WAYS OF KNOWING: OPEN AND CLOSED SYSTEMS
Robbie Davis-Floyd
This article appears in Midwifery Today 69 (Spring): 9-13.
Copyright is held both by Midwifery Today and by Robbie Davis-Floyd.
Both give permission for the replication of t this article for educational purposes.
This special issue of Midwifery Today focuses on midwifery knowledge. The following articles in it will address the specifics of this body of knowledge. But first, it is important to take a broader look at the differences between open and closed knowledge systems. Why? Because any knowledge system whose adherents wish it to remain responsive to changing events in a rapidly changing world must remain open to absorbing new information and adapting itself to that new information. To achieve an open knowledge system, one must first understand what it means for a knowledge system to be “closed.”
How Knowledge Begins
When a baby is gestating in the mother’s womb, neural circuits are being formed in its brain. This process begins in early pregnancy and continues as the baby grows, until by the time of birth the baby’s developing brain already contains millions of pathways and connections. Much of the information that flows along these circuits is cultural. As it develops, the baby receives enormous amounts of cultural information from the mother’s activities—when she goes to sleep, when she wakes, how she moves during the day, her speech patterns, her emotions, etc. So we begin to learn before we are born the most basic patterns of the culture we are born into. From then on, the cultural information most easily processed by the baby after birth is information that conforms to the cultural rhythms to which it is already accustomed. Yet the potential always exists in babies and in children for the easy accommodation of entirely new information. In other words, the brains of babies and children are open systems, readily able to create synaptic connections that generate entirely new neural networks that can process entirely new information. That is why it is so easy for the young to learn new languages, for example: their brain structures are so open to absorbing new information that they have no resistance to it.
A neural pathway at high magnification The development of neural networks in a baby’s brain from birth to age 2
[Note to editor: please delete the writing at the bottom]
Stage One Thinking/Naïve Realism
If a child grows up in one culture and is exposed for the first twenty or so years of its life only to the rhythms, patterns, language, and belief system of that culture, its neural networks will become permanently set in those terms. After that, learning a new language or internalizing the norms and values of a different culture or belief system becomes increasingly difficult over time. Why? Because integrating new information always requires the formation of entirely new neural pathways in the brain. For a child, that process is effortless; for an adult whose neural structures are already set, that process requires enormous amounts of time, energy, and concentrated effort to create new bridges across the synaptic gaps between what they already know and what they desire to learn.
Individuals who are never required to “think beyond” the belief systems of the cultures in which they are raised can over time lose the ability to process new information and can become neuro-cognitively rigid in their thinking. More precisely, humans never really lose that ability, but they can become resistant to it, unwilling to put in the time and energy it would take to develop those new neural pathways. Such individuals are subject to what some brain theorists have called Stage One Thinking.1 For Stage One thinkers, the world is as their culture defines it. There is only one possible set of interpretations of reality, and that set of interpretations IS reality. In other words, theirs is a closed system. Anthropologists call this way of thinking “naïve realism”—the notion that “my way is the only way there is.” Most members of small-scale societies, before their massive exposure to Western culture, were naïve realists. In modern societies, all religious fundamentalists are naïve realists—they are completely convinced and certain that their way of knowing is right and is (or should be) “the only way.”
Stage One Thinking: The Rigid Mind
“Everything in its place”
Across cultures and throughout history, ritual has played a critical role in the creation of Stage One thinkers. Rituals enact a society or group’s core values and beliefs. Through rhythmic repetition and the use of powerful core symbols, ritual constantly works to imprint these core beliefs and the behaviors that accompany them in the minds and bodies of its participants.
Stage Two Thinking/Ethnocentrism
Stage Two thinkers are what anthropologist call “ethnocentric.” Ethnocentrists know that other ways of knowing and believing exist, and may be willing to acknowledge that it’s OK for others to think differently. But they are entirely certain that their way is better. At best, ethnocentric Stage Two thinkers feel pity for everyone else who simply doesn’t understand how much better their way is. At worst, ethnocentrists try to wipe out those who don’t believe as they do, considering the existence of other ways of knowing a threat to their own or an heretical abomination (consider the Crusades, for example). Ethnocentrism, like naïve realism, is a closed system, constantly reinforced by the rituals that enact and sustain that system.
Stage Three Thinking/Cultural Relativism
In dramatic contrast, Stage Three thinkers are entirely open. They come to a realization at some point in their lives that every culture and religion has created their own story about the nature and structure of reality, and who is to say whose story is right? In anthropological terms, Stage Three thinkers are cultural relativists who come to see every story about reality as relative to every other story. Nobody is “right,” nobody has a lock on truth, so every knowledge system must be understood in terms of its ecological, historical, and political context, and must be respected as legitimate in its own right. This kind of cultural relativism can sound ideal—it entails respect for, appreciation of, and understanding of every story that every culture or religion tells. Such tolerance! No bigotism, no racism, no ethnocentrism, no judgment.
And yet it is not ideal in a global sense. In some cultures, such as those of ruralPakistan, men are entitled to beat their wives every night. In some cultures, torture of political prisoners is normal. In some cultures, like that of the contemporary US, putting millions of people in prison for relatively harmless crimes is the norm. In Western biomedicine, which has spread all over the world, women are routinely abused and harmed in the name of a science which is not science but biomedical belief and tradition. By what standard can cultural relativists say that such culturally accepted behaviors are not OK?
Stage Four Thinking/Global Humanism
This dilemma posed by cultural relativism has led to an increased global focus on the development of Stage Four thinking, which anthropologists call global humanism. Stage Four/global humanist thinkers recognize the intrinsic integrity and value of every cultural and religious story, yet seek a higher standard that can be applied in every context to ensure the rights of individuals, most particularly the poorer and weaker members of society. No one should be beaten, or raped, or abused. Everyone should have access to clean water and good nutrition and effective health care and good pay for their work. Such things seem desirable goals to global humanists, yet they do not exist in many places. So global humanists seek to think beyond even cultural relativism, seeking universal standards that work for everyone. They want to validate and legitimate every culture while devaluing and discouraging practices that hurt people who do not deserve to be hurt in this higher sense. They are acutely aware that they are on an almost impossible mission, yet one that must be attempted anyway for the good of all. Knowing that totalitarian systems are always harmful, and that no one system can ever really be perfect, they understand that they must keep their knowledge systems open to new information, engaging in bioethical discussion and debate, trying to figure things out without assuming superiority for any one system.
These are MC Escher prints representing the fluidity and unknowability of reality. Stage Four thinkers can relate: they recognize reality’s ambiguity and fuzziness, and they know that categories are not solid, things can fade into and out of each other. The world is not black and white but many-colored. Things are not in their places because there is no “place.”
Stage Four thinkers do develop and perform rituals, but such rituals are usually very fluid attempts to express and enact larger, more global values. Since the beliefs of Stage Four thinkers are open to flux and change, the rituals they create tend to constantly change as well, or to be spontaneous enactments of something going on in the moment. Think here of the closing rituals at Midwifery Today conferences, which tend to consist of hand-holding and songs that occur to people to sing in celebration of midwives and women. These are very unlike the rigid, pre-set rituals performed in churches, temples, synagogues, etc. that enact very specific and relatively unchanging sets of beliefs.
