The Certified Nurse-Midwife As a Path to Female Agency in Modern Childbirth in the United States
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Vassar College Digital Window @ Vassar Senior Capstone Projects 2016 The certified urse-midn wife as a path to female agency in modern childbirth in the United States Kate Hennessy Vassar College Follow this and additional works at: http://digitalwindow.vassar.edu/senior_capstone Recommended Citation Hennessy, Kate, "The ec rtified nurse-midwife as a path to female agency in modern childbirth in the United States" (2016). Senior Capstone Projects. Paper 617. This Open Access is brought to you for free and open access by Digital Window @ Vassar. It has been accepted for inclusion in Senior Capstone Projects by an authorized administrator of Digital Window @ Vassar. For more information, please contact [email protected]. The Certified Nurse-Midwife as a Path to Female Agency in Modern Childbirth in the United States By Kate Hennessy April 29, 2016 Thesis Advisors: Nancy Pokrywka Janet Gray Thesis submitted in partial fulfillment of the requirements for a major in the Program in Science, Technology, and Society (STS) 1 Table of Contents Introduction ............................................................................................................................... 3 Chapter I: The History of Midwifery and Obstetrics in the U.S .............................................. 8 Chapter II: The Current State of Childbirth in U.S ................................................................ 24 Chapter III: The Renaissance of Midwifery ........................................................................... 38 Twilight Sleep Movement................................................................................................... 39 Home Births and Birth Centers ........................................................................................... 42 Doulas in the U.S ................................................................................................................ 46 Revival of Midwifery in the 21st Century ........................................................................... 50 Chapter IV: The Certified Nurse-Midwife ............................................................................. 52 The Role of the CNM.......................................................................................................... 52 Core Values......................................................................................................................... 56 Divisions in the Field of Midwifery.................................................................................... 57 Collaborative Models .......................................................................................................... 59 Conclusion .............................................................................................................................. 64 Bibliography ........................................................................................................................... 67 2 Introduction Both midwives and obstetricians care for pregnant and laboring women1; however, the fields of midwifery and obstetrics approach the care of expectant mothers in significantly distinct ways. Midwifery emphasizes the normalcy of pregnancy, spotlighting the importance of the woman’s birthing experience, while obstetrics focuses on the potential problems and difficulties of pregnancy and labor, underscoring concern for the fetus’s safety. These differences do not signify a midwife’s disregard for safety nor an obstetrician’s apathy towards a mother’s experience, rather, they convey the distinct focal points in the contrasting models of childbirth under which each field practices: the social model, practiced by midwives, and the medical model, practiced by obstetricians (McIntosh, 25). Not only do these models embody the difference in care administered by a midwife and by an obstetrician, they also reflect the historical origins of each field. Midwifery arose from the social support female friends and family members have traditionally given to one another during childbirth (Donegan, 1978, p. 12). In contrast, obstetrics developed from the rise of modern anatomical research, surgery, and birthing technology. These distinctive origins reflect the resulting divergent ideologies and conceptual practices of midwifery and obstetrics. Although women were historically the sole birth attendants in uncomplicated, normal2 pregnancies, by the eighteenth century, men began infiltrating the midwifery sphere 1 While I acknowledge that not only cis-women get pregnant, in this thesis I will use the language of pregnant and laboring “women” and “mothers,” as cis-women’s health was at the core of the literature I researched. Therefore, for the purposes of this thesis, “women” and “mothers” refer to individuals who can give birth, and since the available literature on this topic overwhelming explores cis-women’s experiences, I will focus on that perspective. By no means do I intend to represent the experiences of all pregnant people. 2 In this thesis, “uncomplicated” and “normal” pregnancies refer to cases in which the mother is not considered “high-risk” because she is in good health and there is no indication prior to labor that there will be any interventions needed. Because there is no “typical” birth experience, “normal” refers only to the absence of anticipated emergency medical interventions. 3 in the United States by attending uncomplicated births (Litoff, 1978, p. 7). Until this point in time, men had only become involved in childbirth as male physicians when complications arose and surgical interventions were needed to save the life of the mother or baby. The inclusion of men in midwifery practices gradually manifested in the creation and eventual domination of obstetrics over midwifery in the U.S childbirth practices. At the start of the 20th century, midwives attended over fifty percent of all births in the U.S, and by 1930 that number dropped to less than 1 percent. This drastic decline came about due to a confluence of factors, one predominant reason being that some members of the healthcare community believed that midwives were main contributors to the high rates of maternal and infant mortality. Persons who held this opinion believed that a ‘more’ trained and ‘professionalized’ midwife would ‘safely’ satisfy any demand for midwives by pregnant women, resulting in the inception of the certified-nurse midwife (CNM) in 1925 (Ettinger, 2006, p.15). Despite these attempts to popularize nurse-midwifery, the CNM was not widely used until the late 20th and early 21st centuries. During these years, there was a surge in the use of CNMs. In 1975, less than 1.0 percent of births were attended by a CNM (Martin et al., 2007). By 2000, approximately 7.3 percent of all U.S births were attended by a CNM and the number continues to rise, as the CDC reported that approximately 8.1 percent of all U.S births were attended by a CNM in 2013 (Hamilton, Martin, Osterman, Curtin & Mathews, 2015; Martin, Hamilton, Ventura, Menacker, & Park, 2002). Although there are other types of midwives that are not CNMs, because CNMs account for approximately 95 percent of midwives in the U.S, a vast majority of the reemergence of midwifery focuses on nurse- midwifery. Currently, a CNM is a registered nurse (RN) who has a master’s degree in midwifery and certification in accordance with the requirements of the American Midwifery 4 Certification Board (AMCB) through a certification exam, which differentiates the CNM from the traditional midwife, who learns through apprenticeship. However, the CNM does not simply represent a modification in the educational requirements of midwives in the U.S, but rather, because its position lies at the center of the historical and current controversy between midwifery and obstetrics, its role symbolizes the larger historical and current controversies within the U.S childbirth sphere. In addition to the CNM’s unique position between obstetrics and midwifery, the recent upswing in the use of CNMs during the 21st century has elevated the visibility of the CNM, raising many questions about the values upheld by nurse-midwifery. These reservations have surfaced due to the fact that the CNM represents the carrier of both obstetrical and midwifery knowledge, and debate has arisen as to whether the CNM can uphold the values of both fields within its practices. Under the current childbirth model dominated by obstetricians, there has been an increase in the use of cesarean sections, drugs, and other technological interventions in childbirth. However, the revival of midwifery at the end of the 20th century and into the 21st century has demonstrated a partial rejection of this technocratic model of childbirth. With these heightened sentiments surrounding childbirth, the dual image of the CNM, as both an insider and an outsider on both sides of the midwife/obstetrics controversy, has become increasingly visible. In this thesis I will explore these complexities, examining the CNM’s composite role within and between these two fields, while also investigating the larger social and economic context in which midwifery, obstetrics, and nurse-midwifery exist. Chapter 1 will narrate the historical transition from midwives to obstetricians as the predominant birth-attendants in the U.S. This historical perspective will encompass the controversy between midwives and obstetricians that formed the foundation for the 5 introduction of the certified nurse-midwife (CNM). I will utilize this historical lens to demonstrate how