered from some members of the medical profession by aligning themselves with the more radical home birth/lay midwifery movement. It is noteworthy that soon after the ACNM made its Joint Statement with the ACOG in 1971, it made an official statement favouring hospital over home births (American College of NurseMidwives, 1973). Lay midwives are generally less collegial with members of the medical profession than nurse-midwives. Because of the close association with physicians, nurse-midwives have been depicted by some lay midwifery supporters as an extension of the oppressive medical establishment (Arms, 1975; Rothman, 1981). These concerns concur with others who argue that the move by nurse-midwives into the mainstream health care system increased the accessibility, professional status, and work opportunities of nurse-midwives, but at the same time represented a significant departure from the nursemidwife being "in charge" (Sharp, 1980). The greater acceptance nurse-midwives garnered from physicians had a price: less autonomy. They were not independent, primary care practitioners but part of a "'team", a team with a leader, the physician. Nurse-midwives' scope of practice and access to clients were largely controlled by physicians. Moreover, in most states nurse-midwifery is not self-governing but is subsumed under either the board of medicine or nursing, and there has been a significant lack of nurse-midwife representation (Evenson, 1982; Flanagan, 1986). Lay midwives and their supporters also point to problems with a reliance on nursing training in that it links nurse-midwives into a history of subordination by physicians (DeVries, 1986) and substantially reduces the pool of potential applicants to nurse-midwifery educational programs. Some nurse-midwives, however, argue that their nursing training is an important and essential element for the wider scope of practice necessary in many settings (Rooks, 1983). The division between lay and nurse-midwives, however, is not clear-cut; increasingly, there has been a convergence between the two groups. For example, some nurse-midwives have come to wonder whether they were becoming more mainstream (Lubic, 1976) and a few began to question interdependence with physicians (Flanagan, 1986; Sharp, 1980). Other nurse-midwives expressed acceptance of a direct-entry form of midwifery, arguing that midwifery practice does not require prior training in nursing (Burst, 1977). This group has advocated multiple routes of entry and sites of midwifery prac-

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tice (Lubic, 1976; Burst, 1981). A few nurse-midwives even became involved in the Home Birth Movement and together with lay midwives developed a national* organization representing all midwives, the Midwifery Alliance of North America (MANA), in 1982 (Schlinger, 1992; Ventre and Leonard, 1982). The M A N A ' s efforts to unify the profession of midwifery met with opposition from the ACNM, which was concerned that an alliance with nonnurse-midwives would tarnish the CNM's professional image and jeopardize recent gains made by the profession (Shah, 1982). The animosity between the ACNM and M A N A was played out on the international scene when M A N A ' s bid to become a recognized member organization of the International Confederation of Midwives (ICM) in 1984 was opposed by the ACNM. This opposition, although unsuccessful, caused many midwives, both nurse- and lay, to regard the ACNM as an elitist organization discriminating against lay midwives (Ventre and Leonard, 1982; Walsh and Jaspan, 1990). There has also been a move towards greater acceptance of credentialization amongst lay midwives with the emergence of a national exam for independent midwives, the North American Registry Examination for Midwives (NAREM), developed in part by M A N A representatives in 1991 (Garland Spindel, 1995). One of the main reasons behind the development of this exam was to enhance the recognition of "direct-entry" midwifery. Recently, the ACNM has attempted to portray a more tolerant stance towards the development of direct-entry midwifery when it made an official statement in 1990 recognizing direct-entry midwifery educational programs as augmenting nurse-midwifery programs (Muzio, 1990). Despite this formal statement of mutual respect (which some argue is simply rhetoric), the political reality is that organizations representing nurse-midwives and lay midwives are still at odds. Thus, midwifery in the U.S. is a profession divided, with lay midwifery being practised predominantly in home settings and nurse-midwifery being practised predominantly in institutional settings, and with lay midwifery having less recog*The MANA is actually a transnational organization encompassing not only the United States but Canada and Mexico as well. tCaution must be taken when comparing these statistics, however, as there is likely to be an under-reporting of the number of lay midwives and lay midwiferyattended births due in large part to the precarious legal context of lay midwifery practice in many states. +Midwifery in the French-speaking province of Quebec followed a somewhat different historical trajectory than that in the English-speaking provinces; this discussion will focus on the development of midwifery in the English-speaking provinces of Canada.

nition than nurse-midwifery. This is reflected in the number of midwives practising, which according to 1994/1995 estimates is between 1500 and 1800 lay or direct-entry midwives (Garland Spindel, 1995), and 4000 nurse-midwives (American College of Nurse-Midwives, 1995). It is also reflected in the number of midwifery-attended births, which has remained at approximately 0.2% of all births for lay/direct-entry midwives, whereas the number of nurse-midwifery-attended births is 4.7% (up markedly from 1% in 1975 and 3.8% in 1988) (Declerq, 1992; Garland Spindel, 1995).t