The Four Stages of Cognition
The following diagram is my attempt to illustrate the differences between these four stages of cognition. The black circle indicates how for Stage One thinkers (naïve realists), there is only one way of perceiving the world. Stage Two thinkers (ethnocentrists) still come out of one way of thinking, are aware of other ways, may find them threatening, amusing, or interesting, yet consider them essentially irrelevant to real knowledge or truth: “our way is best.” Both Stage One and Stage Two systems are closed. Stage Three thinkers (cultural relativists) are usually raised in one system, yet give credence and legitimacy to all systems and are open to learning more, as indicated by the little lines extending out from the circles. Stage Four thinkers (global humanists) try to weave a hologram out of all systems that has its own internal cohesion in terms of standards of behavior that work for everyone, yet are always open to new ideas and always willing to rethink the holograms they weave to accommodate new information and to broaden the systems of meaning they weave.
The Four Stages of Cognition
Midwives, Midwifery Knowledge, and the Four Stages of Cognition
Stage One/Naïve Realist Midwifery Systems
Many traditional midwives, and some professional midwives, are Stage One thinkers. They are socialized during their midwifery training to one way of thinking and knowing about birth, have no exposure to other ways, and thus have no incentive to “think beyond” what they are sure they know about birth. Such “naïve realist” midwives can practice within their communities, whether traditional or hospital-based, for their lifetimes, without ever questioning their practices and the beliefs that underlie them. Such midwives still exist, yet are rare in the contemporary world, in which it is becoming increasingly difficult to avoid exposure to other ways of thinking and knowing.
Stage Two/Ethnocentric Midwifery Systems
It is far more possible for thousands of contemporary midwives to be ethnocentric rather than naively realistic. Ethnocentric midwifery knowledge and practice systems can be (1) indigenous or (2) biomedical.
(1) Indigenous midwives, if left alone, are most likely to be Stage One thinkers. But most traditional midwives are in some way exposed to biomedicine, which has been massively adopted in developing countries as the most “modern” and progressive system. Unfortunately, this exposure has most often taken the form of TBA training courses, which “train” traditional midwives in biomedical ways of thinking and practicing. These trainings are highly ethnocentric: the biomedical practitioners who do the teaching are usually not interested in what the midwives know or how they practice, but rather in teaching them “the best way,” which in their minds is the biomedical way.
Biomedicine is itself an extremely ethnocentric and relatively closed Stage Two system. Biomedical practitioners are constantly exposed to new information, yet they tend to incorporate only the kinds of new information that fit within their pre-existing knowledge system. Physicians, for example, are socialized into biomedical ways of thinking, knowing, and believing for at least four years of medical school, three years of residency, and often more if they go on into subspecialties. Their neural pathways are established in terms of what I call the technocratic model of medicine. Confronted with information that does not match what they learned during their training—in other words, information that does not flow easily along their pre-established neural pathways—they are most likely to ignore or discount such information. An obstetrician who reads a study comparing epidurals with other types of pain medication can easily process that kind of information, for example, but the same obstetrician presented with multiple studies that demonstrate the benefits of doulas, being in water, massage, and constant changes in position for pain relief will be likely to discount this kind of information. To process it, he would have to be willing to take the time and energy it would require to develop thousands of brand new synaptic connections and neural pathways along which this new information could flow and become integrated into his cognitive system. Most obstetricians can barely keep up with the information that comes across their desks every day that updates them on the latest drugs and technologies (simply amplifying things they already know). Entrenched in a belief system that relies on drugs and technological interventions to manage birth, they see no reason to exert the much greater amounts of energy it would take to assimilate information from outside their technocratic paradigm. This is also true of thousands of professional midwives around the world, who work hard to learn accepted biomedical ways and then are thrust into busy practices. Overworked, overstressed, and often underpaid, they too are unwilling to open their cognitive systems to processing information that contradicts the biomedical approaches they are taught.
The drawing below metaphorically illustrates the multiple possibilities such ethnocentric/Stage Two practitioners have for dealing with new information: it can flow along their established neural pathways and be assimilated (filed in accessible filing cabinets, for example), or it can be thrown down one of those tubes into oblivion, or it could be filed way in the back, where the synaptic connections stop, in a filing cabinet labeled “information I don’t want to process but might be useful sometime.”
Bodily habituation to closed systems. The diagrams I have offered to illustrate my points are of the mind. Yet the most effective and enduring kinds of learning have to do with our bodies. When you sit in a classroom and listen to lectures, or read books, you are learning didactically—through your mind. When you take a blood pressure or insert an IV or do a pelvic exam the same way a thousand times, you are learning with your body. Body knowing is the hardest kind of learning to change because it involves habituation. Becoming physically habituated to doing things the same way all the time means that your learning process becomes ingrained not only in your brain but also in the cells and muscles of your hands and arms, legs and feet, posture and movement. This kind of knowing is out of mental consciousness and thus cannot be overcome by mental exposure to studies that contradict it.
How do you gain confidence that a woman’s labor is under control? You hook her up to the monitor and assume that the information that flows through it is telling you all you need to know. How do you resuscitate a baby in distress? You cut the cord and rush to the table attached to the wall where the equipment you think you need is attached. How do you deal with what you have been taught is prolonged pushing? You cut an episiotomy and perhaps grab the forceps or the vacuum extractor. You don’t have to think about it—your body just moves to do it. Birth is not a good catalyst for change in such cases, as most babies come out alive and relatively healthy most of the time anyway. So the more you do it that way, the more it becomes the only way you can imagine doing it.
It is ironic that science, which was supposed to be the foundation of obstetrics, does not support most standard obstetrical practices. Yet science has been used by obstetricians for 150 years to justify the interventions they invented and then increasingly performed. Science used ethnocentrically for Stage Two biomedical thinkers is a blinder for what is really medical tradition, passed down from teacher to student through apprenticeship/experiential learning.
Stage Three/Cultural Relativist Midwifery Systems
I have no data at all to support this assertion, but it seems to me that very few midwives in the contemporary world are true cultural relativists. Midwives deal with life and death, and know that their decisions can result in either one. Stage One midwives make decisions based on the only knowledge they have; Stage Two midwives make decisions based on the knowledge they are sure is best. But of thousands of midwives I have talked with, I can’t think of who bases her decisions on no standards at all. Postpartum hemorrhages must be stopped if at all possible. Babies in transverse lie cannot be born unless the midwife does something. Stage One and Stage Two midwives will deal with such complications as their belief systems dictate. But midwives with open minds and systems fluid enough to encompass multiple cultural realities will not be content to approach such complications in whatever way the culture of the woman they are attending would dictate. If they know a way that is scientifically proven to have better efficacy than a traditional way (whether traditional in a biomedical or an indigenous sense), they will apply it. The decisions they make in life-crisis situations are not based on a “whatever the culture says” attitude, but rather on a “whatever works” attitude. And what midwives with open cognitive systems know about what works will constantly change as they are exposed to new information, whether it comes from science, from traditional midwifery, or from a workshop they just attended the day before.
Stage Four/Gobal Humanist Midwifery Systems
In today’s rapidly changing and highly fluid world, to be truly effective, midwives must remain constantly open to the new information that is constantly emerging from science and from the increasingly availability of midwifery knowledge from multiple systems—allopathic, indigenous, traditional, biomedical, alternative or complementary, etc. Sometimes the best option for a birth complication might be a homeopathic remedy, sometimes it might be a position used by traditional midwives, sometimes it might be a cesarean section. The Stage Four midwife will keep her system open to new learning from many sources. And she will seek the highest moral and ethical standards, which involve giving compassionate, woman-centered care responsive to the needs of the individual regardless of what the system dictates.
