«Access to professional midwifery care is a basic reproductive right that women in the United States have long been denied. Today American midwives ...»
Pushing for Midwives
Homebirth Mothers and the
Reproductive Rights Movement
Access to professional midwifery care is a basic reproductive
right that women in the United States have long been
denied. Today American midwives are growing in numbers
and in organizational and legal strength. Their excellent
outcomes and women’s high levels of satisfaction with their
care are placing increasing pressure on the health care
system to more fully incorporate them, but the battle to make midwifery care readily available to all women is far from won. [Certified nurse midwives] around the country all too often find themselves pushed out of practice by physicians seeking to eliminate the competition, and [direct-entry midwives] are still fighting in many states for the right to practice legally and under regulations that do not erode their autonomy. It is to be hoped that...
American women will be able to reclaim their basic reproductive right to midwifery care.
—Deborah Cordero Fiedler and Robbie Davis-Floyd, “Midwifery as a Reproductive Right” n 2008, the Big Push for Midwives launched a nationally coordinated cam- Ipaign to gain legal access to certified professional midwives (CPMs), a na- tional certification for direct-entry midwives (DEMs) who are independent birthcare practitioners and the primary attendants of homebirth in the United States.1 Organized primarily by homebirth mothers, the Big Push advocates “women[’s] right to choose their maternity care providers and birth settings.”2 A second national effort aimed at gaining federal recognition of CPMs was spearheaded in 2009 by the Midwives and Mothers in Action (MAMA) Cam- paign, a collaborative effort by several professional organizations for midwives and “consumer” groups supporting midwives.3 Both of these campaigns have 2 Introduction drawn nationwide public attention to the recent efforts aimed at expanding women’s reproductive rights to include access to midwifery care.
This intensified “push” is the continuation of growing support for access to midwives across the nation since the 1970s that has paralleled (but in some cases been at odds with) the broader reproductive rights movement. Many midwifery supporters have initially been hesitant to describe their struggle as one for reproductive rights because of associations with feminist efforts for women’s choice regarding abortion and contraception. Yet midwifery organizers—including those who identify as pro-choice and pro-life—have adopted the language of “rights” and “choice” to describe the importance of expanding women’s maternity care options. Recent scholarly and popular books have described midwifery as “a global feminist issue”4 and have positioned the right to birth where and with whom one chooses as a “basic reproductive right.”5 Over the past decade, organizers have also begun to cast access to midwifery as a “consumer rights” issue— one in which a woman’s “right to choose” has been restricted by ill-informed public policies concerning midwives and homebirth. Although, as of this writing in 2010, DEMs are legally authorized to practice in approximately half of the United States— owing largely to the successful state-by-state grassroots organizing efforts of homebirth mothers to legalize their practice—struggles for access to midwives continue throughout the country.6 It was as this movement was gaining steam in the late 1990s that I began to study and participate in efforts to increase access to midwives in Virginia— where performing midwifery ser vices had been restricted to certified nursemidwives (CNMs), and those who had been previously permitted, since 1976.7 Although some CNMs offer homebirth and birth center care in Virginia, since they require “physician supervision” to practice, most currently practice in hospitals.8 Beginning in the 1990s, homebirth mothers and other midwifery supporters worked for eight years to gain access to midwives who would—and could legally—attend their homebirths. They were finally successful when Virginia lawmakers voted to license and regulate nationally recognized CPMs in 2005 and to loosen restrictions on CNMs in 2006. These local victories in Virginia have also proved valuable on the national scene. Many organizers in other states have sought advice and support from Virginia midwives and their supporters as they now embark on efforts to gain legal access to midwives in their own state legislatures and in national efforts for federal recognition of CPMs.9 In this historical moment, when the growing demand for midwives is coalescing into successful lobbying efforts to loosen restrictions on their ability to provide homebirths throughout the United States, it is crucial for activists and scholars to reflect on these struggles for “access to midwifery care for all women” (as the Midwives Alliance of North America advocates10) in light of Introduction 3 the uneven access women have—and have historically had—to reproductive healthcare. Anthropologists Faye Ginsburg and Rayna Rapp have called this differential access to reproductive ser vices “stratified reproduction”—the power relations that empower some women to nurture and reproduce but disempower and constrain others.11 Using this framework to address struggles for reproductive rights—both historically and presently—it becomes evident that despite the best efforts of activists, reproductive healthcare reforms have not always succeeded in ameliorating uneven access to reproductive technologies and services, even when enhancing access to reproductive options for all women has been the stated goal of activist efforts. In this context, it is important for both activists and scholars to ask the following questions: How is the increasing commodification of maternity care in the United States affecting women’s efforts to secure access to midwives? Are all women ultimately benefiting from the enhanced market of reproductive ser vices emerging in the twenty-first century, including midwifery ser vices? What are the possibilities and the limitations of the increasingly popular strategy of advocating for women’s “consumer rights” to access midwives and, more broadly, reproductive rights?