MIDWIFERY IN CANADA

Nurse-midwifery Similar to the U.S., the development of nursemidwifery in Canada:~ arose from concerns by organized philanthropic women's groups, such as the National Council of Women (NCW), over maternal and infant health. In 1897 the NCW attempted to establish a program of lay midwifery care for rural women through the Victorian Order of Home Helpers, but was unsuccessful due in large part to the opposition of the medical and nursing professions (Buckley, 1979; Mason, 1987). Nurses were recruited instead and the Victorian Order of Nurses (VON) was created. These nurses, however, were strictly forbidden from providing midwifery care in all but emergency situations. Despite these official limitations, many VON nurses covertly attended numerous births. The VON attempted to renew the idea of nursemidwifery throughout the early 1900s and in fact sent several nurses to investigate the training and practice of nurse-midwives in the U.S. (Mason, 1987). None of these efforts came to fruition. Interest in nurse-midwifery did not arise again until the 1920s when the Red Cross entered the field of public health by establishing outpost hospitals in Northern Ontario. Although the first of these hospitals were run by physicians, as the number of stations increased, more of them were being staffed solely by nurses. Many of these nurses were practising midwifery, often without any formal training. Estimates were that nurses were spending 80% of their time on maternity, pre- and post-natal care and delivery (Mason, 1987). This maternity work of the Red Cross nurses, however, was never officially referred to as midwifery. In the end, the Red Cross was never able to recruit enough nurses to make this lonely, tiresome and unrecognized form of nurse-midwifery viable. Concurrent with the efforts of the Red Cross in Northern Ontario, the United Farm Women of Alberta (UFWA) and United Farm Men of Alberta (UFMA) lobbied the provincial government to supply midwives to remote areas of the province in response to the scarcity of physicians during World

Integrating nurse-midwifery into U.S. and Canadian health care War I (Mason, 1987). This need was originally met by British-trained midwives, but the U F W A and U F M A also lobbied for a local training program. Finally, after decades of lobbying, a three-month program for public health nurses entitled "Advanced Practical Obstetrics Course for District Nurses" was established in Edmonton in 1944 (Hurlburt, 1981). The word "midwife" was never used in connection with the program. Other educational programs were developed much later in Halifax, Nova Scotia in 1967 for nurse practitioners and in St. Johns, Newfoundland in 1978. The St. Johns program was boldly titled "NurseMidwifery". These latter two programs reflected the expansion of nurse-midwifery practice opportunities in the Canadian North. The development of federal health programs in the North during the late 1950s and early 1960s resulted in an expansion of nursing stations and an increase in nurse-attended births. Many of the nurses staffing these stations were British-trained nurse-midwives, but some were graduates from Canadian "nurse-midwifery" programs. There was little opposition from the medical profession to the development of this unofficial nurse-midwifery in the North because it was largely directed towards native women, and because many physicians did not wish to practice in the North (Mason, 1987). Federal health policy changes during the 1970s resulted in increased evacuation of pregnant native women to physician-attended facilities in Southern settlements. This resulted in decreased opportunities for these "nurse-midwives" to practice and an overall decline of nurse-midwifery in the North. Although the practice of nurse-midwifery in the North was on the decline, there was a resurgence of interest in the concept of nurse-midwifery in other areas of the country in the early 1970s. Advocates of nurse-midwifery argued that nurse-midwives could function effectively in urban as well as remote settings (Hays, 1971; Hurlburt, 1981). Several regional nursing associations also began to promote the notion of nurse-midwives who, as part of the obstetrical care team, could guide the normal pregnant woman through all aspects of the maternity cycle (Hurlburt, 1981). State interest in nurse-midwifery also became evident in the 1970s. A government-appointed committee set up to examine the delivery of health care at the advent of universal medical care insurance in Ontario (the Committee on the Healing Arts), for example, recommended the integration of nursemidwifery into the Ontario health care system (Ontario Committee on the Healing Arts, 1970). The Committee foresaw nurse-midwives as clinical specialists in nursing who would work in the hospital setting or outpatient clinic, under the general direction of a physician. Following this recommendation, the Registered Nurses Association of Ontario (RNAO) made an official statement in 1972

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supporting the development of nurse-midwifery in Ontario. The RNAO then proposed negotiations with the College of Nurses of Ontario, the nursing regulatory body, the medical profession and the Ontario government regarding enabling legislation. These negotiations, however, never came to fruition. Concurrent with these efforts by the RNAO, several nurses in the province who had midwifery training from other jurisdictions had a similar agenda of integrating nurse-midwives into the health care system. These "nurse-midwives', many of whom were working as public health nurses or as labour and delivery room nurses, created the Ontario Nurse-Midwives Association (ONMA) in 1973 and later became a special interest group of the RNAO. The membership of the O N M A ranged from 60 to 75, though it was estimated that there were 5000-7000 nurses registered with the nursing college who had prior midwifery training (Eberts et al., 1987). These "nurse-midwives" never actually practised midwifery due mainly to concerns about the possibility of losing their nursing license. Representatives of the O N M A were unclear about the role nurse-midwives would play in the health care system, and throughout the mid to late 1970s they consulted widely with various women's groups, health policy makers, and nurse-midwives from the U.S. about implementation possibilities. As most members were British-trained nurse-midwives, they would have preferred to have midwifery in Canada follow the British model where midwifery was regulated as a health profession separately from nursing. Given medical opposition to such a proposal, however, O N M A members felt that it would be politically easier to pursue the American nurse-midwifery model.