Why Many Midwives Do Not Give Stage Four, Globally Humanistic Care
Cognitive openness and humanistic standards are not easy to maintain, especially in a busy and stressful practice. Even those Stage Four midwives who want to remain open to new learning and new ways of thinking find that the more stress they are under, the less able and willing they are to process new information. Often they simply don’t have the energy or the time. Persistent stress can reduce even highly fluid, Stage Four thinkers to Stage Two or Stage One levels by causing cognitive overload and the development of “tunnel vision”–the need to shut out most stimuli and focus on one thing only. In other words, stress can make fluid thinkers become rigid, if only for a while. How often have you thought, on an especially stressful day, “just don’t tell me one more thing”? Usually rest will restore Stage Four thinkers to their normal fluid state. But if the stress continues for too long or becomes too intense, anyone can disintegrate into Substage–a condition of hysteria, panic, or even full-fledged nervous breakdown (also known as “losing it”).
Performing rituals can stabilize individuals under stress at Stage One, thereby preventing them from degenerating into Substage. (When the airplane falters, you start to pray. When the crops fail, you make offerings to the gods. When labor slows, you administer pitocin and hook up the monitor.) Stage One rituals can generate a sense that everything is under control (even if it isn’t). Practitioners facing what they see as constant potential crises in childbirth use such Stage One rituals preventatively, so that things always feel or seem to be under control.
Let’s take a quick look at what women studied by anthropologists all over the world have said about professional midwives working under high levels of stress inThird Worldcountries:
- “They shave you.”
- “They cut you.”
- “They leave you alone.”
- “They don’t let your family members in to be with you.”
- “They yell at you and sometimes, they slap you.”
Perhaps most midwives who practice in these ways at first approached midwifery with high ideals of serving women, just as most obstetricians do. But if you are practicing in a rural clinic in Papua New Guinea or a huge hospital in India, where supplies are limited or non-existent, there are more women than you can possibly care for, there is often no running water and little or no food available for the women, you are treated as inferior by physicians and nastily by nurses who resent your authority, and you are paid so little you can barely support your family, it is most likely that your ideals will fade away in face of unbearable realities. You will shut down cognitively and focus on finding any bits of pleasure or relaxation you can—in other words, you will take every opportunity to drink coffee with your colleagues and ignore the women screaming for your help in the next room. Such are the effects of stress, overwork, underpay, and professional devaluation. Many anthropologists have noted that midwives new to work in such places are often initially horrified by the behavior of their elders and work harder to support and care for the women, yet a few months or years later, will be behaving exactly like the colleagues they initially abhorred.2
What about midwives in the developed world, where technology, supplies, clean water, and food, are readily available, the pay is reasonable, and schedules offer time off to be with one’s family? Indeed, it is this kind of midwife who is most likely to care about moving beyond rigid knowledge systems to create a more open, fluid, and individually responsive style of midwifery care. And yet evenFirst Worldprofessional midwives are likely to succumb to the pressures of biomedical socialization and habituation to certain routines, to practice defensively to avoid accusations of malpractice, to conform to institutional systems rather than take the time and energy to fight them.
For one example, in theUK70,000 professional midwives attend 70% of births. To American professional midwives, this situation seems ideal. Yet the Stage Four midwifery thinkers in theUKnote sadly that most of those 70,000 midwives have become the source of, not the solution to, the problem. Habituated to hospital birth and biomedical routines, most British midwives have fought rather than welcomed the British government’s mandate for more home births. Mavis Kirkham and others have documented how such midwives move among their patients giving vague information, refusing to answer specific questions, offering little or no one-on-one support, and dealing with patient requests by answering “Sister wouldn’t like it”—“Sister” meaning the starched and unbending head midwife who runs her clinic more like a business than a support service.
How Midwives Can Foster Stage Four Thinking for Themselves and Other Midwives
(1) Attendance at midwifery conferences. When a midwife goes away to a conference, she is free from the daily pressures of her practice to take in new information. She is exposed to ways of thinking, knowing, and practicing that may not match her own. The midwives in the developed world who tend to become rigid in their practices rarely attend such conferences; they are the ones who most need to attend.
Over the past twelve years, I have attended hundreds of midwifery conferences, and have watched how midwives “get their juice” through being there. Midwifery Today conferences are particularly salient in developing and maintaining Stage Four thinking, as their organizer, Jan Tritten, makes every effort to include all types of midwives—professional, traditional, nurse-, direct-entry—on her programs so that every Midwifery Today conference provides opportunities for midwives to be exposed to the ways other midwives think and know. MANA and ACNM also provide many such opportunities—their conferences include workshops that range from the highly technical to the highly holistic. Particularly exciting are conferences held in countries where midwives are beginning to move outside their normative practices, such as the home birth conferences recently held inSpain. ICM conventions bring together professional midwives from all over the world, and every time slot on the program offers at least a dozen sessions appealing to every possible midwifery knowledge, skill, special interest, or cultural approach. Small-scale regional midwifery conferences allow midwives living in relatively close proximity to share common interests and expand their knowledge bases about their own history and political situations.
Every midwifery conference I have ever attended has offered its participants many ways to “think beyond” established paradigms and practices; thus I encourage every practicing and student midwife to attend as many such conferences as she practically can.
(2) Learning from women. Midwives who practice the same way for many years are usually midwives who have stopped listening to mothers. Every woman a midwife attends can bring something new to her knowledge and practice. I have interviewed hundreds of midwives about their education and practice, and have often been struck by the changes in practice that can result from listening carefully to and learning from just one woman, who perhaps is unusual but who can teach the midwife herself something new about how best to provide woman-centered care.
(3) Learning from midwives. Midwives have lots of stories to tell, and they tend to be excellent story-tellers. When midwives get together and tell stories, they are not just engaging in chit-chat, but are sharing important aspects of what they learn and how they learn it, of what they know and how they use that knowledge, whether it is didactically obtained or intuited in the moment. When obstetricians get together and discuss birth, the stories they tell are usually stories of pathologies that they find intrinsically interesting because of the puzzles they present, or crises in which they saved or failed to save a life. In dramatic contrast, midwives tend to prefer to tell stories of normal birth, or of how they helped a birth that could have become pathological stay normal (a process I call “normalizing uniqueness”). So much midwifery lore and knowledge is encoded in these stories: listen to them, record them, write books and articles full of them so that others can learn what your stories have to teach!
[Note to editor: This paragraph could be cut if necessary] It is fascinating to me that the earliest midwives to write down midwifery knowledge, like Sarah Stone in Britain in 1737, were not able or did not think to abstract what they knew into categories like “how to handle a post-partum hemorrhage.” Rather, they told the stories of the births they attended. The first British midwife to write abstractly about midwifery knowledge, Elizabeth Nihell in 1760, had been taught and heavily influenced by William Smellie, one of the early male midwives.3 That is one reason why Ina May Gaskin’s Spiritual Midwifery has been so important and influential for so many midwives around the world: she told stories, and in the telling one can see how her knowledge developed through her individual experiences with the women she attended.4 Her second book, Ina May’s Guide to Natural Childbirth, offers many stories written by the couples she attended.5 Into these stories, Ina May interjects in her own words the points at which she had a flash of intuition or a “hunch” that such-and-such might be a good thing to do, and tried it out. The stories allow us to witness her learning process in action and observe how her Stage Four thinking abilities kept her open to learning directly from women and from her own intuition, experientially, in the moment.
(4) Attention to the scientific evidence. The body of scientific evidence supporting many traditional and professional midwifery practices is ever-growing. Every midwife should keep up with it, as so much of it reinforces what has become internationally known as “the midwifery model of care.” Real science is differs fundamentally from biomedical tradition. Every Stage Four midwife should have science at her command, all references ready to counteract every biomedical objection to the kind of care she wishes to give.
