- Email: [email protected]
Licensed lay midwifery in Arizona
LICENSEDLAYMIDWIFERY INARIZONA
Rose Weitz, PhD, and Deborah A. Sullivan, PhD
ABSTRACT This paper provides information regarding Arizona’s 27 licensed lay midwives. The midwives’ backgrounds vary widely, from countercultural high school dropouts with no medical training to extremely conservative women with graduate degrees in nursing. Two served as midwife-in-charge at more than 100 births during 1981, while most were the primary caregivers for less than 50 women each. While 20 have seriously considered becoming nurse-midwives, only five intend to do so. Competition makes acceptance into a nurse-midwifery program unlikely, and geographic distance would make attendance difficult or impossible. In addition, the midwives are committed to natural home birth as a normal process. Hence, some do not desire training in nursing, medically interventive techniques, or hospital birthing procedures. Finally, the midwives fear their current independence from medical hierarchies would decrease if they became nurse-midwives.
A recent editorial in this journal focused on the increasing and potentially damaging tensions within the American College of Nurse-Midwives regarding the issue of lay midwifey.l In that editorial, Mary Ann Shah clearly and succinctly presented the opposing positions: On the one hand, the ACNM is accused of becoming an elitist organization, of discriminating against lay-midwives just as physician groups have discriminated against CNMs, of narrowing its basis of support to a powerless few, of caring more for its image than for mothers and babies, and of rejecting its own true heritage. On the other hand, deep concern has been expressed that an alliance with nonnurse-midwives could tarnish the CNM’s professional image, jeopardize recent gains in third-party reimbursement,
splinter
the College
into fac-
Address correspondence to Rose Weitz, PhD, Department of Sociology and Women’s Studies Program, Arizona State University, Tempe, AZ 85287.
Journal of Nurse-Midwifery 0
1984 by the American
College
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tions, render tally confuse the physician struggled so
the ACNM powerless, tothe public, and endanger support that CNMs have hard to obtain.
Shah ended her editorial with a call for dialogue within the College on this subject. Such dialogue needs
to be based on factual information regarding lay midwives and their practices. Unfortunately, there are still major gaps in the research literature on lay midwifery. Most of the literature on lay midwives consists of statements written by individual midwives.2-6 The only survey of lay midwives focused on the attitudes of lay and nurse-midwives towards each other.7 That study found that both nurse-midwives and lay midwives generally value a family-centered birth experience and share a noninterventionist philosophy, but that nurse-midwives have reservations about the education of and standard of care provided by lay midwives. Yet there is growing evidence that planned home births using properly
trained lay midwives in low-risk populations generally present no greater risk than hospital births attended by doctors or nurse-midwives.s-12 The authors of this paper-both sociologists-are engaged in a longrange study of the problems lay midwives face as members of an emerging occupational group. This study focuses upon the development of lay midwifery in the state of Arizona during five years of a reactivated licensing system. We believe these data provide crucial background information on training and standards of practice needed to facilitate meaningful communication between lay and nurse-midwives. Although the data are limited to Arizona, they may well suggest the future contours of lay midwifery in the various states that have adopted or are considering adopting models based in part on the Arizona system. In this paper, we will relate the histoy of midwifery in Arizona, describe the training and background of Ari-
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of Nurse-Midwives
0091-2182/84/$03
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zona’s licensed midwives, and explore why these women have remained licensed lay midwives rather than becoming nurse-midwives. HISTORICAL BACKGROUND
In 1957, the Arizona legislature passed a bill to establish a system for licensing lay midwives who met certain minimal qualifications. The women licensed under this law were probably all members of minority racial, ethnic, or religious groups. Over the next 20 years, this system gradually fell into disuse. Only three women remained in practice by the mid 1970s. In 1977, the state tried to prosecute a practicing unlicensed midwife, but instead found themselves forced by the court to grant her a license Rose Weitz is Director of Women’s Studies and Associate Professor of Sociology at Arizona State University. She received her PhD from Yale University, specializing in medical sociology. Her research on midwifery stems from an interest in the politicization of personal issues. This concern has in the past led her to study and to publish works on feminist consciousness mising groups and on the development of lesbian group consciousness. Deborah A. Sullivan is an Associate Professor of Sociology at Arizona State Uniuersity. She receioed a BS in zoology from the Uniuersity of Massachusetts, an MS in population biology from the Uniuersity of California at Irvine, and MA and PhD degrees in demography from Duke University. Her interest in alternatives in maternity care developed from her experiences with childbirth. She has published articles on consumer satisfaction with maternity care, outcomes of licensed midwifeassisted births, and miscarriage. Her current
research focuses
lay midwives encounter
as marginal
practitioners. interests
on unregulated
and the problems health
Her other
include
they care
research
seasonal
migration
retirees and the effect of the tempo childbearing
22
on population
under the 1957 law. This event, coupled with an apparent increase in the number of unlicensed midwives, prompted the state in 1978 to reactivate the licensing system and to revise the surrounding rules and regulations. The new rules and regulations require that each applicant for a license show evidence of training in midwifery. Without specifying a particular program, the rules and regulations do specify that the content of the training include information on state laws and regulations, aseptic techniques, observational skills, management of emergency situations, and clinical coursework in care of mothers and newborns. The applicant also must have observed a minimum of 10 births and delivered a minimum of 15 women under the direct supervision of a licensed physician, licensed midwife, or certified nurse-midwife. The rules further specify that the course of instruction cover the conditions under which the midwife must call a physician or transfer a mother or infant to a hospital. Each applicant must pass a threepart qualifying examination administered by the Arizona Department of Health Services with a minimum score of 80%. The examination consists of a written test, an oral examination of clinical judgment, and a clinical examination of midwifery skills. The midwives may accept only low-risk clients with prearranged backup medical care. They may not administer drugs, medications, or herbs or perform any operative procedure other than clamping and severing the umbilical cord. Their clients must be examined by a physician or other practitioner supervised by a physician during the last trimester.
growth.