Lay midwifery Concurrent with these nurse-midwifery initiatives in Canada came a "rebirth" of the lay midwifery concept, stemming in part from the influx of ideas from the U.S. The development of lay midwifery and the broader Home Birth Movement in Canada began in British Columbia, largely because it was the counterculture centre of Canada (Barrington, 1985). It was the province of Ontario, however, where midwifery would first become officially recognized. In the late 1970s and early 1980s lay midwives in Ontario worked predominantly as "birth educators" and "birth attendants" assisting the few physicians who attended home births. Like American lay midwives, their training was mainly through participation in home births, informal reading, and apprenticeships. A few had midwifery training from other jurisdictions. Similar to lay midwives in the U.S., these "birth assistants" were paid directly by their clients, and were practising without formal legal recognition (Bourgeault, 1996; Fynes, 1994).

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In response to their vulnerability to charges of practising medicine without a license, which resulted in trials in the U.S. and Canada, Canadian lay midwifery organizations, as in the U.S., formalized around the issue of legalization. Ontario lay midwives formed the Ontario Association of Midwives (OAM) in 1981, and later became members of the newly developed Midwifery Alliance of North America (MANA). One of the mandates of the OAM was to achieve legal recognition for lay midwives and increase accessibility to midwifery care by becoming incorporated into and funded by the provincial health care system. Concerns over their vulnerability came to a head in 1982 and 1983 when the College of Physicians and Surgeons of Ontario (CP50), the medical regulatory body, strongly discouraged physicians from attending or providing backup support for planned home births. The decision did curtail the activities of physicians who attended home births but did not reduce the demand for home birth; hence, lay midwives began to take on clients independent of physicians. Thus, unlike the nurse-midwives of the ONMA, lay midwives in Ontario were actively practising midwifery. Estimates of the number of lay midwives practising in the mid 1980s range from 50 to 70 delivering 600 1500 babies per year (approximately 1% of all births in Ontario) (Baker, 1989; Van Wagner, 1988).*

The unification of midwives in Ontario In 1983, the provincial government of Ontario initiated a Health Professions Legislation Review (HPLR), which was to examine the regulation of all health professions in the province. Among the over 100 established and would-be health professional groups contacted by the HPLR committee were the lay midwives represented by the OAM and the nurse-midwives represented by the ONMA, Representatives from the OAM and O N M A subsequently met to discuss their response to the HPLR and the possibility of making a single submission to the committee. The leaders of the two organizations decided that because of the philosophical compatibility of the two groups, which focused on achieving better maternal and infant care, a single submission to the HPLR representing the "Midwifery Coalition" would be made. In its submission to the HPLR the Coalition strongly expressed a desire to become included as a newly regulated health profession in Ontario and to have their services covered under the provincial health insurance plan. *As was the case for American lay midwifery statistics, caution must be taken in assessing the accuracy of these statistics as there is likely to be an under-reporting of the number of lay midwives and lay midwiferyattended births due in large part to the precarious legal context of lay midwifery practice in Ontario.

Both groups felt that unification would create a larger and more forceful midwifery front. At the meetings between these two groups, O N M A representatives were impressed by the political will of the lay midwives to challenge the system and their commitment to midwifery by practising in a less than ideal legal environment. In contrast, nurse-midwives' initial enthusiasm with pursuing the possibility of implementation back in the 1970s had gradually faded, and many members of the O N M A were not politically active in challenging the system. Through joining forces with lay midwives, some nurse-midwives also envisioned achieving a more autonomous form of midwifery with a potentially larger scope of practice than had been their original aim. They would also benefit from the consumer support which lay midwives had attained. Consumer and public support would prove to be essential in convincing the government that midwives' desire to become incorporated into the health care system was due to more than just the selfinterests of a would-be professional group. As for the lay midwives, they realized, as nursemidwives had, that the American nurse-midwifery model would be a more acceptable form of midwifery practice than lay/independent midwifery to both nursing and medical professions (as evidenced by these professions' responses to the Coalition's submission to the HPLR), hence more easily incorporated into the health care system. By unifying with nurse-midwives and "co-opting" them into the lay midwifery model (not a difficult task as nurse-midwives viewed this model positively), lay midwives would have a better chance of challenging the viability of the nurse-midwifery model. Thus, following the preparation of the HPLR submission, the nurse- and lay midwives in Ontario merged their organizations (OAM and ONMA) into a unified organization called the Association of Ontario Midwives (AOM) in 1984. The main goals of the AOM became achieving legal status for a unified midwifery as a self-regulating profession (i.e. separate from nursing and medicine), and to become incorporated into the publicly funded health care system.