(5) Attention to other healing philosophies and modalities. Naturopathy, chiropractic, homeopathy, Reiki, breath therapy, massage therapy, pre- and perinatal psychology, Ayurveda, Chinese medicine, and many other types of “complementary” health care, as well as many indigenous knowledge systems, have much to offer the contemporary professional midwife. It is not possible for every midwife to know all of these systems, but it is possible to be open to what they can offer by learning about them, incorporating one or some of them, and finding practitioners to whom clients can be referred.
Conclusion
Around the world, midwives are under siege as the power and influence of biomedicine grows. Traditional midwives are in danger of extinction and professional midwives are too often ethnocentric servants to biomedical ways of knowing and practicing. Yet in every country, there are dozens and sometimes thousands of midwives, both traditional and professional, who are Stage Four global humanists striving to think beyond established paradigms and practices. Such midwives are constantly working to combine the best of indigenous, allopathic, and alternative knowledge systems to create fluid and open midwifery knowledge systems responsive to women’s needs and desires, to ideas and information from other midwives and health care workers, to scientific evidence, and to “whatever works” from wherever it can be learned. If you are a midwife practicing in the 21st century, you have two brand new advantages that your historical counterparts did not have: (1) access to information from a rich variety of sources; and (2) strength in local, national, and international organization. I ask you to utilize these strengths, acknowledge your limitations (remember that stress can take you “down” both physically and cognitively), and strive to keep your knowledge systems open to the learning that this new world can multiply provide.
Endnotes
1. The “four stages of cognition” schema I present here can be found in Schroder, H. M., M. Driver, and S. Streufert, Human Information Processing (New York: Holt, Rinehart, and Winston), 1967. The combination of this theory with the anthropological concepts of naïve realism, ethnocentrism, cultural relativism, and global humanism is entirely my own. Further discussion of this combination can be found in Davis-Floyd, Robbie and Gloria St. John, From Doctor to Healer: The Transformative Journey, New Brunswick NJ: Rutgers University Press, 1998 and Davis-Floyd, Robbie and Charles Laughlin, The Anatomy of Ritual (New York: Random House/Schocken), n.d. (forthcoming).
2. The anthropological studies I draw on are too many to be listed here. Partial references can be found in Davis-Floyd, Robbie, “Mutual Accommodation or Biomedical Hegemony,” Midwifery Today, March 2000, pp 12-17, 68-89. Full references to and descriptions of many of these works can be found in Davis-Floyd, Robbie, Sheila Cosminsky, and Stacy Leigh Pigg, “Introduction” to Daughters of Time: The Shifting Identities of Contemporary Midwives” (a special triple issue of Medical Anthropology 20:2-3/4, 2001). This Introduction is also available at www.davis-floyd.com
3. Stone, Sarah, A Complete Practice of Midwifery, Consisting of Upwards of Forty Cases or Observations in That Valuable Art, London: printed for T. Cooper, 1737; Nihell, Elizabeth, A Treatise on the Art of Midwifery. Setting Forth Various Abuses therein, especially as to the Practice with Instruments: The Whole Serving to put all Rational Inquiries in a fair Way of very safely forming their own Judgement upon the Question; Which it is best to employ, In Cases of Pregnancy and Lying-In, a Man-Midwive, or, a Midwife, London: A. Morley, 1760. Stone and Nihell’s works are described and compared by Herrle-Fanning in Body Talk: Rhetoric, Technology, Reproduction, edited by Mary M. Lay, Laura J. Gurak, Clare Gravon, and Cynthia Myntti.Madison:University ofWisconsin Press, 2000.
4. Gaskin, Ina May, Spiritual Midwifery.Summertown,Tennessee: The Book Publishing Company, 1977.
5. Gaskin, Ina May, Ina May’s Guide to Childbirth.New York: Bantam, 2003.
ecofB%?0im?? 8?? link the fate of the planet, metaphorized as Gaia, the Mother Goddess, to the cultural treatment of the female body (see for example Diamond and Orenstein 1990; Starhawk 1988, 1989, 1993; Diamond 1994). Much as they interpret intuition as both spiritual and embodied, they honor the Goddess as a spiritual reality embodied in the earth, and as a metaphor of and for women’s creative power, of which birth is but one expression. As Maggie points out above, to serve the Goddess is to learn to give up one’s desire for control, to surrender to the ebb and flow of Her inscrutable rhythms.
Spirituality is a strong component of independent midwifery, but there is a great deal of variation in spiritual orientation. While most midwives in MANA actively celebrate the Goddess or are quite comfortable with the Goddess-as-metaphor, some have a strongly Christian orientation towards birth. Christian midwives tend to interpret birth not so much as a manifestation of the woman’s own personal power but of God’s power flowing through the birthing woman. This is the view held by Maggie’s client Jane, and the reason why Jane would not appreciate Maggie’s calling her a Goddess, which for Maggie is the highest compliment she can give to express her appreciation for Jane’s profound inner connectedness and strength.
At this point in Maggie’s recounting of this birth, the question of protocols and external diagnostic technologies again came up. The high authority that Maggie placed on her inner knowing during this birth was clearly demonstrated when she said that she never made a decision based on anything that was written on Jane’s chart–her blood pressure, urinalysis, information about rate of dilation and progression of labor, etc.–because, as she put it, “it wouldn’t be neat, it wouldn’t add up, it wouldn’t follow any kind of progression that was any kind of normal anything.” I asked: “So why didn’t you make an effort to make this labor conform to normal by transporting her?” and Maggie answered:
Because every time I [checked with Jane, she would tell me that she was fine and that she knew the baby was fine]. And every time I looked at her, and every time I looked inside myself, and every time I saw that–whatever it is–the place where the baby was–the baby was safe…Inside my head I saw the baby safe–and this is my own metaphor, I realize, but I saw the baby surrounded by sparkling light, kind of like glittery flecks of amniotic fluid.
Q. So your inner vision of the baby corresponded with the mothers?
Yes.
This correspondence of Maggie’s inner vision with the mother’s is a prime example of the kind of connectedness that midwives see as essential for the emergence and the credibility of intuition. Our other interviewees generally agreed on the persuasive power of such correspondence of intuitions.21
Maggie and I explored in further conversation the mystery of why, in some cases, she will urge a woman to transport in the face of a minimum of indicators, while in a case like Jane’s she would stay home in the face of a maximum of indicators for transport. We asked her, “Is that a matter of intuition for you every time?” She replied:
Yes. You see, I don’t know about where it all goes together, because I keep charts, and I do signs, and I check dilation, I look at the color of the amniotic fluid, I take blood pressure–I do those kinds of clinical things….But…. one month I realized that I had been to five births within a month, and only one of them fit within protocols. And I had to look at myself and say, I think of myself as a conservative midwife, but what’s wrong here if four out of five births are out of protocol, am I a radical midwife, am I a dangerous midwife–what’s going on here?
And I really had to evaluate, and look at my charts with somebody else, before I could come up with a picture of me as a midwife, and what I resolved for me is that where birth is not normal, part of a midwife’s job is to return it to normal. For example, in the case of a VBAC, which is regarded medically as high risk and almost universally by midwives as not high risk, what we’re doing in that case is returning birth to normal. And when we go four, five, six hours of pushing, we are also returning birth to normal, a normal that says if the woman pushes for three hours and she’s exhausted, then she can take a rest, and maybe in a couple of hours, she’ll get her strength up, and then she’ll be able to push again–she will get her baby out. When we do things like that, we’re returning birth to normal.