Feminist scholars have a particularly important role to play in answering these questions. In fact, feminist social scientists in the natural childbirth movement during the 1960s and 1970s were among the first to offer important critiques of medicalized childbirth, and, as religious studies scholar and homebirth mother Pamela Klassen has explained, to encourage “women to challenge the system through exercising their consumer power... to turn from obstetricians and hospital birth to midwives and homebirth.”12 Yet while “consumer power” often resonates with middle-class and affluent homebirthers, it has been less applicable to the low-income families seeking midwifery care, who frequently have far fewer “choices” in their reproductive healthcare. While many feminist social scientists—including myself—actively support midwives and women’s right to homebirth, we must also consider ways in which our rhetoric of consumer choice, particularly in the context of recent political and economic shifts, may have unintended negative consequences for the very women our strategic suggestions have sought to liberate.
Reproductive Rights as “Consumer Rights” In the 1960s and 1970s, feminists in the women’s health movement adopted the familiar slogan “a woman’s right to choose” to demand reproductive rights in North America and throughout the world. This push to characterize reproductive healthcare options in terms of choice and rights is important to contextualize. As historian Rickie Solinger has emphasized in her extensive work on reproductive politics in the United States, the rights language and claims
4 Introductionto rights that emerged in the 1960s—particularly within the civil rights movement and feminist organizing of the time—fundamentally reshaped both American politics and culture.13 Reproductive rights and struggles for “choice” became central to both of these movements, albeit not always for the
same reasons. First, reproductive rights posed a dual threat to the status quo:
access to abortion and contraception challenged male authority over women’s reproductive capacity, and the right to be free of coerced sterilization and contraception, which had disproportionately affected women of color and poor women in the United States during the early 1900s, contested eugenic notions of white supremacy.14 Solinger has argued, however, that the almost exclusive focus on women’s “right to choose” that emerged within the feminist movement during this time became problematic for efforts to grant reproductive rights to all women, because the idea of choice was “intimately connected to the possession of resources. Many Americans... developed faith in the idea that women who exercise choice are supposed to be legitimate consumers, women with money.”15 The assumed access to the marketplace of reproductive options that this push for “choice” implied did not take into account the constraints that have historically and presently restricted the reproductive decisions of poor women and women of color. Although the civil rights movement had also sought legislation to guarantee “consumer choice” for African Americans16 —who had long been denied access to goods and services or forced to seek them in segregated, often substandard, facilities—for many minority women, feminist struggles for the “right to choose” abortion smacked of the racism in previous population-control strategies that had been used to constrain reproduction for women of color and poor women.
Thus recent efforts spearheaded by women of color have criticized the singular focus of feminist organizing for abortion rights in the 1960s and 1970s and called instead for “reproductive justice.” This term has been used instead of (and sometimes in addition to) “reproductive rights” to address access to quality, noncoercive reproductive healthcare for all women, especially as they are constrained by “the nexus of systems of oppression based on gender, race, class, sexuality, ability, age and immigration status.”17 Yet although the “choice paradigm” of reproductive rights activism has received much critical attention in recent years, it has remained central to many feminist organizing efforts into the twenty-first century.18 By the 1970s, even organizers in the natural childbirth movement—a movement that prided itself on attracting those who identified as both prochoice and pro-life—had begun to envision nonmedicalized childbirth as an important aspect of women’s right to choose. Many adopted the term “consumer” as what they felt was an empowering term and a calculated alternative Introduction 5 to paternalistic characterizations of the (female) patient and (male) doctor. As sociologist and longtime midwifery supporter Barbara Katz Rothman explains, “A ‘consumer,’ believe it or not, was a role with more dignity, more power, than that of ‘patient.’... In a capitalist system, in a fully consumerist world, consumption and the language of consumers is what comes to hand.”19 Similarly, in a collection of studies entitled Consuming Motherhood, the authors vividly demonstrate how motherhood and consumption were thoroughly enmeshed in North American social life by the turn of the twenty-first century.20 From the decisions that parents must make to have or adopt children to the commodification of maternity and childrearing practices to the commercial relationships between parents and childbirth practitioners, the “consequences of capitalism for motherhood” have become deeply ingrained in women’s experience of childbirth and mothering.21 In the case of North American midwifery, for example, Robbie DavisFloyd, who has described herself as an “anthropological activist who supports all sides of this midwifery story,”22 argues that midwives engage in a form of “qualified commodification,” through which they position themselves as valuable healthcare commodities to “sell” midwifery to legislators, nursing and medical societies, and regulatory boards: “Appropriating the notion of women as agentic consumers of maternity care (an image they [women] helped create), midwives have added themselves to the list of birthcare options from which women can now choose.”23 As Davis-Floyd suggests, mothers now frequently rely on their identities as consumers of maternity care in their struggle to convince legislators and medical officials that they should have the right to choose midwifery care.
In a discussion of how scholars should refer to women who seek midwifery
care, anthropologist Margaret MacDonald explains further:
The term “midwifery consumer” is not to be discarded entirely.... It implies a certain agency and choice on the part of women having midwifery care that has always been important to midwifery. Indeed, the consumer-based campaign for choices in childbirth was a key factor that fueled midwifery as a social movement over the last several decades. The idea of the midwifery consumer, however, is not simply a result of the self-conscious feminist agenda of woman-centered care and the critique of biomedicine. It also speaks to the political economy of reproduction within the context of late capitalism and demographic transition, specifically, the trend towards having fewer children later in life and the trend towards treating pregnancy and childbirth as valuable experiences.24