Integration of midwifery into the Ontario health care system During the early 1980s, there was a great deal of media attention focused on midwifery. Consumer supporters of lay midwifery organized as the Midwifery Task Force of Ontario (MTFO) and staged several demonstrations around the CPSO's statement against home births and the ongoing HPLR process. The greatest amount of media attention came from the highly publicized coroner's inquest into the death of a baby boy after his midwife-attended home birth in 1985. The coroner decided early on that the inquest was not only to deal with the baby's death but was

Integrating nurse-midwifery into U.S. and Canadian health care to be a public inquiry into the state of midwifery in Ontario. The Crown, largely dominated by the medical profession, brought in several expert witnesses to testify that the blame for the baby's death lay with the midwives. The midwives' defense also brought in witnesses to argue that the midwives' management of the case was in order and that the baby's death was unavoidable. While both sides agreed that midwifery should be regulated, they proposed different forms. The Crown, which had come to realize that physicians were increasingly opting out of obstetrics (as was happening earlier in the U.S.), conceded to a nurse-midwifery model with practitioners regulated under the College of Nurses. Midwives and their supporters pushed for self-regulation of midwifery. The jury ultimately did recommend the regulation and integration of midwifery into the Ontario health care system with temporary regulation by the College of Nurses and the later establishment of a self-regulatory body. These recommendations were considered seriously by the HPLR committee, as they were about to make their report to the provincial government regarding which health professions would be considered for legislation. The HPLR recognized that unregulated midwifery could be construed as harmful to the public. Given that "possible harm to the public" was one of the main criteria the HPLR used to make decisions regarding legislation, the committee recommended to the provincial Minister of Health that midwifery become a regulated health profession. Following this recommendation, the Minister of Health announced in January 1986 that midwifery would indeed be incorporated into the Ontario health care system and recognized as a regulated health profession. How midwifery was to become regulated and integrated was to be investigated by a government-appointed Task Force on the Implementation of Midwifery in Ontario. The Task Force was headed by a feminist lawyer, the head of the HPLR, a female family physician and a nursing researcher who had training in the U.S. as a nurse-midwife. All members were arguably pro-midwifery. Two years of research and provincial, national and international consultation went into the over 400-page report that was presented to the government late in 1987 (Eberts et al., 1987). Throughout this process the AOM and the M T F O were actively involved in ensuring that the Task Force was made aware of all available information (international policies, research, etc.) that would support the kind of midwifery they advocated: self-regulated community midwifery. In con*The education ate level to mainstream negotiations leges.

program was promoted at the baccalaureincrease midwives' legitimacy within the maternity care system, helping ease the around securing hospital admitting privi-

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trast, many within the nursing and medical profession continued to recommend the implementation of a nurse-midwifery model. Midwives' and consumers' efforts were ultimately successful. The Task Force recommended that midwifery be implemented as a self-regulating profession with its own college, independent of both medicine and nursing. They also recommended that midwives practice as primary caregivers in both home and hospital, and that there be multiple routes to midwifery education, nursing not being a prerequisite. Strong state support for the implementation of midwifery continued following the Task Force recommendations. In 1988, the Minister of Health appointed a Midwifery Implementation Coordinator, who was to oversee the implementation of the Task Force recommendations. The following year, the Minister appointed and funded an Interim Regulatory Council on Midwifery as the precursor to the midwives' selfregulatory body, the College of Midwives. Numerous other committees were appointed and funded by the provincial government to follow up and carry out the recommendations of the Task Force report. This included setting up hospital admitting privileges and a funding mechanism for midwives to ensure accessibility to midwifery care. The government also helped develop a direct-entry (i.e. non-nursing) baccalaureate program for midwifery education.* State support for the midwifery initiative was forthcoming for two main reasons. First, the argument that midwifery was a cost-effective form of care suited the state's current efforts regarding the rationalization of health care. Second, the government could also be publicly viewed as supporting women's issues and promoting women's rights. It is also not insignificant that the Minister of Health at this time and subsequent Ministers of Health were women who strongly supported the midwifery movement. In November 1991 the practice of midwifery in Ontario officially became legal. One year later currently practising midwives had their training updated and were assessed for licensure through a one-time only, one-year assessment program with faculty from the international midwifery community. In September 1993 the direct-entry baccalaureate educational program for midwifery was established in Ontario with state funding, admitting 27 applicants. As of 31 December 1993, midwifery officially became a self-regulating health profession in Ontario. Approximately 60 government-funded midwives became fully licensed to attend both home and hospital births. Thus, the unified midwifery profession has, with state endorsement, proceeded to be incorporated into the health care system in a uniquely "midwifery friendly" way, consolidating aspects of both nurse- and lay midwifery

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practice into a self-regulating community midwifery model. DISCUSSION