Rather than de-and reconstructing labor to fit abstract and narrowly drawn technocratic parameters of normal–a process that often results in major surgery as the final reconstructive step–what Maggie and her sister midwives do is to continually redraw the parameters, processually expanding their definitions of normal to encompass the range of behaviors and signs actually exhibited by pregnant women as they labor and birth. In short, these midwives are willing to expand protocol parameters to reflect the realities of individual labors, rather than reshaping labor to fit protocol parameters. They see a labor that is unlike other labors, not as a dysfunction to be mechanistically normalized according to the standardized technomedical system of authoritative knowledge, but as a meaningful expression of the birthing woman’s uniqueness, to be understood on its own terms.22
Normalizing Uniqueness: The Connective Dance
The midwifery normalization of uniqueness must be understood in the context of the technomedical pathologization of uniqueness. The technocratic model of birth defines as “normal” only those births that fall within specific parameters–twelve hours for labor, cervical dilation of 1 centimeter per hour, steady fetal heart tones, etc. Labors that take too little or too much time, cervixes that remain “stuck” at four centimeters for hours on end, heart tones that speed up or slow down, meconium in the amniotic fluid–all are defined as dysfunctional “deviations from the norm.” Aware of technomedical parameters, midwives must constantly weigh their trust in and acceptance of women’s individual rhythms against the consequences of straying too far outside of the medical protocols that are regarded as authoritative in the courts.
As in Maggie Bennett’s story above, this tension between the technomedical pathologization and the midwifery normalization of uniqueness is reflected in the following story told byVermontmidwife Judy Luce:
A woman came to me…she was 39 and pregnant with her third child. The first child had been born by cesarean after 37 hours of labor. [The child had a severe genetic defect, and died at the age of three.] And within eight months of that her second child was born, prematurely–a vaginal birth but 31 hours of labor, four hours of pushing, and a forceps delivery for a six-pound ten-ounce baby. So she’s due at the end of September, and wants to have a home birth. She is an artist, she does huge oil paintings, brilliant…incredible intensity, vibrant colors, and she did a whole series that tell stories of her first child’s birth, of the sickness, the dying, the death, and the grieving. Just a whole series which were so amazing and intense. So, the weight–the birth felt very heavy to me. There was a lot staked, not just on having another child, but also on what the birth was going to mean, and you know, the due date came and went and lots of early labor, but nothing happening. You know, it would begin–all night backaches–but never really taking off…
Finally she called and said “My water just broke, and it’s really–it has brown meconium in it.” So I go dashing over there again, and you know, the pad, her underpants, the floor, it’s thick brown. And it’s not thin–there’s nothing thin about this. I listened to the baby through a couple of contractions, and the baby was wonderful, real reactive…And I felt deeply, intuitively, that this baby was fine, but there was a weight around the whole birth…If she had the baby in an hour, I could stay and deal with this, but [she was only two-to-three centimeters dilated, and] what am I going to do if it’s 20 or 30 hours of labor, like the first two times? And how do you defend yourself in court, if the baby aspirates meconium, when you’d have to say, 20 hours ago, I knew this was here?
[So I call my physician backup, and then I talk the couple into going to the hospital.] And the mother felt too dirty and grungy to go to the hospital without a bath, so she got in the shower at about 6:08, and I go in, and she’s standing there, trying to get out, holding her stomach and going “Unnnhhhhhh” [a common sound women make when they push]. So I get her in the bedroom and check her, and the baby’s head is just coming into my hand. And at 6:28 she had an eight-pound baby girl, beautiful birth, no tearing. The baby was clear as a bell, but every bit of the fluid was just filled with meconium–you could just stir it around.
Afterwards, she said to me that when she got in the shower, out of this place she couldn’t even touch, this immense grief came up and she cried, she just sobbed. Her husband said, “What’s the matter?” and she said, “I just need to cry.” And she opened, you know. That sobbing–everything opened. And that baby was born. And I think it’s about holding on to the integrity of what you’re feeling. It’s not because you’re right–there was a dance that went on between us about that decision-making, and that space was big enough for that birth to happen. It was just immensely powerful.
Knowing that “there are no guarantees, even with intuition,” Judy had been planning, “with grief,” as she put it, to take the mother to the hospital in accordance with medical protocols, a decision to which the mother herself had acquiesed. Both of them apparently felt that the mutuality of the decision-making process left room enough, space enough, for the birth to happen at home after all. It was not a question of imposing authority, or even, in this particular case, of anyone holding the key to a particular kind of knowledge that either of them considered authoritative. They both knew that technomedical protocols indicated immediate transport in the case of thick meconium in the amniotic fluid, as the baby is in danger of aspirating the meconium. The midwife also knew from experience that meconium aspiration happens a good deal in the hospital (usually when the umbilical cord is cut too quickly, forcing the baby to breathe strongly before its airway can be completely cleared) but is rare at home (midwives usually wait to cut the cord until it stops pulsating). So, even though the midwife decided on transport, she was not anxious or nervous, but relaxed–her intuition told her the baby was fine, and her reason told her there was no cause for undue alarm, as even with meconium, the baby might be better off at home. The midwife’s relaxed and accepting attitude allowed the woman the time and space to take the shower and thus to experience the emotional release she needed to be able to open up and give birth. Together, even as they both surrendered to the authoritative technomedical protocols that indicated transport, they still managed to hold a consensual space of connection in which the birth could happen at home–the “decision-making dance,” as the midwife called it. In the eyes of midwives, birth has been made abnormal by technocratic medicine. As Judy’s story illustrates, the give-and-take of this “dance” is instrumental in midwives’ ongoing efforts to normalize uniqueness in birth.23
In a recent paper, Brigitte Jordan, whom we honor in this collection, speaks of authoritative knowledge as grounded in a community of practice, adding that within that community:
authoritative knowledge is persuasive because it seems natural, reasonable, and consensually constructed. For the same reason, it also carries the possibility of powerful sanctions, ranging from exclusions from the social group to physical coerciveness. [1992:3]
Certainly this is true of the authoritative knowledge of the technomedical community. But midwives who act on intuition do so in opposition to the cultural consensus on what constitutes authoritative knowledge in birth. Their protocols are their link to that larger biomedical system of authoritative knowledge; like physicians in the hospital, the farther they stray from those parameters, the more they place themselves at risk of the powerful sanctions of whichJordan speaks.
Yet within the midwifery community, intuition does count as authoritative knowledge–to quote Jordan again, “the knowledge that participants agree counts in a given situation, that they see as consequential, on the basis of which they make decisions and provide justifications for courses of action” (1992:3; emphasis in original). When Maggie shared her records with other midwives for peer review and evaluation, she was greeted with reassurance and acceptance; in spite of its devaluation, or simply nonrecognition by the larger culture, these midwives too valued intuition as authoritative.
Jordan points out that “to legitimize one kind of knowing devalues, often totally dismisses, all other ways of knowing, [so that] those who espouse alternative knowledge systems are often seen as backward, ignorant, or naive troublemakers” (1992:2). Her words capture in a nutshell what the larger technomedical culture has done, in this country and many others, to the alternative knowledge systems of midwifery. Hanging out on the ragged edge, far outside of the safety net of cultural consensus, these women of tremendous hearts find their courage not in the normalizing performance of standardized routines, but in their connectedness to the women and babies they attend. As Maggie put it:
Mothers and midwives mirror one another. I know that I get all of my courage from the mother. And I bounce it back to her, and she gets her courage from me….It’s a dance–the woman has to trust her midwife, and the midwife has to trust her woman for that bouncing back.
Sanctioning Intuition as Authoritative Knowledge
The midwife provides care according to the following principles:
Midwives work as autonomous practitioners, collaborating with other health and social service providers when necessary.
Midwives understand that physical, emotional, psycho-social and spiritual factors synergistically comprise the health of individuals and affect the childbearing process.
