Professionalism and

the Midwife

by Laura Barandes


What is Professionalism?
The current thinking on the concept of professionalism is that it is not simply a system whereby the different professions develop according to the same set of steps. In other words, the argument used to be that each trade went through a series of recognizable stages whereby it became a profession, irrespective of its relationship to other trades. The newer idea is instead that professionalism involves constant competition between different expertise over the same space. These struggles for legitimate authority are termed "turf wars" by the leading theorist on the subject, Andrew Abbott.

The constant competition for authority, or ownership of professional space, is fueled by the tools of law, the media, and abstract theory. Each of these mechanisms can be employed to designate certain spaces as belonging to one profession or another:


Laws which enforce a particular profession and professional space are perhaps the most direct mechanism for establishing authority. The legal system often provides concrete boundaries which solidify the jurisdictions of certain professions. For instance, only licensed MD's can prescribe medications to patients. This restriction effectively excludes all others from performing this function.


Popular images influence public perception on a daily -- almost minute-by-minute -- basis. We are, as a society, inundated by information. The media's acceptance of doctors as the primary legitimate source of health care does much to ensure that the public begins to view them as such. If television, newspapers, magazines, and other forms of media only report or show women giving birth in hospitals, the audience has a predisposition to view this situation as the norm.

Abstract Theory

This mechanism is the one employed from within the profession itself. In order to separate itself from simple practitioners (people who cut, stitch, and medicate), the medical profession has developed a complicated abstract theory. Language is an example of the way that doctors often attempt to distance themselves from other people. The jargon that doctors use is symbolic of the special knowledge they possess, a constant reminder of their legitimate ownership of that professional space.

Yet, medical professionals must strike a careful balance between practical application of skills and their abstract theory. If they focus too exclusively on practical application, anyone who masters some of those particular skills could claim legitimate ownership of part of the space. Once the skills become separated too greatly from the theory, they can be coopted by outsiders. On the other hand, if medical professionals focus too heavily on theory, they risk alienating their patients to the extent that these consumers will look for more intelligible help elsewhere. The recent explosion of homeopathic remedies is an example of people looking for treatment and service that they can understand and in which they can be more equal participants. Thus, the medical profession must carefully weigh their emphasis on practical application and abstract theory.

How Does Medical Professionalism Apply to Pregnancy and Birth?
The models that abstract theory allows professional groups to construct are often applied to issues outside of the original authoritative space. For instance, while sexual disfunction was for many years considered to be a psychological disorder, the emergence of Viagra as a remedy has shifted sexual disfunction into the medical model. As Abbott notes, "it is with abstraction that American medicine claims all deviance, the abstraction of its all-powerful disease metaphor."1 In the same way, the medical profession has applied its disease metaphor to pregnancy and birth, shifting them out of natural and woman-centered life experiences into a category requiring physician intervention and the ever-looming assumption of high-risk. In other words, "the professions," in this case the medical community, "did not serve disembodied needs but rather imposed both definition of needs and manner of service on atomized customers."2 Pregnancy and birth have become caught up in the discourse of illness, necessitating medical care and drawing them into the "turf" of professional authority.
Selective History of Medical Professionalism Regarding Birth

19th Century - Wealthy women began to invite male doctors to assist in their births. The primary attendants, however, were still other women. During this time, hospitals were mostly for the poor and lower class people. The rich received service at home.

1900 - 5% of women gave birth in hospitals. Hospitals in the early 20th century were not particularly safe places for giving birth. The risk of infection in these institutions was staggeringly high in comparison to the home.

1920 - Dr. Joseph Lee publishes "The Prophylactic Forceps Operations," which reduced birth to predictable patterns and began the routine use of forceps and episiotomies.

