Informed Choice for Women
Part III:
Birth Attendants: Historical & Modern
by Mary Ceallaigh
The Tradition of Labor Companions
As in today's context, historical labor companions have ranged in personality,
specialities, and working style - and societal contexts have varied widely, also like
today (North American birth culture has cultural variations, and Western culture varies
greatly between North America, Scandinavia, and Europe). Sometimes women have
had a choice of birth attendants, sometimes not.
A History of Birth Attendants
Women have given birth for millennia, usuallly attended by other women who have
given birth themselves and/or have helped other women during birth and in the arts
of self-care.
The primary arts of the traditional non-medical labor companion, or midwife, were
devoted nutritional education, herbal wisdom, hygiene, physical mobility techniques,
meditative guidance for the psyche of the laboring woman, and newborn parenting
support. There have always been traditional midwives in native and/or rural peasant
cultures varying in their specific arts according to cultural beliefs that were faith-
based, and often involved meditations and prayer formulas. Traditional birth
attendants typically had longstanding social relationships with birthing women - often
elderly midwives had helped two generations or more in one family.
In flourishing agricultural peoples the world over, birth has overwhelmingly been
embraced as a healthy, unhindered journey of Life at its best. Traditional birth
attendants have often been supported by their communities, with esteem, housing
provisions, and, often, leadership roles in old age.
The involvement of men at births in early modern Europe began in royal households,
when the odd science of the time joined forces with butchers who had likely surgical
tools. The allure of early alchemical thought was often combined with a hodgepodge
of blood-letting surgeries and superstitious interventions, and was the appealing "new"
medicine for various patriarchs of the time. Royal wives, often being imported and
isolated brides (many of whom spoke another language than the local peasant
midwives) were candidates for various of their spouses' "scientific" brothers, many of
them perishing in various phases of childbearing. Aristocratic ladies who instead
stayed in their homelands generally had much better outcomes as they were typically
attended by midwives and other ladies familiar to the family, from a lineage of service.
In malnourished lower class Europe of recent history, (as in present day famine/poverty
zones the world over) where pelvic bone deformities, anemia, and pelvic floor muscle
malfunction was common - birth was indeed a perilous journey that many of these
women did not survive. Midwives in those circumstances of social illness, without
cesarean surgery options, often faced maternal mortality and sick babies.
The advent of urban Western "hospitals" (of a sort) in the late 1700s, where cesareans
were performed, offered some new hope - however at a great price: well-meaning
butcher-obstetricians of the time (formal medical schools only began in the early
1800s) did not follow hygienic technique and did not wash their hands in between
examining patients, thus spreading rampant infection (the infamous
"childbed/puerperal fever" often erroneously assumed to be homebirth-related) in
indigent maternity wards as well as upper class wings where privileged women had
been convinced to try the "modern" setting.
In the 1850s, Drs. Simpson (Scotland) and Seimmelweiss (Austria), in separate inquiries,
determined the iatrogenic (doctor-caused disease) roots of the rampant puerperal
fever and immediately instituted strict hand-washing in their regional hospitals, with
immediate and drastic improvement of mother & baby survival rates. In the decade
following, hospitals in all the major cities in the Western world followed suit in their
maternity wards. They also decided to implement hospital-wide hygiene standards,
improving the survival of many other people - God bless Simpson and Seimmelwiess!
In contrast to the lack of wisdom in western urban health history, in the pre-colonized
Native American context as well as the Eastern world, traditional midwives and the
medicines of traditional Africa, India, and Asia often had unique and effective
hygienic practices such as usage of antimicrobial herbs, practitioner purification
rituals, and/or non-invasive protocols. Likewise, in ancient Greece there was extensive
knowledge and practice of hand-washing and general hygiene - they even had a
Goddess named Hygieia.
Vocations and Careers:
The Spiritual Midwife, The State Midwife
The history of traditional midwifery in the western world is quite a fascinating one as
documented by the social historian Hilary Marland in the extensive scholarly text The
Art of Midwifery: Early Modern Midwives in Europe (Routledge,1993).
Historically, whenever midwives have given themselves over to church or state law,
there has been a subsequent period of flourishing for a select group of a few
'registered' midwives who practice according to the interests of the prevailing
authorities, and a marginalizing of those who do not, many of them traditional
healers. The 'interests' of these authorities were costly tax & registration payments (in
the case of government mafias) or the carrying out of baptismal mandates or
extracting of secret details from unwed mothers for public shaming (in the case of early
Vatican law). Modern interests in today's context would be likewise costly licensing &
taxes, as well as competition for healthy pregnant clients between hospital and non-
hospital based practitioners.