There are several parallels in the development and organization of midwifery in Canada and the U.S. nurse-midwifery services in both countries were originally often provided by British-trained nurse-midwives and in areas where physicians did not practise. Lay midwifery emerged from similar social movements in both countries. The practice of nurse-midwifery is regarded with less opposition from medicine than the practice of lay midwifery. The prosecution of lay midwives in courts and at coroners' inquests created a platform through which midwives could openly promote the legitimacy of their work, but it also revealed the precarious legal situation in which practising midwives found themselves (Arms, 1975; Barrington, 1985; Burtch, 1988; McCool and McCool, 1989). There is also a trend in both countries toward increasing state support for midwifery (nurse-midwifery more so than lay midwifery in the U.S.). There are, however, some important differences in the practice, organization and legitimacy of midwifery in the U.S. and Canada. Midwifery in the U.S. is divided between nurse- and lay midwives who have separate and more limited scopes of practice than do midwives who form a single profession in some Canadian provinces. This difference could be due in part to the introduction of nurse-midwifery in the U.S. system of health professions before the resurgence of lay midwifery. Nurse-midwifery in Canada never became officially incorporated into the health care system, and therefore "nurse-midwives" had less of an incentive to attempt to exclude lay midwives. Differences in the system of health professions, relations between health professions and the state, and differences in the relationship of feminism to midwifery and the state in the U.S. and Canada can also be argued to have a strong effect on the different state of midwifery in these two countries. First, physicians in the U.S. and Canada were, and are still, increasingly opting out of practising obstetrics. In the U.S. opting out is due mainly to increasing malpractice suits and consequently increasing malpractice insurance premiums for physicians practising obstetrics. According to a 1987 and 1994 poll, reasons Canadian physicians give for opting out of obstetrics are an interference with personal and professional life, as well as higher liability insurance fees (as in the U.S., even though there are few cases brought against physicians in Canada) (Lofsky, 1995). Opting out occurred sooner in the U.S. (in the early 1970s) than it did in Canada (the mid 1980s, around the time the malpractice insurance system was revised). It could he argued that this time difference in opting out, coupled with the fact

that there are fewer general practitioners in the U.S. to begin with, resulted in an earlier demand for midwifery services in the U.S. than in Canada. The need for maternity care attendants in the U.S. was met by nurse-midwives as they were more organized than lay midwives, who at that time were just beginning to enter the scene. This in turn resulted in nurse-midwives becoming more institutionalized in the American system of health professions before a resurgence of interest in lay midwifery developed amongst white, middle-class women. Thus, nursemidwives in the U.S. seized the opportunity to capitalize on a "vacant jurisdiction" (Abbott, 1988) of normal childbirth attendance, and in turn practised dual closure strategies, usurping the role of physicians and excluding lay midwives from practising within this domain (Witz, 1990, 1992). In Canada nurse-midwifery did not develop as early as it did in the U.S. and never attained the legitimacy that was garnered in the U.S. This helped enable the unification of nurse- and lay midwives, as both groups had more to gain than lose by seeking integration into the health care system together; there were few vested interests to overcome. One should not confuse historical description with explanation. That is, although time differences in the development of nurse-midwifery in Canada and the U.S. are an important factor, it can explain only part of the differences between the two countries. It does not explain why nurse-midwives arose in Canada, given that there was no vacant jurisdiction for nurse-midwives at the time. It also does not answer the question why midwives in Canada were able to achieve legitimation of a more autonomous form of midwifery with a larger scope of practice than possible in the U.S., and a related question, why lay midwives in the U.S. sometimes are able to achieve state legitimation despite opposition from nurse-midwives and physicians. In order to answer these questions, one must examine the larger influence of the state on the system of health professions. In Canada, the state has a greater role in health care not only as regulator of health professions but as third-party payer of medical services. In the U.S. the state is less involved in managing the costs of health care, with the exceptions of Medicare and Medicaid. It could be argued that in turn the medical profession in Canada has less power vis-d-vis the state within the system of healtl{ professions than it does in the U.S. When one examines the role of the Canadian state in health care, and more specifically its position visCt-vis midwifery, the two general roles of the state--capital accumulation and legitim a c y - h a v e to be taken into consideration (Simmons and Keohane, 1992). In its role of maintaining capital accumulation, the state is increasingly involved in rationalizing health care and in turn supports midwifery, as it is believed to be a cost-effective form of maternity care. Although

Integrating nurse-midwiferyinto U.S. and Canadian health care there is surprisingly little evidence in support of this view (Cherry and Foster, 1982; Rooks, 1986; Reid and Morris, 1979), midwives are generally regarded as less expensive to educate than physicians, they can be paid less, and they also use less expensive technology and less interventions in managing childbirth than do physicians (Evans, 1981; Fooks and Gardiner, 1986). Lay or community midwifery could be argued to be even more economically rational than nurse-midwifery because it does not require prerequisite nursing training, and because community midwifery practice involves home birth, an even less expensive form of care than a low intervention hospital birth. Thus, it could be argued that in Canada the state sought to implement the least expensive form of midwifery care in order to maintain its rationalizing objective. Given greater state power over health care in Canada, it was able to do so. In supporting midwifery the state is also responding to women's issues, which is important to the state in maintaining its legitimacy vis-6-vis a female electorate. From the state's perspective implementing midwifery could be seen as "killing two birds with one stone"; it is potentially cutting health care costs and at the same time appears to be responding to women's issues. This is where midwives' sponsorship by feminist activists makes an impact. Given that midwifery developed later in Canada than the U.S., it was able to draw on a greater mass of support from politically active feminists, many of whom had by that time begun to change their perspective regarding the importance of childbirth to the women's movement.* The unification of midwives in Canada helped to consolidate this support for one form of midwifery--community midwifery whereas in the U.S., feminist support for midwifery may be divided between the two forms. This is compounded by what might be considered a comparative lack of support for the issue of maternity care rights generally by the women's movement in the U.S. than is the case in Canada. Thus, there is stronger and more unified support for midwifery from politically active feminists in Canada than in the U.S. This situation takes on even more importance when one considers the argument that women's groups have a greater impact on the state than on civil society due to the state's necessity to maintain its own legitimacy (Armstrong and Armstrong, 1990; Witz, 1992). This is especially true when the Ministers of Health are women who strongly support women's initiatives, as was the case in Ontario throughout the midwifery implementation process. Because of the organization of the health care sys*They argued that women should not only be in control of whether they have babies but also of how they have their babies.

