Rocking the Birth Dogma Boat

“Because history left unaddressed becomes the present” | September 23, 2011

This was a quote from my eighth grade history class, when we had a guest speaker come and talk about the holocaust.  So here is some midwifery history, a history we have not addressed:


This is an ad from the New England Journal of Medicine at the turn of the last century.  Another ad from the same era showed a flattering picture of a clean White male doctor next to a stereotypical image of a dirty female African-American midwife, with a caption describing her as a former slave.  Bold text under the photos asked women who they would prefer to deliver their baby, with the obvious right choice being the male doctor.  This smear campaign against midwives was a prerequisite for moving birth to the hospital, and quite successful: In the late 1890’s, about 10% of births occurred in the hospital.  By the 1930’s, over 50% of all births, and 80% of urban births took place in hospital settings.

This was a huge shift, and moving birth to the hospital solidified the hospital itself as a real institution.  (This continues today, with birth representing over 25% of all hospitalizations, and providing a solid financial foundation that subsidizes all other hospital activities, and in many cases allows hospitals to keep their doors open.) Huge cultural shifts do not happen on their own, and in the classic telling of the story I learned in midwifery school, the demonized doctors wanted to make money off birth and gain control of women’s bodies, so they initiated a smear campaign against midwives, convincing the naive public in a matter of months to give up homebirth and midwifery care.  We love this mythology, that midwives were great and doctors were evil and we got screwed over, and it was personal.

However, the key element that’s been left out of the telling is the role of racism.  For birth to move to the hospital, women had to believe the smear campaign on a personal level, and that personal level was racism and anti-immigrant sentiment.  The U.S. at the turn of the last century was in the middle of a wave of new immigration in the north, cities filling up with “ethnic” immigrants who were considered dirty, impure, other, and certainly not White.  Reconstruction had done nothing to address the persistent racial tension and discrimination.  But our population was becoming more and more diverse, and it was not comfortable.

The smear campaign against midwives that moved birth to the hospital was effective because it drew up the racism, fear and anti-immigrant feels of the day.  Casting hospital birth as an elite “option”  with whiteness as a prerequisite allowed  privileged women to define themselves by how they gave birth.  Giving birth in the hospital was a badge of social standing, a statement of one’s worth.  Home was where the masses gave birth, attended by immigrant midwives from the old country, dirty Italians, Jews, Irishwomen.  Home was where women who couldn’t afford better gave birth, attended by ignorant midwives who were born into slavery and didn’t live much better once they were freed.  Midwives cared for everyone, no matter what.  Hospital birth became a way to prove one’s worth by distinguishing one’s self from everyone else.  Hospital birth meant you were not an immigrant, not African-American, not like everyone else, deserving of better.  In a country where being different from immigrants and from blacks was important, moving birth as a way of proving one’s whiteness and differentiating one’s self from the masses made sense. Racism made the shift possible.

And history left unaddressed becomes the present……..

So now we fast forward to our own time, when the natural birth movement is waging a less well funded smear campaign against hospital birth, and elite women are defining themselves by how they give birth, only this time it’s at home, away from the unenlightened masses “choosing” hospital birth.  We are more diverse than ever, and experiencing another wave of immigrants.  Race-based health disparities are our largest health problem, with discrimination determining the length of one’s life, and whose children survive childbirth and childhood.  But these are not midwifery issues-our issue is where women give birth, and we frame it as a choice, though very few women have access to all the choices.

In states like mine where midwives are not legally recognized, medicaid does not reimburse midwifery care, and midwives remain out of the reach of most women.  The hospital cares for everyone, not as well as the individualized care offered by midwives, maybe, or the spa treatments and supports offered by doulas, but cares for everyone nonetheless.  Except of course for the women who distinguish themselves from the masses by “choosing” home birth. To be different, better and above everyone else, women who can afford it “choose” homebirth, and look down on the masses-the rest of us who cannot afford midwifery care-as unenlightened and less deserving.

Watching the Business of Being Born, I noticed a sea of white faces in penthouses.  The message was clear-the granddaughters of the clean white doctor on the poster chose homebirth.  The granddaughters of the midwives in the poster, the former slaves and immigrant women who cared for everyone, no matter what, we give birth in hospitals, full of unnecessary intrusions into our bodies and our dignity, and somehow this is less of a midwifery issue than where the granddaughters of the clean white doctor give birth.  Great-grandchildren of the African-American midwives die at 4 times the rate of great-grandchildren of the white doctor, and this is less of a midwifery issue than where these great-grandchildren are born.

Birth and birth location has once again become a definer of identity in a racist age.  Birth has become a way to define yourself as more deserving, more worthy, better educated, and above all, different from the outsiders, the immigrants, the women of color, without quite saying it in those terms.  Homebirth, like hospital birth before it, has become an upper class white phenomenon, while the ideal of midwifery care for all falls to the wayside.

This is part of why I’m leaving this fight.  My heart is not in helping people with more than their fair share of the world’s power have empowered births, though I do feel everyone deserves an empowered birth.  But I do not want to repeat this history, and I welcome your thoughts on how to address history, how to stop history from repeating itself.

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  1. I completely agree with this article. Know that there are many of us homebirth midwives who are trying on our small scale to serve those who are poor, work on sliding scales, and barter with families to both provide for our families and improve access to homebirth. I’m still thinking of some solutions and will be back to comment further, but you are so right.

    Comment by Sara — October 16, 2011 @ 8:47 pm

    • Hi Sara, Thanks for your comment. i don’t doubt that there are midwives who try on a small scale to improve things for women, and who work on sliding scales, barter systems and even do births for free. I was one of those midwives, and I know there are others because I refer the women who still contact me looking for a sliding scale or barter arrangement to them, sometimes with a guilty heart. I know the sacrifices we make to live our ideals, and I am grateful that you, too, are making them. But my larger point was that we make enough sacrifice, and we need more than self-sacrificing midwives. We need systemic change. We need to stop asking individual midwives to try to make things right in a system that was built to continue historic wrongs, and built on a premise of inequity. I do not in any way mean to denigrate the hard, hard work you do and the excellent and equitable care you give, but I think we need to stop framing it as an individual responsibility to change things on a small scale, and instead go big. I think true sustainable change will happen on a large level, to make it so that you do not need to sacrifice. I am not sure how to make this happen, and I would love your thoughts. Best, Nechama

      Comment by Brave Little Bug — November 12, 2011 @ 8:30 pm

  2. […] a woman through encouraging self-education and personal responsibility for healthy pregnancies. Home birth and midwifery care has become rare in the Land of the Free and Home of the Brave, but it seems pretty damn American to me. Parenting […]

    Pingback by Top Ten Reasons Why This Attorney Chose a Home Birth - Fearless Parent — February 26, 2015 @ 2:07 am

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