of of
METHODOLOGY AND DESCRIPTION OF THE SAMPLE
During the second half of 1982, the authors conducted intensive inter-
Journal of Nurse-Midwifery
views with 27 of the 29 women licensed to practice midwifery at any time between 1977 and August 1982. The exceptions were one woman who had left the country and another who lives out of state and has never practiced in Arizona. The semistructured interviews, containing both open-ended and close-ended questions, averaged about three hours and ranged from two to five hours. Each interview was taped, transcribed, and coded for content analysis, In addition, the Director of the State licensure program was interviewed regarding her background and perceptions of the program. Four of the midwives in the sample (including a registered nurse whose midwifery license was subsequently suspended) obtained their licenses under the minimal 1957 legal requirements. Thirteen others (including a self-taught midwife whose license was later revoked) received licenses by challenging the examination and were not required to take any specific coursework. These 13 include six who are registered nurses. Ten other women met all the requirements for examination and coursework established in the 1978 rules and regulations. Since this study ended, 14 additional women have obtained provisional licenses under a temporary less-stringent law. That law established a one-year grace period during which individuals could obtain provisional licenses by challenging the examination without having to take the coursework required in the 1978 legislation. After successfully delivering 15 babies, they will receive regular licenses. None of these provisionally licensed women is included in this study. BACKGROUND
OF THE MIDWIVES
The midwives range in age from 2469, with the majority falling between 25-35 years of age. Sixteen are married, most (21) have children, and all are women.
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The women became interested in midwifery through a variety of routes. Three British-born women grew up in a society in which midwifery was an acceptable occupation for a woman, equal to teaching. Three others grew up and still reside in a rural closed religious community, in which midwives have always been the primary caregivers during pregnancy and childbirth. Most of the women (17) became interested in midwifery through their own or friends’ experiences in seeking alternatives to hospital birthing. We did not ask each woman whether she had given birth at home. However, during the interviews, 13 women volunteered that they had had a home birth, while nine volunteered that they had not. Only nine participated in any childbirth organizations before becoming a midwife and 17 remained uninvolved subsequently. The women’s interest in alternative health care systems extends beyond midwifery. Three-quarters of the midwives (20) have personally used the services of an osteopath or chiropractor. Five have gone to even more marginal practitioners such as acupuncturists, myopractors, and naturopaths. Only seven have never used a marginal practitioner for nonmidwifery care. Approximately half of the women follow countercultural lifestyles. However, some are quite conservative and only two or three express any political motivations for entering midwifery. Only two have participated in any women’s rights groups and none have worked with the feminist health movement. The midwives typically do not see their work as leading towards any broader political change. Instead, they are committed to midwifery because they view it as a healthy, safe experience that nurtures family bonding. The women strongly believe in the value of their work, and regard it as a service to their communities. Most believe the need for midwives is so acute that it is worth certain personal
Journal of Nurse-Midwifery
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risks and sacrifices on their part. For this reason, only five said they probably would stop practicing if midwifery were made illegal. EDUCATION, TRAINING, AND EXPERIENCE
The educational level of the midwives ranges from high school dropouts to persons with masters degrees. Eight have not attended any college, eleven have some college education, six have completed four years of college, and two have completed graduate programs. Ten of the 27 midwives are registered nurses, including two with graduate training in nursing and two who are British certified midwives. Three registered nurses and eight others attended the unaccredited and now defunct Arizona School of Midwifery and did apprenticeships through that school. From all reports, the quality of that schooling varied greatly from year to year. Four women (including two licensed practical nurses) learned midwifery through apprenticeship with lay or licensed midwives; one of these women also worked extensively with doctors. The remaining five midwives have no nursing background and are basically self-taught. All of the midwives demonstrate interest in continuing education and have attended seminars sponsored by the state and by the Arizona Perinatal Trust on such topics as newborn resuscitation and management of maternal hemorrhage. In addition, 20 have taken other courses such as emergency medical treatment and anatomy and physiology. The midwives also have organized a variety of seminars and mini-residencies (ie, week-long hospital observations); at least two have attended midwifery workshops and conferences in other states. Despite their interest, however, the midwives generally find it difficult to pursue any lengthy training programs because of responsibilities to their own families, the de-
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mands of their practices, and the large geographic distances between Arizona’s major cities. Because the sample includes women recently licensed as well as some who have practiced midwifery for decades, the range in total births attended as the midwife-in-charge is tremendous. Two women-one a British certified midwife and the other the primary health care provider in her isolated comunity for many years-report attending the births of thousands of women. Six have attended less than 50 births as the midwife-in-charge, eight have attended 50-75 births, and 11 have attended 100-600 births. Other data suggest that these statistics underestimate the midwives’ experience, however, because some may not have reported births they managed before licensing or as part of a team. PRACTICE CHARACTERISTICS The volume of current practice also vanes enormously among the midwives. Two women served as the midwife-in-charge at more than 100 births each during 1981. Four attended 50-100 women and the remainder were the primary caregiver for fewer than 50 women each during that year. Again, the number of births reported may not include some attended before licensing or as part of a team. The low volume of practice that characterizes many of the midwives stems from a variety of factors beyond simple lack of demand for their services. Four only recently received their licenses and had not practiced for a full year. Three have restricted their practices, most commonly because of the desires to spend more time with their families and to provide time-intensive care to their clients. Two of the women interviewed did not practice during 1981 -one because of license suspension and one because of full-time nursing responsibilities for an elderly
23
relative. Of the remaining 25, 13 report midwifery as their sole occupation and 6 regard it as their primary occupation. The fees charged by the midwives range from $200 to $650 for prenatal through postpartum care. Three women who operate a sevenbed medical clinic providing all basic care for their rural closed religious community report taking from the clinic’s income “whatever we need to live on.” The other 15 midwives who maintained active practices during 1981 report incomes ranging from $3000-$13,000, and averaging $6,892. The figures obtained when number of births attended is multiplied by fees charged per birth suggest strongly that a few midwives underreported their income, had trouble collecting fees, or occasionally take clients for less than their standard fees. Income from midwifery is a major factor in the family budgets of these women, because 14 report household income under $15,000. About two-thirds of Arizona’s licensed midwives initially practiced without licenses. Licensing and the related changes in practice appear to have pressured the midwives towards a more medical definition of childbirth and style of practice. While the midwives continue to state their belief in childbirth as a safe, natural process for most women, their exposure to medical literature and training, their accountability to the Department of Health Services, and their cumulative experience with unexpected complications have forced them to reevaluate their earlier nonmedical definitions of childbirth.13 As a result of their greater awareness of unpredictable problems, the expansion of their clientele to include persons who choose home birth primarily for financial reasons, and their desire to protect their licenses, the midwives have adopted a more hierarchical style of practice in which they are firmly in control. Their practices continue to be distinguished from those of most obstetri24