Each period of a flourishing midwifery elite in western culture has directly been
followed by a period of widespread social backlash and punitive legislation when the
tides of prevailing authorities and social liaisons would change - as they always do -
ushering in imprisonments, and various restrictions diminishing all midwifery (not unlike
the current American context where several licensed and unlicensed midwives in most
states have been legally harassed and/or imprisoned and where CNMs are finding it
more difficult to sustain a home or hospital practice). It is estimated that during Middle
and Late Europe hundreds of thousands of people were considered 'infidels' by various
dominating groups at the time and killed during the Inquisition as well as various wars -
many traditional healers, herbalists, and midwives being among them.
Upon the settlement of North America by the English and Dutch in New England, the
rising authorities of Puritan governing bodies ushered in new backlashes against
traditional women's wisdom culture, with the infamous Salem witch hunts among
them, wherein any free-thinking & free-speaking person who did not conform to or
who threatened the religious order at the time was freely imprisoned and executed.
More about this time of American history can be found in the women's health classic
Witches, Midwives, and Nurses: A History of Women Healers by Barbara Ehrenreich
(Feminist Press, 1972).
Midwives and Male Healers
Traditional birth attendants from ancient tribal societies as well as more modern
European or American rural peasant/sharecropper communities would, on occasion,
confer and collaborate with men who were tribal healers or country physicians, when
faced with an ill mother or an unresolved complication.
Traditional midwives were keen observers of physiological signs & symptoms and
monitored fetal health by addressing the mother's intuitive process, and, more
recently, by using wooden acoustic listening devices (called Pinard horns) still used by
Amish midwives, and later, fetoscopes, as did all early physicians. Traditional midwives
relied on maternal signs & symptoms and dialogue much more than internal exams
(doing very few, if any, vaginal exams in labor) did not practice surgeries such as
episiotomies, nor did they do venipuncture administration of fluids and drugs. Such
practices would have been considered the domain of doctors rather than the art of
midwifery.
My own grandmother told me of her midwife mother's friendly relationship with their
rural family doctor who referred healthy farm ladies to her saying "You don't need me,
you need Minnie Mae." Likewise, my great-grandmother and the doctor had an
understanding that she could alert him for conference and/or assistance if ever she
needed, and at least one time she did, with a positive outcome for al. This legacy of
positive inter-relationship between faith-based midwives and free-thinking male
physician-healers of the time existed in the rural Black south as well. Traditional "grand
midwives" were openly supported by a scattering of empathic physicians who
recognized and properly esteemed the quality care of rural midwives in a time when
the burgeoning American Medical Association (99% male at the time) was generally
demeaning and/or seeking punition towards non-medical birth attendants.
The growth of immigrant cities as well as rural migration brought potential clients to
growing urban hospitals and created a social trend whereby the new medical
establishment began to "manage" many births, even for healthy women.
Modern Birth Attendant Options for Healthy Women
Obstetricians
Obstetricians are the most common choice of maternity care provider and birth
attendant in the US, especially in situations where a pregnancy is considered “high
risk”.
Although many obstetricians are becoming more supportive of a less aggressive
approach to childbirth, there still seems to be a prevalent belief that childbirth is a
condition that needs to be managed, rather than a physiological process that, in
most cases, will and should be allowed to occur, empathically facilitated with little to
no intervention. Likewise, prevention of illness during pregnancy through nutritional
education is rare with obstetricians, as they typically receive only 4-6 hours of nutrition
class times, as compared to the hundreds of hours of apprenticeship study and
dedicated nutritional focus of midwives.
Obstetricians can vary greatly in philosophy and internship experience, and the vast
majority of obstetricians have never witnessed a homebirth or a waterbirth, nor have
they been educated in the appropriate use of birthing pool for pain management.
Many obstetricians have never witnessed a first-time mother (primipara) give birth
without drugs in the labor room. As obstetricians are primarily relied upon by hospitals
for logistical supervision and actual delivery of babies, most have never provided
continuous emotional labor support and coping guidance for a laboring woman -
and frankly, the vast majority of modern obstetricians do not consider labor support a
requisite skill for them to master.
Being that the Latin word root of "obstetrics" is "to stand in front of or to obstruct" and
that old English's "midwife" means "with woman" it is not surprising that obstetrics is
focused on a mastery that depends on interventions as its forte. Taking that into
consideration, it is important to interview a potential obstetrician with candor and
depth, which necessitates informed choice preparation on the part of the pregnant
woman. Unfortunately, many healthy pregnant women find it difficult to even make
serious inquiry of a potential obstetrician, due to inhibitions and the overwhelming
cultural imprint of doctors-as-experts! Many women simply go with the friendliest OB of
what's available with their insurance, or the referred doctor-associate of a fertility tech
MD, or the obstetrician that an acquaintance simply has described as "really nice" -
for the most intimate and personal journey of their lives.