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tem in Canada, midwives sought legitimacy directly from the state. With less state influence in the health care system in the U.S., lay and nurse-midwives must seek legitimacy through the medical profession in civil society, such as through the sponsorship of elite, influential physicians. This is easier for nurse-midwives to accomplish than for lay midwives. Thus, there was a convergence of influential factors which, added together, created a more conducive environment for midwifery legislative efforts in Canada than in the U.S. Specifically, Canadian midwives enjoy more unified support from politically active feminists who tend to have a greater impact on a state, which in Canada is more influential in the system of health professions. Midwifery in the U.S. had, and continues to have, more barriers to overcome. Acknowledgements--We would like to acknowledge the contributions to this manuscript from David Coburn, Mike Saks, Gerry Larkin, Louis Orzack, Cecilia Benoit, Evan Willis, and to the three anonymous reviewers. This research was supported in part by the National Health Research and Development Program and the Social Sciences and Humanities Research Council of Canada through doctoral fellowships to Ivy Bourgeault and by the University of Toronto through a Simcoe Special Fellowship to Mary Fynes. An earlier version of this paper was presented at the International Sociology Association Conference on the Professions, Paris, April 1994.

REFERENCES

Abbott, A. (1988) The System of Professions. University of Chicago Press, Chicago. American College of Nurse-Midwives (1973) American College of Nurse-Midwives Statement on Home Births.

American College of Nurse-Midwives, Washington, DC. American College of Nurse-Midwives (1995) Membership Estimates. American College of Nurse-Midwives, Washington, DC. Arms, S. (1975) Immaculate Deception. A New Look at Women and Childbirth in America. San Francisco Book Company, San Francisco. Armstrong, P. and Armstrong, H. (1990) Theorizing Women's Work. Garamond, Toronto. Baker, M. (1989) Midwifery: A New Status. Background Paper, Library of Parliament, Ottawa. Barickman, C., Bidgood-Wilson,M. and Ackley, S. (1992) Nurse-midwifery today: a legislative update, part II. Journal of Nurse-Midwifery 37(3), 175-209. Barrington, E. (1985) Midwifery is Catching. NC Press, Toronto. Bidgood-Wilson, M., Barickman, D. and Ackley, S. (1992) Nurse-midwifery today: a legislative update, part I. Journal of Nurse-Midwifery 37(2), 96-140. Biggs, C. L. (1983) The case of the missing midwives: a history of midwifery in Ontario from 1795 1900. Ontario History 65, 21-35. Biggs, C. L. (1989) No bones about chiropractic? The quest for legitimacy by the Ontario chiropractic profession, 1895-1985. Ph.D. dissertation, University of Toronto. Bourgeault, I. (1996) Delivering midwifery: an examination of the process and outcome of the incorporation