additional training. At the same time, because the program is highly selective-accepting only 10 students per year-some feel it is unlikely that they would gain admittance, particularly if they are stigmatized as licensed midwives. Resistance to becoming nursemidwives also arises from a variety of practical and ideological concerns. For many, responsibilities to their families and (for the three from a rural religious community) their community, make extended professional training a hardship, particularly if it must be obtained at a distant location. In addition, while all feel further training is useful, they also feel they are already knowledgeable practitioners. As one said: “I don’t really see the need. I have my skills. It’s just a paper to brandish around people. It means nothing, really.” Thus some believe that certification in nursemidwifery would simply give additional legal recognition to the knowledge they already have. The midwives are ideologically committed to natural home birth as healthy person care. They, therefore, tend to believe that training in nursing sick people is not relevant to their practices. As one midwife expressed:
cians, however, by their strong commitment to holistic care. A’ITITUDES TOWARDS BECOMING NURSE-MIDWIVES Twenty of the licensed midwives have seriously considered becoming nurse-midwives. They believe that the additional knowledge would be valuable in their practice. These licensed midwives also want the legal ability to perform procedures and to work in settings and with clients that are now proscribed. Some, for example, would like to use antihemorrhagic drugs, cut episiotomies, suture lacerations, and continue care when clients have to be transported to the hospital. Because the licenses these women now hold are legally recognized only in Arizona, certification in nurse-midwifery would also greatly increase their ability to work in other geographic areas. Finally, the women believe that training in nursemidwifery would improve their status and gain them greater acceptance, especially within the medical community. Although at the time of the interviews 20 of our respondents had seriously considered becoming nursemidwives, only five intended to do so. One of these began nurse-midwifery school last fall; a second recently applied. In addition, one woman who had stated in the interviews that she did not intend to pursue nurse-midwifery training has since applied. All three who have taken steps towards becoming nursemidwives are already registered nurses. The primary obstacle to nursemidwifery training is the limited access to programs. Only one program in nurse-midwifery exists in the state, which covers an area of 113,417 square miles-significantly larger than all of New England. That program only accepted its first full class in 1980. Because students must already be registered nurses, the 17 licensed midwives who are not nurses would be ineligible without extensive Journal of Nurse-Midwifery
Whenever they open the exam for nurse-midwifery to licensed midwives, I’ll be the first to sit for it, but 1will not go to nursing school. I have no interest in becoming a nurse. I don’t see myself as a healer, to begin with, and I don’t want to see myself trying to become a member of a healing profession. I’m not comfortable around sick people.
In addition, except in emergencies, the licensed midwives generally do not want to use many of the medical interventions that nurse-midwifery programs teach. Five women mentioned this as a reason they did not want to become nurse-midwives. One midwife
stated:
I don’t want to waste a lot of time dealing with a lot of the invasive kinds of things that a nurse-midwife can do, that I wouldn’t even do if I could do. ??
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If a midwife is trained how to cut an episiotomy, she may go ahead and do it. And you don’t usually know if you needed one until the last minute or afterwards, anyway. Or if you’re delivering in a hospital and you’ve got that fetal monitor there, it’s there. You might as well go ahead and use it. And these kinds of things I’m not comfortable with. I don’t like using that kind of stuff. I’d rather use just the basics. Finally, most of the licensed midwives prefer the way they are cur-
rently practicing. nurse reported:
One
registered
More and more, I see that it would not change [anything.] I’m doing what I want to do. 1 am doing home births and I think if we get some changes in the rules and regulations [to allow us to use antihemorrhagic drugs and to stitch lacerations] that there’s going to be no problem. More specifically, the licensed midwives appreciate and want to maintain their independence from medical hierarchies. A licensed midwife must see that her client has a backup physician, the relationship is legally between client and physician not between midwife and physician. Licensed midwives believe that nursemidwives are much more under the supervision and control of physicians. Thus they fear that certification
as nurse-midwives might cost them some of their current independence and might, most importantly, force them to do only hospital births if doctor supervision for home births was unavailable. One midwife stated: I’ve considered it [training in nursemidwifery], but I’ve decided that I wouldn’t want to. Because my main interest is in normal, natural home births, and I think that certified nursemidwives, most of them, are practicing in hospitals, and I wouldn’t want to practice in hospitals.
SUMMARY AND CONCLUSION
The licensed midwives we studied believe strongly in the value of midwifery and home birth and are personally committed to their work. As dedicated practitioners, they are keenly interested in maintaining and developing skills. Access to any extended training program is generally blocked, however. Thus only if “schools without walls” for nursemidwifery are developed will we be likely to see large numbers of lay and licensed midwives becoming certified nurse-midwives. Such programs might consist of videotaped course work in conjunction with supervised clinical training at local birth centers and hospitals.
For those lay midwives who are not interested in nursing training, perhaps the ACNM should consider instituting a two-tiered system similar to the old British system. This would allow women to receive nationally recognized certification in midwifery alone, rather than in nurse-midwifery. Thus the ACNM would be in a better position to meet the needs of persons desiring home birth, while still controlling standards of midwifery care. Moreover, such a system might decrease tensions between lay and certified nurse-midwives and allow for the development of a united voice, speaking for quality in maternity care. This system would incorporate the common goals and concerns of lay and certified nursemidwives that have resulted in the formation of the Midwives Alliance of North America. The desire to maintain standards of practice has kept many certified nurse-midwives from supporting lay midwives. Yet both groups have similar interests and much to gain from mutual cooperation that would increase the strength and visibility of midwifery as a field. We hope this study will increase understanding and communication between lay midwives and certified nurse-midwives.
APPENDIX Questionnaire
Summary*
1. Why did you decide to become a midwife? 2. Do you have any children? 3. Could you please think back to the first birth at which you were present [either your own child’s or someone else’s]. What was your role at the birth? Were you the: a) Mother? b) Friend or relative? c) Midwife? d) Midwife assistant? 4. Did that experience affect your decision to become a midwife? How? 5. Did giving birth to your own children affect your decision to become a midwife? How? 6. Before you decided to become a midwife, were you involved with any childbirth groups? 7. Since becoming a midwife, have you become involved with any childbirth groups?