Midwives recognize that a woman is the only direct care provider for herself and her unborn baby; thus the most important determinant of a healthy pregnancy is the mother herself.
Midwives synthesize clinical observations, theoretical knowledge, intuitive assessment, and spiritual awareness as components of a competent decision-making process.
–Excerpts from the “MANA Core Competencies for Midwifery Practice,” a five-page document approved in final form by the Board of the Midwives’AllianceofNorth America,October 3, 199424
Until recently, homebirth midwives’ use of intuition as authoritative knowledge at births has been entirely informal, experienced in the uniqueness of the situation, talked about in wonder and awe among themselves and with the mothers25 they attend, but not formally encoded as an official source of authoritative knowledge. With the finalization and approval-by-consensus of the “MANA Statement of Values and Ethics” (quoted earlier) at the MANA business meeting on November 13, 1992 in New York City, and the 1994 approval of the “MANA Core Competencies” quoted above, intuition received formal recognition from midwives themselves as an integral aspect of competent midwifery practice. Some new challenges thereby arose.
One of the most pressing issues facing postmodern homebirth midwives is that of certification and licensure. Midwives in many states have been lobbying for legalization and licensing for years, and increasingly are achieving these goals. Members of MANA have been well aware that if they do not establish their own testing and certification process, others–state governments, theAmericanCollegeof Nurse-Midwives, medical boards–will establish one for them. So MANA has created NARM–the North American Registry of Midwives–as a separate, nonprofit corporation, and empowered the seven members of the NARM board to develop and implement a national certification process for direct-entry midwives, guided by a Certification Task Force of approximately 40 state representatives.
This in itself is a somewhat oxymoronic situation. MANA prides itself on its inclusivity, yet the essence of certification is some degree of exclusivity. When tests and standards are created that all midwives must meet, some will pass and some will fail, and, quite possibly, midwives who are competent at births will remain uncertified simply because they do not test well. In an effort to minimize this type of exclusionary outcome, which would limit homebirth midwifery to those who excel at ratiocinative thinking, the members of the Certification Task Force are trying very hard to create testing and evaluation systems that will be fair to all. Agreeing that written (ratiocinative) tests, while the easiest to administer, cannot provide the whole picture, task force members considered the idea of multiple options for demonstrating skill, including a simulated skills exam, in which the aspiring licensee could come to a central site and demonstrate her skills on plastic models of a birthing woman and child. When this idea was presented to the general membership of MANA, a common response was exemplified by one midwife who exclaimed in dismay, “My spiritual guides are the ones who tell me what to do at births, but they will not be there if I am working on plastic dummies!” Another midwife emphasizes intuition’s central role:
Let’s decide how a midwife should be tested, and let’s test her that way. Let’s not kiss up to the standards of the medical profession in order to satisfy them that we are competent. Let’s satisfy ourselves that we are competent–and we’ll know that competency if our hearts are true, and if we’re honest about our intuitive skills. Intuition is often what makes us smart, what makes us do the work best, what makes us able to pick up problems earlier than anyone else and therefore deal with them more effectively. [Jill Breen, community midwife, quoted in Chester 1994:3)]
In response to such appeals, the NARM board has developed a certification process for the Certified Professinal Midwife (CPM) that is balanced between the ratiocinative and the hands-on: it requires (1) that the applicant be checked off on a long list of required skills by her midwifery mentor, who will have many opportunties to see her demonstrate those skills during the course of her training in a connective context in which she can indeed listen to her guides and inner voices; (2) passing a challenging day-long written exam that tests the extent and depth of her knowledge; (3) passing a hands-on skills assessment exam administered by an experienced midwife. The proposal’s balance, as well as MANA’s Statement of Values and Ethics and Core Competencies, indicates the increasing determination of these midwives to honor both ratiocination and intuition as communally sanctioned and respected sources of authoritative knowledge.26
Conclusion
In this article we have sought to examine the phenomenon of midwives’ occasional willingness to rely on intuition as a primary source of authoritative knowledge in a society that grants conceptual and legal legitimacy only to ratiocination. We have seen that the trust these midwives place in inner knowing is a seamless part of their overall philosophy, as expressed in the “MANA Statement of Values and Ethics,” and as exemplified in the stories they tell about their individual experiences with intuition and birth. In contrast to the technocratic model, which charters an ever-expanding plethora of separation-based diagnostic and remedial technologies, this holistic midwifery philosophy supervalues inter- and intrapersonal connection, and charters a range of behaviors expressive of that connective “dance.”
Intuition, in these midwives’ view, emerges out of their own inner connectedness to the deepest bodily and spiritual aspects of their being, as well as out of their physical and psychic connections to the mother and the child. The trustworthiness of intuition is intrinsically related to its emergence from that matrix of physical, emotional, and spiritual connection–a matrix that gives intuition more power and credibility, in these midwives’ eyes, than the information that arises from the technologies of separation. That midwives nevertheless carry with them and freely utilize such technologies demonstrates not only that they also value ratiocination, but that they are becoming experts at balancing the protocols and demands of technologically obtained information with their intuitive acceptance of women’s uniqueness during labor and birth. We submit that their deep, connective, woman-to-woman webs, woven so lovingly in a society that grants those connections no authority of knowledge and precious little conceptual reality, hold rich potential for restoring the balance of intimacy to the multiple alienations of technocratic life.
Notes
Acknowledgments. We wish to thank Carolyn Sargent, Ann Millard, Gay Becker, and midwives Judy Luce, Karen Erlich, Penfield Chester, Anne Fry, Marimikel Penn, and Sharon Wells for their excellent editorial assistance, four anonymous reviewers for their useful suggestions, and our midwife-interviewees for giving so generously of their time and experience.
Correspondence may be addressed to the first author at 1301 Capital of Texas Hwy. B128, Austin TX 78746; (512)327-4726; fax (512)327-3459; davis-floyd@mail.utexas.edu.
1. It is common usage among mothers and midwives in the alternative birth movement to refer to birth at home as “homebirth”–especially when used as an adjective, as in “homebirth mothers”; I follow that usage here.
2. Non-nurse midwives in the U.S. used to be known as “lay midwives.” But in recent years, such midwives, including those who are apprentice-trained, have developed an extensive array of skills including the ability to use various high technologies (see note 11), have banded together in professional associations, and have organized politically to create a national certification program and to fight for state licensure. Thus many of them have come to think of themselves as professionals, and to resent the appellation “lay,” which we do not use in this article.
3. The global scope of postmodern midwifery was evidenced by the attendance of over 3000 midwives from 44 countries at the 1993 convention of the International Confederation of Midwives (ICM) in Vancouver, Canada. Members of the ICM share in common a commitment to the midwifery (“with woman”) approach to prenatal, natal, and postnatal care, and a growing concern for an increasingly compromised scope of practice. In Germany, for example, midwives may assist delivery but can do no prenatal care; in France they may do prenatal care but are greatly restricted in deliveries; and, as we have seen elsewhere in this volume, in the Third World the midwife’s role is increasingly constrained by biomedicine. Generally, the ICM represents midwives with professional academic preparation, but its membership is increasingly beginning to reflect a determination on the part of midwives in both developed and underdeveloped countries to ensure the continued viability of the independent midwife able to assist birth in any setting, particularly the home.
4. In Hawaiian, “mana” means “an underlying, vital energy that infuses, creates, and sustains the physical body” (MANA News 1990). As one of our anonymous reviewers aptly pointed out, mana in Greek is the affectionate term for “mother.” And of course, in Hebrew and Greek, manna means divinely supplied spiritual nourishment.