1062

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of midwifery in Ontario. Ph.D. thesis, University of Toronto. Buckley, S. (1979) Ladies or midwives? Efforts to reduce infant and maternal mortality. In A Not Unreasonable Claim: Women and Reform in Canada 1880s-1920s, ed. L. Kealey, pp. 131-149. Women's Press, Toronto. Burst, H. V. (1977) Harmonious unity. Journal of NurseMidwifery 12(3), 10 11. Burst, H. V. (1981) Two roads--which one? Journal of Nurse-Midwifery 26(5), 7-12. Burtch, B. E. (1988) Midwifery and the state: the new midwifery in Canada. In Gender and Society: Creating A Canadian Women's Sociology, ed. A. T. McLaren, pp. 349 371. Copp Clark Pitman, Toronto. Butter, I. H., Carpenter, E. S., Kay, B. J. and Simmons, R. S. (1987) Gender heirarchies in the health labor force. International Journal of Health Services 17(1), 133-149. Cherry, J. and Foster, J. C. (1982) Comparison of hospital charges generated by certified nurse-midwives and physicians' clients. Journal of Nurse-Midwifery 27, 7-11. Coburn, D. (1994) State authority, medical dominance, and trends in the regulation of the health professions: the Ontario case. Social Science & Medicine 37, 129 138. Coburn, D. and Biggs, C. L. (1986) Limits to medical dominance: the case of chiropractic. Social Science & Medicine 22, 1035 1046. Collins, R. (1990) Changing conceptions in the sociology of the professions. In The Formation of the Professions, eds R. Torstendahl and M. Burrage, pp. 11-23. Sage, London. Connor, J. T. H. (1989) Minority medicine in Ontario, 1795 1903: a study of medical pluralism and its decline. Ph.D. thesis, University of Waterloo. Corea, G. (1977) Hidden Malpractice: How American Medicine Mistreats Women. Harper Colophon, New York. Crawford, M. (1968) Nurse-midwifery-licensure or certification. Bulletin of the American College of NurseMidwifery 13(2), 18-23. Declerq, E. (1992) The transformation of American midwifery: 1975 1988. American Journal of Public Health 82, 680 684. Devitt, N. (1977) The transition from home to hospital birth in the United States, 1930 1960. Birth and the Family Journal 4(2), 47-58. DeVries, R. G. (1982) Midwifery and the problem of licensure. Research in the Sociology of Health Care 2, 77120. DeVries, R. G. (1986) Barriers to nurse-midwifery: is the enemy us? Journal of Nurse-Midw!fery 31(6), 277-278. Donegan, J. B. (1978) Women and Men Midwives: Medicine. Morality and Misogyny in Earl); America. Greenwood, Westport, CT. Donnison, J. (1977) Midwives and Medical Men. Heinemann, London. Eberts, M., Schwartz, A., Edney, R. and Kaufman, K. (1987) Report of the Task Force on the Implementation of Midwifery in Ontario. Queen's Park Printers, Toronto. Ehrenreich, B. and English, D. (1973) Witches, Midwives, and Nurses." A History of Women Healers. Feminist Press, Old Westbury, NY. Etzioni, A. (ed.) (1969) The Semi-Professions and Their Organization: Teachers, Nurses. and Social Workers. Free Press, New York. Evans, R. G. (1981) The economic implications of midwifery: money, midwives and medical men. In Midwifery is a Labour of Love, eds Midwifery Task Force of British Columbia and British Columbia Midwives Association, pp. 68-74. Midwifery Task Force of British Columbia, Vancouver.

Evenson, D. (1982) Midwives: survival of an ancient profession. Women's Rights Law Reporter 7(4), 313-330. Flanagan, J. A. (1986) Childbirth in the eighties: what next? Journal of Nurse-Midwifery 31(4), t94-199. Fooks, C. and Gardiner, B. (1986) The Implementation of Midwifery in Ontario. Current Issue Paper No. 50, Legislative Research Services of the Government of Ontario, Toronto. Fynes, M. T. (1994) The legitimation of midwifery in Ontario 1960~1987. Master's thesis, University of Toronto. Garland Spindel, P. (Coordinator, Midwifery Communication and Accountability Project) (1995) Personal communication, August. Gort, E. and Coburn, D. (1988) Naturopathy in Canada: changing relationship to medicine, chiropractic and the state. Social Science & Medicine 26, 1061-1072. Grandjean, B. D. and Bernal, H. H. (1979) Sex and centralization in a semiprofession. Sociology of Work and Occupations 6(1), 84-102. Haas, J. E. and Rooks, J. P. (1986) National survey of factors contributing to and hindering the successful practice of nurse-midwifery: summary of the American College of Nurse-Midwives Foundation Study. Journal of Nurse-Midwifery 31(5), 212 215. Hays, P. (1971) Midwives? In Canada? Let's hope so! Canadian Nurse July, 17 19. Heagerty, B. V. (1990) Class, gender and professionalization: the struggle for British midwifery 1900-1936. Doctoral dissertation, Michigan State University. Hearn, J. (1982) Notes on patriarchy, professionalization and the semi-professions. Sociology 16(2), 186-202. Hogan, A. (1975) A tribute to the pioneers. Journal of Nurse-Midwifery 10(2), 6-11. Hosford, E. (1976) The home birth movement. Journal of Nurse-Midwifery 21(3), 27-30. Hurlburt, J. (1981) Midwifery in Canada: a capsule in history. The Canadian Nurse February, 30-31. Johnson, T. (1995) Governmentality and the institutionalization of expertise. In Health Professions and the State in Europe, eds T. Johnson, G. Larkin and M. Saks, pp. 7-24. Routledge, London. Kammerer, D. A. (1992) U.S. antitrust law and the control of nurse-midwifery: 1975 to the present. Doctoral dissertation, George Washington University. Kobrin, F. E. (1966) The American midwife controversy: a crisis of professionalism. Bulletin of the History of Medicine 40, 350-363. Langton, P. A. (1991) Competing occupational ideologies identities, and the practice of nurse-midwifery. Research on Occupations and Professions 6, 149-177. Larkin, G. (1983) Occupational Monopoly and Modern Medicine. Tavistock, London. Leavitt, J. W. (1986) Brought to Bed: Childbearing in America 1750 1950. Oxford, New York. Litoff, J. B. (1978) American Midwives: 1860 to the Present. Greenwood, Westport, CT. Lofsky, S. (1995) Family practice obstetrics in Ontario revisited. Ontario Medical Review May, 41-46. Lubic, R. W. (1976) The Childbearing Center: a demonstration project in out-of-hospital care. Journal of Nurse-Midwifery 21(3), 24-25. Mason, J. A. (1987) The history of midwifery in Canada. In Report of the Task Force on the Implementation of Midwifery in Ontario, eds M. Eberts, R. Schwartz, R. Edney and K. Kaufman, pp. 195-232. Queen's Park Printer, Toronto. Mason, J. A. (1988) Midwifery in Canada. In The Midwife Challenge, ed. S. Kitzinger, pp. 99-133. Pandora, London. Matthews, J. J. and Zadak, K. (1991) The alternative birth movement in the United States: history and current status. Women and Health 17(1), 39-56.