* Summary only includes questions pertinent to this article. The full questionnaire consisted of 185 questions. Journal of Nurse-Midwifery
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8. Before you decided to become a midwife, did you personally use the services of any of the following? a) Osteopath or DO b) Chiropractor c) Women’s health movement d) Certified nurse-midwife e) Any other health practitioners other than an MD or RN 9. Since becoming a midwife, have you personally used the services of any of the following? a) Osteopath b) Chiropractor c) Women’s health movement d) Certified nurse-midwife e) Any other health practitioners other than MD or RN 10. Before you decided to become a midwife, were you trained in any health profession? If yes, what? 11. Before you decided to become a midwife, did you work in the women’s health movement? 12. If yes, in what capacity? Did it influence your decision to become a midwife? 13. Before you decided to become a midwife, were you involved with any women’s rights or feminist groups other than the women’s health movement? 14. If yes, were the groups you were involved with mostly liberal groups such as NOW or more radical groups? 15. In what year did you attend your first birth as the midwife-in-charge? 16. About how many births, in total, have you attended as the midwife-in-charge? 17. About how many births were you present at during 1981? 18. In how many of those births were you responsible as head midwife? 19. In about how many births last year were you present as part of a team of midwives or midwives and assistants? 20. (If part of a team) What does your team usually consist of? a) Licensed midwives only b) Licensed midwives plus helpers c) Licensed midwives plus student midwives 21. How do most of your clients hear about you? 22. Are there any other ways in which your clients hear about you? 23. What do you think are the most common reasons clients choose a licensed midwife instead of some other kind of practitioner? 24. Do prospective clients ever come to you for reasons which you regard as “bad’ or “inappropriate”? 25. Who do you feel has the basic responsibility for decisions about birthing procedures, the woman, the couple, or the midwife? Why? 26. Most people think that midwifery involves a great deal of responsibility. Do you agree or disagree with this view? 27. Does that responsibility ever bother you? 28. Do you think that your feelings about the responsibility of being a midwife have changed over time? 29. What do you think are the advantages of using licensed midwives compared to certified nurse-midwives? 30. Do you think that there are any disadvantages to using licensed midwives compared to certified nurse-midwives? 31. What do you think are the advantages of using licensed midwives compared to obstetricians? 32. Do you think there are any disadvantages to using licensed midwives compared to obstetricians? 33. What do you think is the attitude of most obstetricians and family practitioners towards licensed midwives? 34. Why do you think that they have this attitude? 35. What do you think is the attitude of most certified nurse-midwives towards licensed midwives? 36. Why do you think they have this attitude? 37. What do you think is the attitude of most nurses other than certified nurse-midwives towards licensed midwives? 38. Why do you think they have this attitude? 39. For each topic I will mention, could you tell me how serious an obstacle you think it presents to your practice as a licensed midwife. a) Vocal organized resistance by professional medical groups b) Refusal of individual physicians to provide medical backup c) Refusal of hospitals to provide medical backup d) Refusal of hospital privileges to midwives e) Harassment of physicians who support midwifery f) Lack of third party reimbursement g) Lack of a national licensed midwifery association similar to the American College of Nurse-Midwives 26
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h) Limited number of training programs in midwifery (other than nurse-midwifery) i) Lack of public awareness of existence of licensed midwives
j)
Competition from other midwives k) Public’s confusion about legal status of licensed midwifery 1) Lack of formal studies publicly establishing the outcomes of licensed midwife assisted births. n-4Various requirements for obtaining a license 4 Legal restrictions on whom a licensed midwife can accept as a client 0) Legal restrictions preventing licensed midwives from performing episiotomies PI Legal restrictions preventing licensed midwives from repairing first degree lacerations 9) Legal restrictions preventing licensed midwives from administering any drugs, medications, or herbs other than silver nitrate r) Legal restrictions preventing licensed midwives from trying to correct fetal presentations by external or internal version s) Cost of midwife-assisted care 40. (For each type considered serious): How does that present an obstacle? How have you dealt with that? 41. Are there any other obstacles to the practice of midwifery in Arizona, other than those we have already discussed? 42. About how much do you charge for your services as a midwife? 43. Do you ever have trouble collecting your fee? 44. What effects, if any, do you think licensure of midwives has had? 45. We have used the word “profession” a few times in this interview. Do you think of midwifery as a profession? . . What does being a profession mean to you’? 46. To get your license in midwifery, were you required to take course work as well as a qualifying exam, or just a qualifying exam? 47. What did your training for midwifery consist of? 48. Are there any other ways in which you have prepared for your profession? 49. Beyond those required for your license, have you attended any workshops or seminars on childbirth sponsored by the state or other organizations? 50. (If yes) What were they? Did you think they were worthwhile? In what ways? 51. Have you taken any other health-related courses that you think are valuable for midwives? 52. Have you ever considered leaving midwifery? 53. What do you see as the major benefits of being a midwife? 54. Have you ever considered becoming a certified nurse-midwife? 55. Are you planning on becoming a certified nurse-midwife? 56. If midwifery were made illegal, would you continue to do it? Why or why not? 57. Did you deliver babies before you were licensed? 58. In what year were you born? 59. How many children do you have? 60. What is your marital status? 61. What was the highest grade of formal schooling completed by your father? Your mother? Your husband? Yourself? 62. What is your husband’sicohabiter’s occupation? 63. Before becoming a midwife, what was your occupation? 64. Do you have another occupation now in addition to midwifery? What is it? 65. Do you consider yourself primarily a midwife, or primarily a (other occupation) or equally both? 66. Is your household income before taxes above or below $15,000? Above or below $25,000? Above or below $50,000? 67. How much income did you receive from midwifery last year?
REFERENCES
ized lay midwife. Birth Family J 3:109115, 1976.
1. Shah MA: The unification of midwives: a time for dialogue. J Nurs Midwif 27: l-2, 1982.
3. Gaskin IM: Spiritual Midwifery. Summertown, TN, The Book Publishing co, 1977.
2. Ventre F: The making of a legalJournal of Nurse-Midwifery
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4. Baldwin
R: How to become
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a
midwife. The workbook 3:221-230, 1978. 5. Ortman-Glick S: A look at lay midwifery in Austin, Texas. J Nurs Midwif 22:39-45, 1978. 6. Raisler J: Interview with a rural midwife. J Nurs Midwif 22:36-38, 1978. 27
7. Kreinberg N, McSweeney M: An attitude survey of lay-midwives and nurse midwives. J Nurs Midwif 26:43-50, 1981. 8. White G: Twenty-five years experience with both home and hospital delivery. J Repro Med 19:310-311, 1977. 9. Dingley EF: Birthplace and atten-
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dants: Oregon’s alternative Women Health 4239-253,
experience. 1979.