Many healthy, "low-risk" women feel that an obstetrician can provide a higher quality
of care, because of their medical background, training and a perceived ability to
handle complications and emergency situations more effectively than a midwife. This
is not necessarily the case, especially when you consider the fact that conventional
medical school education perpetuates the misconception that birth is an inherently
dangerous event and our babies need to be “evacuated” from our wombs as quickly
as possible by using "interventions as preventions". Conventional medical schools and
their textbooks are still promoting the paradigm of women laboring in a bed, if not
completely on our backs, and being managed by IV administrations. This creates a
tendency to "over manage" birth, and significantly increases the risk of further and
serious complications to the mother-baby, including but not limited to an increased
risk for cesarean section.
General or Family Practitioners are an alternative to obstetricians, especially in Britain
and Australia. They are trained to provide well- and preventive care and more family-
oriented, and often view birth as the more natural, family-centered event that it is.
Many women who chose a general or family practitioner as their maternity care
provider and birth attended can be very satisfied with their birth experiences and the
more personal care provided by their family physician. Of course, even though they
may provide well-woman care, many American GPs do not provide maternity care or
attend births because of malpractice insurance issues as well as difficulty securing
hospital privileges due to the highly competitive nature of obstetrical interests
promoted by the American College of Obstetricians and Gynecologists.
Friendly questions to ask a potential OB:
Midwives: Medical and Traditional
The Midwifery Model of Care is based on the fact that pregnancy and birth are
normal life events and that philosophy is usually reflected in their approach to
childbirth. Midwives tend to be conscientious in helping a woman co-create her own
birthing experience. Midwives dedicate more time and attention to individual cases,
typically spending an additional half hour of each prenatal appointment discussing
personal or nutrition matters beyond vital signs and lab tests.
Medical Midwives
CNMs: Certified Nurse-Midwives (CNM) are chosen as the primary attendant for a
significant percentage of US births in both freestanding birth centers and hospitals,
often times in conjunction with obstetric practices. A small number of CNMs practice
as independent homebirth midwives. CNMs are regular RNs with an additional year
of training in midwifery. Client education is a major theme in their practices.
CNMs are often restricted to some degree by the current obstetric model of care, and
indeed their general practice is discouraged by a portion of AMA-associated
legislative and political bodies, varying state by state. A CNM is oftentimes limited to
provide maternity care for women who have had “low risk” pregnancies (an
ambiguous term that seems to eliminate most everyone these days) and any situation
involving possible complications would be referred to an obstetrician. Most CNMs
have never attended a homebirth and some may not have much experience or
commitment towards facilitating instinctive birth.
LMs or CPMs: Direct-Entry Licensed Midwives or Certified Professional Midwives are
under the jurisdiction of the state, and supervised by state medical or nursing boards.
LMs/CPMs attend a much smaller percentage of births in the US, in freestanding birth
centers and in homes. Training for a direct entry midwife varies depending on state
licensing requirements, but usually involves an extensive apprenticeship with an
experienced midwife involving a variety of homebirth and sometimes birth center
scenarios, along with completing an academic formal midwife-training program.
LMs/CPMs tend to focus more on whole-body wellness (specifically nutrition and its
impact on healthy pregnancy and birth) and women's education. They often create
more personal relationships with clients due to smaller practices, dedicating more time
and attention to each individual case, and aspiring to establish emotional and
physiological support to their clients for the pregnancy, birth and postpartum.
LMs/CPMs do at least one prenatal home visit, and several postpartum home
checkups in the first days and first two weeks after birth. This is very attractive to
women who are choosing intentional confinement at home the first 40 days, greatly
reducing potential stress on the new mother-baby who are generally expected by OBs
and CNMs to leave home and travel for office visits during this supremely tender time.
(OBs and most CNMs do not have practices that are designed to incorporate any
home visits, and will refuse to come to the home for early postpartum follow-ups, if
requested).
LMs also provide consistency in care, usually being the only care provider that their
clients see during their prenatal visits and who will attend their births – not the
unpredictable “OB or CNM roulette” that is found in so many hospitals and birth
centers. This consistency provides a level of security that can create a more positive
and relaxed pregnancy and birth experience for women and families.
LMs/CPMs seek to help women successfully birth outside of the hospital and have
chosen the responsibilities various EMT medical tools and interventions in the name of
homebirth. These medical practices, many of which can be refused by clients,
include regular ultrasonic doppler checks (some carry portable EFMs, and some others
are willing to use fetoscopes or pinards if requested) and may include amniotomy, IV
antibiotics, oxygen administration, cutting of the vulva (episiotomy) in 5% of clients,
suctioning and wrapping of baby before giving it to the mother, typical severance of
the cord before the birth of the placenta and/or within 10 minutes of birth, injections
of pitocin in forth stage, injection of lidocaine for suturing, newborn weighing and
Vitamin K administration within the first hour of birth, and PKU heel stick newborn tests.