1921 - over 50% of births took place in hospitals (in urban areas)

If hospitals were not, statistically speaking, safer places to give birth, why did women begin to use them? Why was the cultural myth constructed such that hospitals were regarded as better than the home as the location of birth? The answer is that women saw the medical profession -- and by extension the hospitals -- as being able to provide relief from pain. The ideology of pain was a force strong enough to overshadow the infection risks and surgical mistakes that were far more common in the hospital setting than in the home. As the birthing process was moved to the site of medical professionalism, utilizing the practices of licensed professionals, these practices soon became accepted as normal interventions. Capitalizing on the fact that they could sometimes produce a baby from an otherwise insurmountable crisis, doctors soon coopted all of the birthing processes into their illness metaphor. Only within this model, where treatment was expected, could the medical processionals claim jurisdiction through "necessary" practices.3

Why Hasn't Midwifery Become a Profession?
There are several reasons why midwifery has not gone through the process of becoming a profession. The premises on which midwifery is based actually, in many ways, stand in complete opposition to the methodology that guides professional establishment and maintenance.

Complementary Practices

Midwifery is largely based on incorporation and shared learning. In other words, midwives do not compete for authority in the same way that medical professionals do. They most readily incorporate new medical knowledge and integrate their own experiences with those of other women, both birth attendants and those giving birth. While the medical community would be careful about taking on any practices of midwives, often for fear of losing any professional authority or "turf," the midwife does not operate with such an exclusionary methodology.

Sharing, Not Distancing

While medical professionals often employ special language to create a separation between themselves and those they treating, midwives strive for exactly the opposite. They want the woman they attend to be an active and authoritative participant in the pregnancy and birth. While the doctor works "on" the woman, the midwife works "with" the woman.

Experience, Not Theory

The knowledge that midwives employ is gained largely through experience, rather than a uniform body of objective information. To the extent that there is a type of "theory," it concerns a conscious emphasis on the woman's birthing experience and does not serve the purpose of distancing the midwife from the woman she is attending.

Birth and The Internet
It is interesting to examine the ways in which the medical profession uses the internet in comparison to midwifery associations/groups. Performing a rudimentary search for the phrase "OBGYN," one finds that most of the websites are geared toward the OBGYN's themselves. There are a few that advertise for patients, but the majority are sources of information for the internal professional community.

In contrast, when searching for "midwife," one finds references to a mixture of schools that provide training, sources for women looking for a midwife, but most often sites that contain large amounts of information for women interested in the birthing process. These latter examples usually include links to detailed birthing experiences of women. In other words, the midwives seem more focused on creating an interface between themselves and birthing women -- in addition to creating a forum for women to share their experiences -- rather than creating a network of midwives. This evidence supports the contention that midwives emphasize connection and shared experience in contrast to the distancing performed by the medical professionals.

Examples of Websites Resulting from "Midwife" search:

How Does Technology Fit In?
While fully acknowledging the many benefits that medical technology has brought to pregnancy and birth, these advancements have often meant the sacrificing of personal autonomy for women. Yet, there are ways that women can take back some of that autonomy, utilizing technology. The internet has become a fertile (excuse the term) place for discussion and the sharing of experiences regarding pregnancy and birth. A woman interested in learning more about what kinds of options she has for birthing can find a myriad of different resources and personal accounts from which to glean information. This information, furthermore, exists outside of the technocratic model though it ironically uses technology. In the technocratic model, science and strict learning of objective information occupy the legitimate space, while experiential knowledge is relegated to the backseat -- if not out of the car altogether. With the internet, women can access experiential knowledge in a way that has not been possible since families have become more nuclear, populations more urban, and information less experiential. Here are a few example of what a woman might find with a simple search for "pregnancy and birth":

Emily and Steven Chaplin

Essential Survival Guide to Pregnancy, Birth and Beyond - photos from my pregnancy and my baby's birth story. How to beat the rollercoaster of emotions, essential survival advice and more.

Father's Birth Story - diary of the day my son was born. Specifically, my son's birth. Detailed yet entertaining.

Just Me - pregnancy journal.

Kathrine's Pregnancy Page - personal information about pregnancy and birth.

Labor of Love - devoted to women's amazing birth stories. Info on water and home birth also available.

Payne, Bethany - about teen pregnancy, includes a weekly journal of a personal experience, and helpful info links and fun links.

Pregnancy: The Final Frontier - expectant teen mother's guide to pregnancy.

Shag Pregnancy Story - personal prego page with midwifery and homebirth info.


1 Abbot, Andrew Delano. 1988. The System of Professions. Chicago: University of Chicago Press.

2 ibid

3 ibid

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Laura Barandes

last updated 12/16/98