10. Burnett CA, Jones J, Rooks J, Chen CH, Tyler C, Miller A: Home delivery and neonatal mortality in North Carolina. JAMA 2442741-2745. 1980. 11. Mehl LE, Ramiel JR, Leininger B, Hoff B, Kronenthal K, Peterson G: Evaluation of outcomes of non-nurse mid-
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wives: matched comparisons with physicians. Women Health 5:17-29, 1980. 12. Sullivan DA, Beeman R: Four years experience with home birth by licensed midwives in Arizona. Am J Public Health, 73641-645, 1983. 13. Weitz R, Sullivan DA: Licensed lay midwifery and the medical model of childbirth. Paper presented at the Society for the Study of Social Problems, Detroit, MI, August 1983.
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Rose Weitz, PhD, and Deborah A. Sullivan, PhD
ABSTRACT This paper provides information regarding Arizona’s 27 licensed lay midwives. The midwives’ backgrounds vary widely, from countercultural high school dropouts with no medical training to extremely conservative women with graduate degrees in nursing. Two served as midwife-in-charge at more than 100 births during 1981, while most were the primary caregivers for less than 50 women each. While 20 have seriously considered becoming nurse-midwives, only five intend to do so. Competition makes acceptance into a nurse-midwifery program unlikely, and geographic distance would make attendance difficult or impossible. In addition, the midwives are committed to natural home birth as a normal process. Hence, some do not desire training in nursing, medically interventive techniques, or hospital birthing procedures. Finally, the midwives fear their current independence from medical hierarchies would decrease if they became nurse-midwives.
A recent editorial in this journal focused on the increasing and potentially damaging tensions within the American College of Nurse-Midwives regarding the issue of lay midwifey.l In that editorial, Mary Ann Shah clearly and succinctly presented the opposing positions: On the one hand, the ACNM is accused of becoming an elitist organization, of discriminating against lay-midwives just as physician groups have discriminated against CNMs, of narrowing its basis of support to a powerless few, of caring more for its image than for mothers and babies, and of rejecting its own true heritage. On the other hand, deep concern has been expressed that an alliance with nonnurse-midwives could tarnish the CNM’s professional image, jeopardize recent gains in third-party reimbursement,
splinter
the College
into fac-
Address correspondence to Rose Weitz, PhD, Department of Sociology and Women’s Studies Program, Arizona State University, Tempe, AZ 85287.
Journal of Nurse-Midwifery 0
1984 by the American
College
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tions, render tally confuse the physician struggled so
the ACNM powerless, tothe public, and endanger support that CNMs have hard to obtain.
Shah ended her editorial with a call for dialogue within the College on this subject. Such dialogue needs
to be based on factual information regarding lay midwives and their practices. Unfortunately, there are still major gaps in the research literature on lay midwifery. Most of the literature on lay midwives consists of statements written by individual midwives.2-6 The only survey of lay midwives focused on the attitudes of lay and nurse-midwives towards each other.7 That study found that both nurse-midwives and lay midwives generally value a family-centered birth experience and share a noninterventionist philosophy, but that nurse-midwives have reservations about the education of and standard of care provided by lay midwives. Yet there is growing evidence that planned home births using properly
trained lay midwives in low-risk populations generally present no greater risk than hospital births attended by doctors or nurse-midwives.s-12 The authors of this paper-both sociologists-are engaged in a longrange study of the problems lay midwives face as members of an emerging occupational group. This study focuses upon the development of lay midwifery in the state of Arizona during five years of a reactivated licensing system. We believe these data provide crucial background information on training and standards of practice needed to facilitate meaningful communication between lay and nurse-midwives. Although the data are limited to Arizona, they may well suggest the future contours of lay midwifery in the various states that have adopted or are considering adopting models based in part on the Arizona system. In this paper, we will relate the histoy of midwifery in Arizona, describe the training and background of Ari-
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of Nurse-Midwives
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zona’s licensed midwives, and explore why these women have remained licensed lay midwives rather than becoming nurse-midwives. HISTORICAL BACKGROUND
In 1957, the Arizona legislature passed a bill to establish a system for licensing lay midwives who met certain minimal qualifications. The women licensed under this law were probably all members of minority racial, ethnic, or religious groups. Over the next 20 years, this system gradually fell into disuse. Only three women remained in practice by the mid 1970s. In 1977, the state tried to prosecute a practicing unlicensed midwife, but instead found themselves forced by the court to grant her a license Rose Weitz is Director of Women’s Studies and Associate Professor of Sociology at Arizona State University. She received her PhD from Yale University, specializing in medical sociology. Her research on midwifery stems from an interest in the politicization of personal issues. This concern has in the past led her to study and to publish works on feminist consciousness mising groups and on the development of lesbian group consciousness. Deborah A. Sullivan is an Associate Professor of Sociology at Arizona State Uniuersity. She receioed a BS in zoology from the Uniuersity of Massachusetts, an MS in population biology from the Uniuersity of California at Irvine, and MA and PhD degrees in demography from Duke University. Her interest in alternatives in maternity care developed from her experiences with childbirth. She has published articles on consumer satisfaction with maternity care, outcomes of licensed midwifeassisted births, and miscarriage. Her current
research focuses
lay midwives encounter
as marginal
practitioners. interests
on unregulated
and the problems health
Her other
include
they care
research
seasonal
migration
retirees and the effect of the tempo childbearing
22
on population
under the 1957 law. This event, coupled with an apparent increase in the number of unlicensed midwives, prompted the state in 1978 to reactivate the licensing system and to revise the surrounding rules and regulations. The new rules and regulations require that each applicant for a license show evidence of training in midwifery. Without specifying a particular program, the rules and regulations do specify that the content of the training include information on state laws and regulations, aseptic techniques, observational skills, management of emergency situations, and clinical coursework in care of mothers and newborns. The applicant also must have observed a minimum of 10 births and delivered a minimum of 15 women under the direct supervision of a licensed physician, licensed midwife, or certified nurse-midwife. The rules further specify that the course of instruction cover the conditions under which the midwife must call a physician or transfer a mother or infant to a hospital. Each applicant must pass a threepart qualifying examination administered by the Arizona Department of Health Services with a minimum score of 80%. The examination consists of a written test, an oral examination of clinical judgment, and a clinical examination of midwifery skills. The midwives may accept only low-risk clients with prearranged backup medical care. They may not administer drugs, medications, or herbs or perform any operative procedure other than clamping and severing the umbilical cord. Their clients must be examined by a physician or other practitioner supervised by a physician during the last trimester.