5. There have been and still exist sharp divisions and disagreements between ACNM and MANA over the nature of midwifery and the definition of what constitutes appropriate midwifery education and competent midwifery care. Nevertheless, these two organizations do both place high value on coexistence and cooperation, and have enacted those values for the past several years through the Carnegie Interorganizational Workgroup on Midwifery Education, created and funded by the Carnegie Foundation. This group included an equal number of representatives from ACNM and MANA. During lengthy deliberations, the ACNM representatives agreed to accept the concept of another type of certifiable midwife besides the medically trained CNM. After enormous effort, group members reached consensus on the definition of the certified nurse-midwife (CNM) and the certified midwife (CM*) in a “joint statement on certification” endorsed by both MANA and ACNM in 1993. This statement makes it clear that, while educational preparation and accountability mechanisms vary, the CNM and the CM will share a common scope of practice: both will be certified to offer full-spectrum midwifery care. Since 1993, MANA members have been actively establishing verification and testing procedures for certification of the CM (see concluding section). [*At a meeting of the Certification Task Force on October 4, 1994, by consensus, CM was changed to CPM--Certified Professional Midwife. The word "professional" had been the subject of debate in MANA over its exclusionary connotations; nevertheless, the 40 members of the task force came to consensus on its use, in part out of strong feelings that the competence of independent midwives has been fully demonstrated and that they deserve to claim full professional status equal, not subordinate, to that of CNMs.]
6. This issue of apprenticeship is a major impediment to continued consensus between MANA and the ACNM, which honors only formal educational training as an appropriate route to midwifery, and insists that apprenticeship is not a valid educational route. (See Jordan 1993 Ch. 7 for a detailed discussion of the differences between experiential and didactic learning.) The question of apprenticeship has proved to be so divisive that it has resulted in a fresh controversy between these two organizations. In June 1994, the ACNM voted to accredit direct-entry midwives (which in this case means midwives with no training in nursing) who are educated in university-based midwifery programs. At the time, members of MANA perceived this as an act overtly subversive of their efforts to create their own certification process for the CM–certified midwife–who can qualify for certification through either formal schooling or hands-on experiential apprenticeship training (or a combination of both). The fact that they agreed by consensus to change CM to CPM reflects their strong belief that both competence and professionalism can be achieved through either route. The coauthors of this article are presently engaged in research and writing on this highly contested issue in postmodern midwifery.
7. Copies of the MANA Statement of Values and Ethics can be obtained from Signe Rogers, Editor, MANA News, P.O. Box 175, Newton KS 67114.
8. Contemporary CNMs, many of whom are or wish to be in independent practice, seriously question the limitations imposed by their structural subordination to physicians. Some members and officials of the American College of Nurse-Midwives are currently contemplating a focused effort to re-create nurse-midwifery as an independent primary health care profession, subject not to nursing but to autonomous midwifery boards.
9. Breastfeeding constitutes a good example of the pragmatic ramifications of insisting on the value of connection. 98 per cent of American women give birth in hospitals; around 50 per cent of them breastfeed their babies during the early months of life. Of the 2 per cent of women who give birth at home or in freestanding birth centers–in other words, in accordance with the connection-based holistic model of birth–close to 100 per cent choose to breastfeed (Arms 1994:201). That connectedness also facilitates birth itself has been amply demonstrated by the doula studies, which show beyond a doubt that the nurturing presence of a woman companion during labor reduces length of labor, lessens perceptions of pain, and improves birth outcomes, both physical and emotional (Sosa et al. 1980, Kennell et al. 1988).
10. The importance of the web metaphor to the members of MANA as an expression of their lived experience was demonstrated during the closing ceremonies of the 1993 San Francisco conference. Four hundred and fifty midwives formed a giant circle around the edges of an otherwise-empty ballroom. They passed balls of yarn in many colors around the circle; each participant looped each color of yarn that came to her around her wrist, until all were physically connected. Then they tossed many more balls of yarn across the floor to each other, tying those around their wrists also, until all that yarn formed a giant rainbow-hued spider web that filled the ballroom floor, linking everyone to everyone through myriad connections. Spontaneously lifting the giant web into the air by lifting their arms, the midwives quickly discovered that, if one person moved her arm, the whole web would move in response. And if a ball of yarn got stuck in the middle of the floor, at least 30 people had to move in synchrony for one person to retrieve it. This of course was a perfect ritual and symbolic enactment of the high value these midwives place on human interconnectedness.
11. Interviewees Maggie Bennett, Jeannette Breen, Elizabeth Davis, and Judy Luce insisted on being identified by their own names, in keeping with their strong beliefs in the value of their work and of their intuitive experiences. All other names following quotations are pseudonyms.
12. Items that a typical postmodern midwife carries with her to a home birth include: a pager and/or a cellular phone; a blood pressure cuff; a stethoscope; a fetoscope and a Doppler–an electronic amplifier of the baby’s heartbeat (for monitoring fetal heart tones); sterile gauze; antiseptics–alcohol, peroxide, betadine, or hibiclens; alcohol prep pads, alcohol swabs; Q-tips and cotton balls; flashlights; urinalysis strips (to test for glucose, ketones, PH, blood, and protein); Fleet enema (rarely used); nitrazen paper (to test for leaks in the amniotic sac); culture tubes (for taking a baseline culture of the amniotic fluid); equipment for drawing blood to send to a lab for a white count (to check for infection); urinary catheter kits; sterile KY jelly; a variety of herbs, tinctures, and homeopathic remedies, including rescue remedy (for severe stress), goldenseal (for drying the cord stump after it is cleaned with alcohol), arnica salve (for skin swelling and trauma), black and blue cohosh and colophyllum (for enhancing contractions), evening primrose oil (for assisting cervical dilation), spirits of peppermint (for assisting bladder function–often can be used instead of a catheter), angelica (for assisting placental expulsion), shepherd’s purse (for preventing postpartum hemmorrhage), Crampease (a mixture of herbs) for afterpains, black haw (for postpartum cramps), and valerian (for relaxation); olive oil for perineal massage; a birthing stool; an amni-hook for breaking the waters if they are still intact when the baby crowns (so that they won’t break all over the midwife–AIDS can be transmitted through the amniotic fluid); waterproof pads and sheets; an oxygen tank, mask for the mother, and infant resuscitation bag and mask (rarely used); special scissors for cutting an episiotomy (rarely used); syringes and drugs (injectable pitocin, injectable methergine, and oral methergine) to stop a postpartum hemorrhage; IV lines and fluids; instruments and sutures for repairing vaginal tears; sheets to create a sterile barrier field while suturing; a tensor or desk lamp (for visibility during suturing); a local anesthetic (xylocaine or 1 or 2per cent lidocaine) for pain relief during suturing; a heating pad to assist in warming the baby; a bulb syringe (for suctioning the baby’s airways) and DeLee suction catheters (for sucking amniotic fluid out of the deeper respiratory passages of the newborn–rarely used); assorted hemostats and clamps; special scissors for cutting the cord; scales for weighing the baby and a tape measure; oral vitamin K; erythromycin ointment (to place in the baby’s eyes to prevent blindness from venereal disease–a requirement in most states); footprint pads in multi-colors (for taking the baby’s footprint for the birth certificate); sitzbath herbs (for soothing the woman’s vaginal area postpartum); red-top sterile vacuum tubes (for collecting umbilical cord blood for testing); and a file full of papers for charting, preparing the birth certificate, etc. Most midwives carry enough supplies with them at any one time to attend three births in a row without repacking.
