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Midwifery Practice and State Regulation a Sociological Perspective

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Midwifery Practice and State Regulation a Sociological Perspective MIDWIFERY PRACTICE AND STATE REGULATION A SOCIOLOGICAL PERSPECTIVE By BRIAN ERIC BURTCH B.A., Queen's University, 1972 MA., University of Toronto, 1978 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIRE• MENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES Department of Anthropology and Sociology, University of British Columbia We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA April 1987 ©Brian Eric Burtch, 1987 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Anthropology and Sociology The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date 1.198 7 r>F-Gn/R-n ABSTRACT Supervisor: Dr. R.S. Ratner Midwifery practice in Canada is anomalous in that, unlike other industrialized nations, a distinct legal status for nurse-midwives and community midwifery has yet to be established. Despite this constraint, community midwifery has survived the lack of institutional support for home births and legal prohibitions directed against it The manner of State regulation of midwives is a central issue in this study. It is shown that the State shapes the possibilities of midwifery in a contradictory manner, promoting midwifery on the one hand, and prosecuting and restricting midwifery practice on the other. A modified structuralist perspective on the State is developed with respect to midwifery. The Canadian State serves to limit possibilities for midwifery through various provincial enactments in quasi-criminal law, through the greater likelihood of criminal prosecution of midwives than physicians or nurses, and through funding of the established professions and hospitals. This thesis then, offers a critical examination of the anomalous occupational and legal status of Canadian midwives, using historical materials on the development of midwifery practice and cross-cultural data on the role of midwives in traditional cultures. It is argued that many of the reservations about community (lay) midwives are no longer applicable, and that the containment of nurse-midwives reflects an historical accommodation between the nursing and medical professions in Canada. This accommodation meets the need for highly-skilled obstetrical nurses or nurse-midwives within the tradition of physician dominance in health care. A major empirical focus of the study is a documentary analysis of birth records from community midwives, primarily in British Columbia and Ontario, between 1972 and 1986. Analysis of the data confirms that qualified community midwives, working under normal circumstances, manage births safely and with a minimum of interventions during labour and delivery, and during the prenatal and postpartum periods. Where comparisons with provincial ii and national populations are available, women attempting home birth under the care of a community midwife tend to have lower rates of forceps delivery, caesarean section, and episiotomy. These women are also likely to deliver their babies in positions other than the standard lithotomy position or prone position, and to have a lower incidence of perineal tears. Nevertheless, difficulties associated with the unregulated and often idiosyncratic situation of community midwives are underscored, particularly with regard to establishing guidelines for domiciliary midwifery. Data from the Low-Risk Clinic at Vancouver's Grace Hospital, together with reports on other nurse-midwifery programmmes, reinforce the claim that nurse-midwives can practice autonomously in providing prenatal care, assistance in labour and delivery, and postnatal care. The likelihood of realizing autonomous midwifery practice depends upon the particular agendas of the State, the structural interests of the professions, and the initiatives of midwives and health consumers who lobby for certification of safe alternatives in maternal and infant care. iii TABLE OF CONTENTS ABSTRACT . ... ....... • 11 List- of Tables—.... viii! ACKNOWLEIXJEMENTS ... .— x I. INTRODUCTION .. .. 1 Preface: The Proper Person 1 Central Problem of the Research . 6 Scope of the Research . ..— 11 Ethical Considerations — 24 Significance of the Research . — 26 Midwifery, Medicine, and the State 27 II. STATE, HEALTH, AND JUSTICE . 31 Introduction —. .. 31 Theoretical Approaches to the State 32 The State and Health Care . ...... 41 Law and the Regulation of Health Care . 