growth.
of of
METHODOLOGY AND DESCRIPTION OF THE SAMPLE
During the second half of 1982, the authors conducted intensive inter-
Journal of Nurse-Midwifery
views with 27 of the 29 women licensed to practice midwifery at any time between 1977 and August 1982. The exceptions were one woman who had left the country and another who lives out of state and has never practiced in Arizona. The semistructured interviews, containing both open-ended and close-ended questions, averaged about three hours and ranged from two to five hours. Each interview was taped, transcribed, and coded for content analysis, In addition, the Director of the State licensure program was interviewed regarding her background and perceptions of the program. Four of the midwives in the sample (including a registered nurse whose midwifery license was subsequently suspended) obtained their licenses under the minimal 1957 legal requirements. Thirteen others (including a self-taught midwife whose license was later revoked) received licenses by challenging the examination and were not required to take any specific coursework. These 13 include six who are registered nurses. Ten other women met all the requirements for examination and coursework established in the 1978 rules and regulations. Since this study ended, 14 additional women have obtained provisional licenses under a temporary less-stringent law. That law established a one-year grace period during which individuals could obtain provisional licenses by challenging the examination without having to take the coursework required in the 1978 legislation. After successfully delivering 15 babies, they will receive regular licenses. None of these provisionally licensed women is included in this study. BACKGROUND
OF THE MIDWIVES
The midwives range in age from 2469, with the majority falling between 25-35 years of age. Sixteen are married, most (21) have children, and all are women.
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The women became interested in midwifery through a variety of routes. Three British-born women grew up in a society in which midwifery was an acceptable occupation for a woman, equal to teaching. Three others grew up and still reside in a rural closed religious community, in which midwives have always been the primary caregivers during pregnancy and childbirth. Most of the women (17) became interested in midwifery through their own or friends’ experiences in seeking alternatives to hospital birthing. We did not ask each woman whether she had given birth at home. However, during the interviews, 13 women volunteered that they had had a home birth, while nine volunteered that they had not. Only nine participated in any childbirth organizations before becoming a midwife and 17 remained uninvolved subsequently. The women’s interest in alternative health care systems extends beyond midwifery. Three-quarters of the midwives (20) have personally used the services of an osteopath or chiropractor. Five have gone to even more marginal practitioners such as acupuncturists, myopractors, and naturopaths. Only seven have never used a marginal practitioner for nonmidwifery care. Approximately half of the women follow countercultural lifestyles. However, some are quite conservative and only two or three express any political motivations for entering midwifery. Only two have participated in any women’s rights groups and none have worked with the feminist health movement. The midwives typically do not see their work as leading towards any broader political change. Instead, they are committed to midwifery because they view it as a healthy, safe experience that nurtures family bonding. The women strongly believe in the value of their work, and regard it as a service to their communities. Most believe the need for midwives is so acute that it is worth certain personal
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risks and sacrifices on their part. For this reason, only five said they probably would stop practicing if midwifery were made illegal. EDUCATION, TRAINING, AND EXPERIENCE
The educational level of the midwives ranges from high school dropouts to persons with masters degrees. Eight have not attended any college, eleven have some college education, six have completed four years of college, and two have completed graduate programs. Ten of the 27 midwives are registered nurses, including two with graduate training in nursing and two who are British certified midwives. Three registered nurses and eight others attended the unaccredited and now defunct Arizona School of Midwifery and did apprenticeships through that school. From all reports, the quality of that schooling varied greatly from year to year. Four women (including two licensed practical nurses) learned midwifery through apprenticeship with lay or licensed midwives; one of these women also worked extensively with doctors. The remaining five midwives have no nursing background and are basically self-taught. All of the midwives demonstrate interest in continuing education and have attended seminars sponsored by the state and by the Arizona Perinatal Trust on such topics as newborn resuscitation and management of maternal hemorrhage. In addition, 20 have taken other courses such as emergency medical treatment and anatomy and physiology. The midwives also have organized a variety of seminars and mini-residencies (ie, week-long hospital observations); at least two have attended midwifery workshops and conferences in other states. Despite their interest, however, the midwives generally find it difficult to pursue any lengthy training programs because of responsibilities to their own families, the de-
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mands of their practices, and the large geographic distances between Arizona’s major cities. Because the sample includes women recently licensed as well as some who have practiced midwifery for decades, the range in total births attended as the midwife-in-charge is tremendous. Two women-one a British certified midwife and the other the primary health care provider in her isolated comunity for many years-report attending the births of thousands of women. Six have attended less than 50 births as the midwife-in-charge, eight have attended 50-75 births, and 11 have attended 100-600 births. Other data suggest that these statistics underestimate the midwives’ experience, however, because some may not have reported births they managed before licensing or as part of a team. PRACTICE CHARACTERISTICS The volume of current practice also vanes enormously among the midwives. Two women served as the midwife-in-charge at more than 100 births each during 1981. Four attended 50-100 women and the remainder were the primary caregiver for fewer than 50 women each during that year. Again, the number of births reported may not include some attended before licensing or as part of a team. The low volume of practice that characterizes many of the midwives stems from a variety of factors beyond simple lack of demand for their services. Four only recently received their licenses and had not practiced for a full year. Three have restricted their practices, most commonly because of the desires to spend more time with their families and to provide time-intensive care to their clients. Two of the women interviewed did not practice during 1981 -one because of license suspension and one because of full-time nursing responsibilities for an elderly
23