Many medical midwifery practices have a large client load, with midwives' energy
being spread thin when there are back-to-back births and postpartum visits to
accomplish. The lighter your medical midwife's monthly schedule is, the more
available her energies will be for authentic relationship with you.
Friendly Questions to ask a potential Medical Midwife:
What sorts of settings have you attended births in? What is your current client load?
What happens if you have more than one client in labor?
Would you be willing to take a low-tech approach? (fetoscope, minimal VEs, minimal interruptions)
Do you provide traditional labor support services throughout labor if needed? What sorts of activities might that entail?
If not, do you welcome Doulas?
Would you be comfortable supporting me in a birthing tub?
Are you comfortable supporting my committed partner to support me in private?
In the unexpected scenario of hospital transport, would you continue with me in a labor support capacity?
Will you do at least one prenatal home visit appointment? Are you supportive of a 40 Day postpartum intentional
confinement for healthy mother and baby?
Are you informed about extended-delayed cord severance and non-severance, do you ever facilitate Lotus Births?
Traditional Non-medical Midwives
Though common throughout rural North America in the first half of the 20th Century,
Traditional Midwifery has declined in recent years, as elderly "grand-midwives" have
passed away and apprenticeship options in the old arts of midwifery have become
quite limited. Along with this has been an aggressive social promotion of obstetric
dependency for healthy low-risk women by the American Medical Association, state
lawmakers, and the mainstream media, much of it based in misinformation and/or
profiteering.
Subsequently, the arts of non-medical midwifery are rare to find and less openly
promoted, though still existent in some communities of various orthodox religious or
spiritual sects (Amish, Hasidic Jewish, Mormons and rural Christian-Patriots, and Spiritual
Ecologists to name a few). Because of current state control of "midwifery," any midwife
who is paid to attend a birth can be arrested and significantly harassed by ignorant
civil servants and medical/nursing boards for any negative outcome or complication,
regardless of client support and understanding. As traditional midwives do not
use medical tools and do not perform episiotomy, rather than being charged with
"practicing medicine without a license" they are instead faced with scapegoating
accusations of "negligence" if an unresolvable maternal complication arises for rural
hospital transport or a baby arrives with birth defects.
As Robbie Davis Floyd Ph.D. (Birth as an American Rite of Passage) and Suzanne Arms
(Immaculate Deception) have documented in their birth industry research: 1)
maternal complications in otherwise healthy women happen consistently in the
hospital, 2) maternal mortality rates are deceptively accounted for as "Anesthesiology"
complications, and 3) American hospital-based birthing care results in being only 27th
on the WHO's list of nation-state Infant Mortality prevention.
From a feminist perspective, the diminishment of the art of traditional midwifery in
name of medical midwifery and obstetrics for healthy women may certainly not be in
the best interests of all women and babies! For anyone who esteems their civil liberties
and the pursuit of life, liberty, and happiness in their own bedroom/home, this can
create a personal dilemma when desiring traditional, non-medical care for religious or
informed-choice reasons as it can be very hard to find such a practitioner in the
current professional environment. There are some traditional midwives, such as
Jeannine Parvati, who have stopped attending births altogether and are instead
focusing their midwifery skills on helping healthy women prenatally prepare to be their
own midwife for a planned freebirth.
Unattended Birthing
Freebirth, or unattended birthing is another option for healthy women who long for an
instinctive, cosy homebirth in the manner that they conceived their baby. In fact, it
can be very helpful for most healthy, inquisitive pregnant wowemn to meet with other
women who have had freebirths and hear their stories, or at least see a freebirth
documentary film such as A Clear Road to Birth. Incorporating freebirth into the
spectrum of possibilities can actually empower many women who are planning
various attended birth scenarios.
Healthy women who choose freebirth feel it is an inherently natural and normal event
of privacy and sacred sexuality, not requiring the presence of a professional
attendant. They feel they are assisted by their own intuition, their inner midwife, and
have worked on developing their inner guidance through their life experiences,
previous birth experiences, and/or yoga & meditation sadhana (daily practice).
It is extremely important, when considering an unattended birth, to do research on
pregnancy and childbirth, and to become familiar with the physiology or childbirth, so
that you are able to recognize subtle signs and symptoms of possible complications
and respond to them with loving stability and flexibility. Most freebirth families are well-
informed of their options and strategies in the unlikely event of healthcare back-up.
Prepared freebirth women report an expanded capacity for birth pleasure and
ecstatic birth. And, like all women, these women also report having intensely
uncomfortable or painful and challenging moments in labor! However, there is a
markedly reduced incidence of unresolved complications compared to attended,
healthy parturient women, which is a subject of fascinating discussion in the freebirth
community.
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