47 The Midwifery Movement and the Canadian State 50 Unlawful Practice of Medicine: Quasi-Criminal Law 54 Criminal Prosecution of Birth Attendants 59 Inquests into Infant Deaths 63 Criminal Negligence and Physicians 64 Civil Suits against Birth Attendants . , . 65 Conclusion 66 HI. HISTORICAL AND CROSSCULTURAL PERSPECTIVES ... ..... 71 Introduction . ..... 71 Historical Perspectives on Midwifery 72 iv Midwifery in Europe ~ 72 Midwifery in Canada 77 Law and the Containment of Midwifery 82 ^^ldv^ifcry in the United St&tes »««»»»»»»«»»»«M»»»»»»»»»»»«»»»»»"«««»»««»*»»«"»«»»«"MM«»«»«««»»»««»«»«»M«»»»M»»»»*»»«»»«»»« 8S CROSS-CULTURAL Pl^SPECnVES ON MIDWIFERY ... 87 Variations in Infant Mortality Rates 89 Traditional Practices and Medicalization of Birth 92 Birth Practices in Western Countries 97 Midwifery in Japan and China . 98 Conclusion . .—. 99 IV. RESEARCH METHODS 102 Introduction: Studying Childbirth ...— 102 Research Design . 105 Literature Review 107 Sampling Procedures - . 109 Documentary Evidence . 117 Summary ........................................................... 120 V. COMMUNITY MIDWIFERY AND NURSE-MIDWIFERY « 124 Introduction ^ . 124 COMMUNITY MIDWIFERY PRACTICE IN CANADA ........... .—.............. 126 Midwifery Practice and the Course of Labour —.......—. 141 Delivery of the Infant . ... 145 Post-Partum Measures .—-—. 152 Safe Practice: Guidelines and Peer Review ....... ... ... 161 State Control and Resistance .. 164 NURSE-MIDWIFERY PRACTICE 169 Introduction , ..— 169 v Central Problems in Nurse-Midwifery 169 Home Birth and Midwifery Policy 174 Alternative Birth Centres . 176 Demonstration Projects: Canada and the U.S 178 Prestige and Professionalization 182 Midwifery Practice and Formal Authority . 183 VI. CRITICAL REFLECTIONS ON COMMUNITY MIDWIFERY . 191 Introduction » 191 "We and They": Oppositional Ideologies ... 192 "Midwife means to be with woman": Serving Mothers 193 Class Composition of Clients . 195 Material Basis of Practice . ........ 196 Formal Structure, Idiosyncratic Practice 197 Documentation of Midwifery Practice 199 Availability of Services . 200 Expanded Role of Nurse-Midwives and Hospitals 201 From community to bureaucracy? . 202 Summary . * . 203 VH. CONCLUSIONS .. ...... .... 204 Midwifery Initiatives and Conflicts 204 Self-Determination in Reproduction and Work 207 Promoting Midwifery, Prosecuting Midwives — 210 Further Research and Policy Development . 210 Birthing Centres and Women's Clinics 213 Conclusion . .... 215 Bibliography . 221 References Consulted, Not Cited 247 vi Appendix A: Glossary 265 Appendix B: Codesheet for home birth records 268 Appendix C: Letter of Consent 272 Appendix D: Interview Frame .. ... 273 Appendix E: Occupations of Home Birth Mothers and Fathers . ... 280 Appendix F: Delivery Positions: Attempted Home Births 283 vii LIST OF TABLES Table Page 1 Average Income of Physicians and Other Taxpayers .— 20 2 Home Births by Province 111 3 Home Births by Year and Province 133 4 Ages of Home Birth Clients and Women Giving Birth in Canada 134 5 Gravida and Parity of Home Birth Clients . 135 6 Family Income: Home Birth Clients . 137 7 Previous Caesarean Section . ... 138 8 Home Birth Mothers Diet . 139 9 Alcohol Use During Pregnancy . 139 10 Smoking among Home Birth Mothers 140 11 Prenatal Visits by Community Midwives . 141 12 Rupture of Membranes: Attempted Home Births 142 13 Meconium Staining: Attempted Home Births 143 14 Use of Oxytocin in Attempted Home Births . ........... 144 15 Anaesthesia in Attempted Home Births ...... 144 16 Walking During Labour: Home Birth Clients 145 17 Place of Delivery . ............ 146 18 Delivery Positions: Attempted Home Births . .— 148 19 Type of Delivery: Attempted Home Births ..149 20 Episiotomies: Home Births and the Low-Risk Clinic .. ., 150 21 Perineal Tears: Home Births and the Low-Risk Qinic . 151 22 Suctioning Techniques: Attempted Home Births 152 23 Apgar Scores: Infants Delivered at Home 153 24 Delivery of Placenta 154 25 Perinatal Mortality: Home Births. BC, and Canada . 158 viti 26 Neonatal Mortality: Home Births, B.C., and Canada 159 27 Post-Partum Visits: Home Birth Clients 160 28 Mode of Delivery . 179 29 Demonstration Projects in the United States 179 ix ACKNOWLEDGEMENTS This research has developed through the efforts of many individuals. My Dissertation Committee provided constructive criticism and generous support over the years. I am grateful to my Thesis Advisor. Dr. Bob Ratner, for his perennial support and his useful criticisms of the manuscript. Dr. Helga Jacobson provided insightful observations on the research, and Dr. Neil Guppy was very helpful throughout the writing of the study. I am thankful for the materials and encouragement
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