relative. Of the remaining 25, 13 report midwifery as their sole occupation and 6 regard it as their primary occupation. The fees charged by the midwives range from $200 to $650 for prenatal through postpartum care. Three women who operate a sevenbed medical clinic providing all basic care for their rural closed religious community report taking from the clinic’s income “whatever we need to live on.” The other 15 midwives who maintained active practices during 1981 report incomes ranging from $3000-$13,000, and averaging $6,892. The figures obtained when number of births attended is multiplied by fees charged per birth suggest strongly that a few midwives underreported their income, had trouble collecting fees, or occasionally take clients for less than their standard fees. Income from midwifery is a major factor in the family budgets of these women, because 14 report household income under $15,000. About two-thirds of Arizona’s licensed midwives initially practiced without licenses. Licensing and the related changes in practice appear to have pressured the midwives towards a more medical definition of childbirth and style of practice. While the midwives continue to state their belief in childbirth as a safe, natural process for most women, their exposure to medical literature and training, their accountability to the Department of Health Services, and their cumulative experience with unexpected complications have forced them to reevaluate their earlier nonmedical definitions of childbirth.13 As a result of their greater awareness of unpredictable problems, the expansion of their clientele to include persons who choose home birth primarily for financial reasons, and their desire to protect their licenses, the midwives have adopted a more hierarchical style of practice in which they are firmly in control. Their practices continue to be distinguished from those of most obstetri24
additional training. At the same time, because the program is highly selective-accepting only 10 students per year-some feel it is unlikely that they would gain admittance, particularly if they are stigmatized as licensed midwives. Resistance to becoming nursemidwives also arises from a variety of practical and ideological concerns. For many, responsibilities to their families and (for the three from a rural religious community) their community, make extended professional training a hardship, particularly if it must be obtained at a distant location. In addition, while all feel further training is useful, they also feel they are already knowledgeable practitioners. As one said: “I don’t really see the need. I have my skills. It’s just a paper to brandish around people. It means nothing, really.” Thus some believe that certification in nursemidwifery would simply give additional legal recognition to the knowledge they already have. The midwives are ideologically committed to natural home birth as healthy person care. They, therefore, tend to believe that training in nursing sick people is not relevant to their practices. As one midwife expressed:
cians, however, by their strong commitment to holistic care. A’ITITUDES TOWARDS BECOMING NURSE-MIDWIVES Twenty of the licensed midwives have seriously considered becoming nurse-midwives. They believe that the additional knowledge would be valuable in their practice. These licensed midwives also want the legal ability to perform procedures and to work in settings and with clients that are now proscribed. Some, for example, would like to use antihemorrhagic drugs, cut episiotomies, suture lacerations, and continue care when clients have to be transported to the hospital. Because the licenses these women now hold are legally recognized only in Arizona, certification in nurse-midwifery would also greatly increase their ability to work in other geographic areas. Finally, the women believe that training in nursemidwifery would improve their status and gain them greater acceptance, especially within the medical community. Although at the time of the interviews 20 of our respondents had seriously considered becoming nursemidwives, only five intended to do so. One of these began nurse-midwifery school last fall; a second recently applied. In addition, one woman who had stated in the interviews that she did not intend to pursue nurse-midwifery training has since applied. All three who have taken steps towards becoming nursemidwives are already registered nurses. The primary obstacle to nursemidwifery training is the limited access to programs. Only one program in nurse-midwifery exists in the state, which covers an area of 113,417 square miles-significantly larger than all of New England. That program only accepted its first full class in 1980. Because students must already be registered nurses, the 17 licensed midwives who are not nurses would be ineligible without extensive Journal of Nurse-Midwifery
Whenever they open the exam for nurse-midwifery to licensed midwives, I’ll be the first to sit for it, but 1will not go to nursing school. I have no interest in becoming a nurse. I don’t see myself as a healer, to begin with, and I don’t want to see myself trying to become a member of a healing profession. I’m not comfortable around sick people.
In addition, except in emergencies, the licensed midwives generally do not want to use many of the medical interventions that nurse-midwifery programs teach. Five women mentioned this as a reason they did not want to become nurse-midwives. One midwife
stated:
I don’t want to waste a lot of time dealing with a lot of the invasive kinds of things that a nurse-midwife can do, that I wouldn’t even do if I could do. ??
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If a midwife is trained how to cut an episiotomy, she may go ahead and do it. And you don’t usually know if you needed one until the last minute or afterwards, anyway. Or if you’re delivering in a hospital and you’ve got that fetal monitor there, it’s there. You might as well go ahead and use it. And these kinds of things I’m not comfortable with. I don’t like using that kind of stuff. I’d rather use just the basics. Finally, most of the licensed midwives prefer the way they are cur-
rently practicing. nurse reported:
One
registered
More and more, I see that it would not change [anything.] I’m doing what I want to do. 1 am doing home births and I think if we get some changes in the rules and regulations [to allow us to use antihemorrhagic drugs and to stitch lacerations] that there’s going to be no problem. More specifically, the licensed midwives appreciate and want to maintain their independence from medical hierarchies. A licensed midwife must see that her client has a backup physician, the relationship is legally between client and physician not between midwife and physician. Licensed midwives believe that nursemidwives are much more under the supervision and control of physicians. Thus they fear that certification
as nurse-midwives might cost them some of their current independence and might, most importantly, force them to do only hospital births if doctor supervision for home births was unavailable. One midwife stated: I’ve considered it [training in nursemidwifery], but I’ve decided that I wouldn’t want to. Because my main interest is in normal, natural home births, and I think that certified nursemidwives, most of them, are practicing in hospitals, and I wouldn’t want to practice in hospitals.
SUMMARY AND CONCLUSION
The licensed midwives we studied believe strongly in the value of midwifery and home birth and are personally committed to their work. As dedicated practitioners, they are keenly interested in maintaining and developing skills. Access to any extended training program is generally blocked, however. Thus only if “schools without walls” for nursemidwifery are developed will we be likely to see large numbers of lay and licensed midwives becoming certified nurse-midwives. Such programs might consist of videotaped course work in conjunction with supervised clinical training at local birth centers and hospitals.
For those lay midwives who are not interested in nursing training, perhaps the ACNM should consider instituting a two-tiered system similar to the old British system. This would allow women to receive nationally recognized certification in midwifery alone, rather than in nurse-midwifery. Thus the ACNM would be in a better position to meet the needs of persons desiring home birth, while still controlling standards of midwifery care. Moreover, such a system might decrease tensions between lay and certified nurse-midwives and allow for the development of a united voice, speaking for quality in maternity care. This system would incorporate the common goals and concerns of lay and certified nursemidwives that have resulted in the formation of the Midwives Alliance of North America. The desire to maintain standards of practice has kept many certified nurse-midwives from supporting lay midwives. Yet both groups have similar interests and much to gain from mutual cooperation that would increase the strength and visibility of midwifery as a field. We hope this study will increase understanding and communication between lay midwives and certified nurse-midwives.