Some midwives also carry: physician-prescribed antibiotics, and Phenergan suppositories for stopping violent vomiting; a laryingiscope (for looking into the baby’s trachea and larynges if there is reason to believe the baby may have aspirated meconium) and sterile saline (to wash the baby’s vocal chords if necessary)–these are very rarely used; breast shields (for cracked nipples) and breast shells (for helping the nipples to become more prominent so the baby can more easily latch on to the breast); and a newborn screening kit (this kit consists of a syringe and a specially treated piece of paper, on which the midwife places samples of the baby’s blood to be sent to the health department and checked for metabolic disorders). (The above information was gleaned from a questionnare handed out to 30 and returned by 25 homebirth midwives, all of whom are members of MANA, and most of whom serve on the CPM Certification Task Force (see note 5).)
13. Meconium is the babyís first bowel movement. If present in the amniotic fluid, it is sometimes associated with fetal distress, which is usually also indicated by fetal heart patterns. It is generally recognized, even in most hospitals, that thin or light meconium staining during labor is not problematic, especially when the heart rate patterns fall within a normal range. Heavy, thick, and chunky meconium in the amniotic fluid is usually indicative of fetal distress.
14. Decelerations of the fetal heart rate, as recorded on the electronic fetal monitor, are sometimes indicative of fetal distress.
15. The Apgar score provides a standardized means by which birth attendants can assess the baby’s condition at birth. Signs rated at two points each on a preprinted chart are skin color, muscle tone, breathing attempts, heartbeat, and response to stimulus, such as a touch or pin-prick. Babies are rated twice, at one minute after birth and again at five minutes, because many babies, especially anesthetized ones, take some time to turn pink and begin full breathing on their own. Ten is the highest obtainable score. Babies with Apgars of 2 and 2 (2 at one minute, and still 2 at five minutes) are severely distressed.
16. “Slantboarding” is a midwifery technique that often proves effective in getting breech babies to turn before delivery. The mother must get her head lower than her pelvis. A bean bag chair can be used, or an ironing board (or door) can be placed against a sofa or heavy chair at a 45 degree angle; the pregnant woman lies on her back, head down on the board with her feet pointing upwards for fifteen to twenty minutes, two or three times a day. During this time she is encouraged to relax and to visualize the baby turning. (For other such techniques, see Kitzinger 1991:98.)
17. Hospital labors are usually artificially speeded up with drugs, episiotomies, forceps, or cesarean section. Home birth labors, which are allowed to take their natural course, tend to take far more time than hospital births do. During a long labor, it is essential for a mother (and indeed, her birth attendants) to keep up their strength by eating and drinking plenty of nutritious food and fluids. Homebirth midwives recognize that contractions that have been going on for 18 hours and are still 5 minutes apart mean that the mother is still in “early labor”–”active labor” has not yet kicked in–and there is plenty of time for the midwife to go out for food.
18. Note Maggieís refusal to adopt the physicianís technomedical discourse here–a discourse that simultaneously reduces the differences between cesarean and vaginal birth to a matter of geography and subtly expresses the value that this culture consistently places on “above” in relation to “below.”
19. Hospital practitioners generally allow one, and a maximum of two, hours for pushing, after which a cesarean will usually be performed. Homebirth midwives accept a wide range of pushing stages, but more than four hours of pushing is rather unusual, even at home.
20. Following is a brief summary of Maggie Bennett’s personal protocols:
To qualify for staying at home for the birth:
Mother:
Blood pressure has to be no more than 20 pts. diastolic above her baseline.
Dilation should take place at the general rate of 1/2 cm./hr. after 4 cm.; one 3-hour plateau (in which no dilation takes place) is acceptable. [Authorsí note: Hospital protocols usually call for birth to take place within 26 hours of entry into the hospital, period. For many women, it can take days of "early labor" to reach 4 cm. If such women enter the hospital, they end up with cesareans.]
Good labor should be established within 24 hours after rupture of membranes.
Birth should take place within 72 hours after rupture of membranes.
[Hospital protocols call for birth to take place with 24 hours of rupture of membranes, due to the danger of infection, which is increased by the frequent vaginal examinations performed in the hospital. Midwives at home avoid performing such exams as much as possible in cases of prematurely ruptured membranes.]
Birth should take place within 4 hours from the time the mother learns to push. [As noted above, hospital protocols generally allow a maximum of two hours for pushing, and do not mention the motherís "learning to push." Here again, we see the midwifeís woman-centered focus, her respect for the mother as active birth-giver.]
No temperature. Not too fatigued.
Baby
Fetal heart between 124-160 and in accordance with baby’s baseline.
Good beat-to-beat variability. No heavy meconium–light ok.
21. Our interviewees also agreed that, in the rare instances in which the mother and the midwife have conflicting intuitions about a potential problem during labor, they are clearly not connected. In such a situation, they feel that transport is essential, as this “total lack of synergy” seriously impedes their ability to provide good, empathic–i.e., connected–care.
22. It is important to note that this appreciation of women’s uniqueness can extend even to crises and complications that midwives cannot handle at home, as is evidenced in the following story from Elizabeth Davis:
Sometimes if a woman has had a difficult birth, part of the reason why it’s been difficult is that things have come up for her that she has not worked through…I think of a Japanese woman with a Chinese husband who was culturally supposed to have a son, and it was a girl, and you can bet that nothing I said or did stopped her trickle bleeding from a partially separated placenta that finally took us to the hospital. When she felt safe enough in the hospital, she staged this massive hemorrhage, and rallied her husband to her side, where he had not been since he saw the sex of the baby.
So you know, the choreography of the woman’s expression of need is something that’s really beyond the practitioner–it’s really none of your business. But it is your business to maintain the parameters of safety, as we say, so some part of your attention has to turn to doing as much as you can in advance to raise those issues, and help a woman cope with them. It’s a fine line–permission to have your birth be whatever it is going to be, and the midwife’s skill and also her need to have a safe outcome. I think really most of us struggle with that.
23. As one anonymous reviewer aptly pointed out, the words “normal” and “abnormal” may not even be appropriate when talking about birth from the standpoint of intuitive knowing, as the concept “normal” “has long been grounded in a worldview that is based on ratiocinative reasoning and the averaging of all experiences into one standardized experience….Foucault’s concept of “normalization” might be an interesting springboard here.” Space does not allow us to further address the issue of midwives’ efforts to normalize uniqueness vs. medicine’s efforts to pathologize it as “deviance,” but it is an issue deserving of scholarly probing, and we call attention to it here in the hopes of stimulating further research and analysis.
24. Copies of the MANA Core Competencies can be obtained from Signe Rogers, Editor, MANA News, P.O. Box 175, Newton KS 67114.
25. Homebirth mothers themselves often have rich intuitive experiences worthy of anthropological study in their own right, as do mothers in general, about birth, about childraising, etc. We call attention to this understudied subject in hopes of generating more academic research into women’s perceptions of and experiences with intuition. Additionally, we call for more research into how midwives negotiate childbirth with their clients and the role that intuition plays in these negotiations. What difference does it make, for example, when women hire midwives to save money rather than because of a shared worldview?
26. This national certification process is now in place and functioning, making national certification for direct-entry and independent midwives a reality for the first time in United States history. Several hundred midwives have taken the NARM exam; the first to successfully pass through the complete certification process was Abby J. Kinne, who was formally certified as a CPM (Certified Professional Midwife) on November 10, 1994. As of this date of writing (April 1, 1996), approximately 100 midwives have become CPMs. This first group to pass through the first phase of the certification process consists primarily of experienced midwives who have been in practice for at least five years. The next phase is about to begin: NARM is poised to process applications from entry-level midwives; at present, 120 entry-level applications are pending.
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