Integrating nurse-midwifery into U.S. and Canadian health care McCool, W. F. and McCool, S. J. (1989) Feminism and nurse-midwifery: historical overview and current issues. Journal of Nurse-Midwifery 34(6), 323-334. McCormick, 1. (1983) Childbearing and nurse-midwives: a woman's right to choose. New York University Law Review 58, 661-713. Midwifery Communication and Accountability Project (1994) Fact Sheet 1990 Statistics from Midwifery and the Law. Newton Highlands, MA. Muzio, L. G. (1990) Midwifery education and nursing: curricular revolution or civil war? Nursing and Health Care 12(7), 376-379. O'Brien, M. (1981) The Politics of Reproduction. Routledge, New York. Ontario Committee on the Healing Arts (1970) Report of the Committee on the Healing Arts. Queen's Park Printers, Toronto. Reid, M. (1989) Sisterhood and professionalization: a case study of the American lay midwife. In Women as Healers." Cross-Cultural Perspectives, ed. C. Shepherd McClain, pp. 219-238. Rutgers University Press, London. Reid, M. L. and Morris, J. B. (1979) Perinatal care and cost effectiveness: changes in health expenditures and birth outcomes following the establishment of a nursemidwife program. Medical Care 7, 491-500. Rooks, J. P. (1983) The context of nurse-midwifery in the 1980s: our relationships with medicine, nursing, lay-midwives, consumers and health care economist. Journal of Nurse-Midwifery 28(5), 3-8. Rooks, J. P. (1986) Cost-effectiveness of nurse-midwifery care. In Nurse-Midwifery in America, eds J. Rooks and J. E. Haas, pp. 52 53. American College of NurseMidwives, Washington, DC. Rooks, J. P. and Fischman, S. H. (1980) American nursemidwifery practice in 1976-77: reflections of 50 years of growth and development. American Journal of Public Health 70(9), 990-996. Rothman, B. K. (1981) Awake and aware, or false consciousness: the cooptation of childbirth reform in America. In Childbirth: Alternatives to Medical Control, ed. S. Romalis, pp. 150-180. University of Texas Press, Austin. Rothman, B. K. (1989) Recreating Motherhood." Ideology and Technology in a Patriarchal Society. Norton, New York. Rushing, B. (1991) Market explanations for occupational power: the decline of midwifery in Canada. American Review of Canadian Studies Spring, 7-27. Rushing, B. (1993) Ideology and the reemergence of North American midwifery. Work and Occupations 20(1), 46-67.

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Ruzek, S. B. (1978) The Women's Health Movement: Feminist Alternatives to Medical Control. Praeger, New York. Schlinger, H. (1992) Circle of Midwives. Schlinger, LaFayette, NY. Shah, M. A. (1982) The unification of midwives: a time for dialogue. Journal of Nurse-Midwifery 27(5), 1-2. Sharp, E. S. (1980) Interdependence reexamined. Journal of Nurse-Midwifery 25(5), 1-3. Simmons, A. B. and Keohane, K. (1992) Canadian immigration policy: state strategies and the quest for legitimacy. Canadian Review of Sociology and Anthropology 29(4), 421-452. Sullivan, D. A. and Weitz, R. (1988) Labor Pains." Modern Midwives and Home Birth. Yale University Press, New Haven. Teasley, R. (1983) 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. Doctoral thesis, Michigan State University. Tjaden, P. G. (1987) Midwifery in Colorado: a case study in the politics of professionalization. Qualitative Sociology 10( 1), 29-45. Tom, S. A. (1982) Political midwifery. Journal of NurseMidwifery 27(3), 19-20. Van Wagner, V. (1988) Women organizing for midwifery in Ontario. Resources for Feminist Research 17, 115 118. Ventre, F. and Leonard, C. (1982) The future of midwife r y - a n alliance. Journal of Nurse-MMwiferv 27(5), 2324. Walsh, L. V. and Jaspan, A. L. (1990) Lay midwifery to nurse-midwife: perceived learning needs and attitudes toward to the learning experience. Journal o/" NurseMidwifery 35(4), 204 213. Wardwell, W. I. (1981) Chiropractors: challengers of medical dominance. Research in the Sociology of Health Care 2, 207-250. Wertz, R. W. and Wertz, D. C. (1977) Lying-In." A History ~f Childbirth in America. Schocken, New York. Willis, E. (1989) Medical Dominance: The Division ~if Labour in the Austrialian Health Care System, 2nd edn. Allen and Unwin, Sydney. Witz, A. (1990) Patriarchy and professions: the gendered politics of occupational closure. Sociology 24(4), 675 690. Witz, A. (1992) Professions and Patriachy. Routledge, London.