APPENDIX Questionnaire
Summary*
1. Why did you decide to become a midwife? 2. Do you have any children? 3. Could you please think back to the first birth at which you were present [either your own child’s or someone else’s]. What was your role at the birth? Were you the: a) Mother? b) Friend or relative? c) Midwife? d) Midwife assistant? 4. Did that experience affect your decision to become a midwife? How? 5. Did giving birth to your own children affect your decision to become a midwife? How? 6. Before you decided to become a midwife, were you involved with any childbirth groups? 7. Since becoming a midwife, have you become involved with any childbirth groups?
* Summary only includes questions pertinent to this article. The full questionnaire consisted of 185 questions. Journal of Nurse-Midwifery
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8. Before you decided to become a midwife, did you personally use the services of any of the following? a) Osteopath or DO b) Chiropractor c) Women’s health movement d) Certified nurse-midwife e) Any other health practitioners other than an MD or RN 9. Since becoming a midwife, have you personally used the services of any of the following? a) Osteopath b) Chiropractor c) Women’s health movement d) Certified nurse-midwife e) Any other health practitioners other than MD or RN 10. Before you decided to become a midwife, were you trained in any health profession? If yes, what? 11. Before you decided to become a midwife, did you work in the women’s health movement? 12. If yes, in what capacity? Did it influence your decision to become a midwife? 13. Before you decided to become a midwife, were you involved with any women’s rights or feminist groups other than the women’s health movement? 14. If yes, were the groups you were involved with mostly liberal groups such as NOW or more radical groups? 15. In what year did you attend your first birth as the midwife-in-charge? 16. About how many births, in total, have you attended as the midwife-in-charge? 17. About how many births were you present at during 1981? 18. In how many of those births were you responsible as head midwife? 19. In about how many births last year were you present as part of a team of midwives or midwives and assistants? 20. (If part of a team) What does your team usually consist of? a) Licensed midwives only b) Licensed midwives plus helpers c) Licensed midwives plus student midwives 21. How do most of your clients hear about you? 22. Are there any other ways in which your clients hear about you? 23. What do you think are the most common reasons clients choose a licensed midwife instead of some other kind of practitioner? 24. Do prospective clients ever come to you for reasons which you regard as “bad’ or “inappropriate”? 25. Who do you feel has the basic responsibility for decisions about birthing procedures, the woman, the couple, or the midwife? Why? 26. Most people think that midwifery involves a great deal of responsibility. Do you agree or disagree with this view? 27. Does that responsibility ever bother you? 28. Do you think that your feelings about the responsibility of being a midwife have changed over time? 29. What do you think are the advantages of using licensed midwives compared to certified nurse-midwives? 30. Do you think that there are any disadvantages to using licensed midwives compared to certified nurse-midwives? 31. What do you think are the advantages of using licensed midwives compared to obstetricians? 32. Do you think there are any disadvantages to using licensed midwives compared to obstetricians? 33. What do you think is the attitude of most obstetricians and family practitioners towards licensed midwives? 34. Why do you think that they have this attitude? 35. What do you think is the attitude of most certified nurse-midwives towards licensed midwives? 36. Why do you think they have this attitude? 37. What do you think is the attitude of most nurses other than certified nurse-midwives towards licensed midwives? 38. Why do you think they have this attitude? 39. For each topic I will mention, could you tell me how serious an obstacle you think it presents to your practice as a licensed midwife. a) Vocal organized resistance by professional medical groups b) Refusal of individual physicians to provide medical backup c) Refusal of hospitals to provide medical backup d) Refusal of hospital privileges to midwives e) Harassment of physicians who support midwifery f) Lack of third party reimbursement g) Lack of a national licensed midwifery association similar to the American College of Nurse-Midwives 26
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h) Limited number of training programs in midwifery (other than nurse-midwifery) i) Lack of public awareness of existence of licensed midwives
j)
Competition from other midwives k) Public’s confusion about legal status of licensed midwifery 1) Lack of formal studies publicly establishing the outcomes of licensed midwife assisted births. n-4Various requirements for obtaining a license 4 Legal restrictions on whom a licensed midwife can accept as a client 0) Legal restrictions preventing licensed midwives from performing episiotomies PI Legal restrictions preventing licensed midwives from repairing first degree lacerations 9) Legal restrictions preventing licensed midwives from administering any drugs, medications, or herbs other than silver nitrate r) Legal restrictions preventing licensed midwives from trying to correct fetal presentations by external or internal version s) Cost of midwife-assisted care 40. (For each type considered serious): How does that present an obstacle? How have you dealt with that? 41. Are there any other obstacles to the practice of midwifery in Arizona, other than those we have already discussed? 42. About how much do you charge for your services as a midwife? 43. Do you ever have trouble collecting your fee? 44. What effects, if any, do you think licensure of midwives has had? 45. We have used the word “profession” a few times in this interview. Do you think of midwifery as a profession? . . What does being a profession mean to you’? 46. To get your license in midwifery, were you required to take course work as well as a qualifying exam, or just a qualifying exam? 47. What did your training for midwifery consist of? 48. Are there any other ways in which you have prepared for your profession? 49. Beyond those required for your license, have you attended any workshops or seminars on childbirth sponsored by the state or other organizations? 50. (If yes) What were they? Did you think they were worthwhile? In what ways? 51. Have you taken any other health-related courses that you think are valuable for midwives? 52. Have you ever considered leaving midwifery? 53. What do you see as the major benefits of being a midwife? 54. Have you ever considered becoming a certified nurse-midwife? 55. Are you planning on becoming a certified nurse-midwife? 56. If midwifery were made illegal, would you continue to do it? Why or why not? 57. Did you deliver babies before you were licensed? 58. In what year were you born? 59. How many children do you have? 60. What is your marital status? 61. What was the highest grade of formal schooling completed by your father? Your mother? Your husband? Yourself? 62. What is your husband’sicohabiter’s occupation? 63. Before becoming a midwife, what was your occupation? 64. Do you have another occupation now in addition to midwifery? What is it? 65. Do you consider yourself primarily a midwife, or primarily a (other occupation) or equally both? 66. Is your household income before taxes above or below $15,000? Above or below $25,000? Above or below $50,000? 67. How much income did you receive from midwifery last year?
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